Every finding on record at Avina on 32nd

Based on interview and record review, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services.Dietary Manager (DM)-G did not have a qualified certificate to manage the kitchen.This deficient practice had the ability to affect all 50 residents who receive meals from the kitchen.Findings include:On 6/23/26 at 11:04 AM, DM-G provided Surveyor a copy of their certificate of completion for Food Safety for Handlers. DM-G stated they are working on getting a manager certificate. Surveyor confirmed that DM-G's certificate is not a national certification for food service management and safety from a national certifying body. Surveyor noted DM-G's hire date was documented as 9/20/2023.On 6/23/26 at 1:28 PM, Surveyor interviewed DM-G, who confirmed they have not started a course yet, but they plan to do a certified food manager course. DM-G stated their previous certificate expired in 2020 and has not been renewed since then. DM-G denied having an associate's degree in food service or hospitality. DM-G was not aware if the facility had a waiver in place for not having the proper certification.On 6/23/26 at 2:59 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, director of operations-C, and regional nurse consultant-D that DM-G did not have a national certification for food service management and safety from a national certifying body. Director of operations-C confirmed no waiver was in place. Director of operations-C stated they thought DM-G had the proper certification and would look for it.On 6/24/26 at 12:36 PM, Director of operations-C provided Surveyor with a copy of the same Food Safety for Handlers certification for DM-G. Director of operations-C stated they were aware the certification is not from an accredited national certifying body.On 6/24/26 at 1:31 PM, Director of operations-C stated they reached out to the facility's corporate team to get DM-G signed up for the correct program.

Based on interview and record review, the facility did not ensure accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers of Medicare and Medicaid Services (CMS).Staffing information for Fiscal Year Quarter 2 2026 (January 1, 2026 - March 31, 2026) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 51 residents residing in the facility.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30.Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal Year Quarter 2 2026 (January 1 - March 31, 2026; run date 6/8/2026), which documented the facility had excessively low weekend staffing and one star staffing rating.Surveyor reviewed facility weekend schedules with nurse postings for Quarter 2 2026 (January 1 - March 31, 2026). Surveyor reviewed the facility assessment and noted staffing ratios, and Surveyor compared them to the schedules provided. No discrepancies were found between the schedules during Quarter 2 for 2026. Surveyor noted licensed nurses and certified nursing assistants on each shift and unit scheduled per facility assessment. Surveyor noted schedules included call ins and documented the staff that picked up the shift. On 6/29/26 at 11:13 AM, Surveyor interviewed human resources director (HRD)-S, who stated they complete all the scheduling for the facility. HRD-S stated they do not directly handle the facility's PBJ reporting, but they do assist the director of recruitment-AA with audits or if there are any discrepancies director of recruitment-AA reaches out to them about. HRD-S stated sometimes a nurse's hours or a medication technician's hours do not get added correctly on the timecard, which could cause a discrepancy on the PBJ report.On 6/29/26 at 2:03 PM, Surveyor interviewed director of recruitment-AA via phone call. Director of recruitment-AA stated they take the timecard data from the facility and upload it into different software, which analyzes the data and creates any alerts such as missing staff coverage. Director of recruitment-AA stated if there are any alerts, they will reach out to HRD-S to see if there was a call in that was not fixed on the timecard, or if some other staffing data is missing from the timecard related to that alert. Director of recruitment-AA stated once they are satisfied that the data is accurate, they upload the data to CMS and receive confirmation that the information was accepted. Director of recruitment-AA was not sure why the facility specifically triggered for one star staffing and excessively low weekend staffing during Quarter 2 2026. Director of recruitment-AA stated if the facility gets alerted for something really concerning like no registered nurse (RN) coverage, they will fix that right away, but for other triggers on the PBJ report, the data really is not investigated.On 6/29/26 at 2:30 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Director of Operations-C, and Regional Nurse Consultant-D that PBJ data was not submitted accurately for Quarter 2 2026.

Based on record review and interview, the facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.The facility did not conduct a background information disclosure (BID) every four years for certified nursing assistant (CNA)-M or CNA-V.This has the potential to affect residents who may receive care from CNA-M or CNA-V.Findings include:The facility policy titled Abuse, Neglect, and Exploitation with implemented date 1/2026 and revised date 2/25/26 documents: . Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Screening . potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. screenings may be conducted by the facility itself, third-party agency or academic institution. the facility will maintain documentation of proof that the screening occurred.On 6/24/26, Surveyor requested employee files for 8 randomly selected employees from human resources director (HRD)-S. Surveyor reviewed facility employee files to ensure completed background checks, including background information disclosure (BID) with Department of Justice (DOJ) response and Integrated Background Information system (IBIS) letter, which are to be completed every four years by State of Wisconsin regulation.Surveyor reviewed the employee file for CNA-M, with hire date documented as 9/14/21, and located a BID form dated 9/3/21, DOJ response document dated 9/8/21, and IBIS letter document dated 9/8/21. Surveyor noted the dates of these screenings were greater than four years old.Surveyor reviewed the employee file for CNA-V, with hire date documented as 9/1/22, and located a BID form dated 9/20/21, DOJ response document dated 10/1/21, and IBIS letter document dated 10/1/21. Surveyor noted the dates of these screenings were greater than four years old.In an interview on 6/24/26 at 2:15 PM, HRD-S stated they were aware the background checks for CNA-M and CNA-V were out of compliance and was unable to locate any updated background checks from the last four years for CNA-M or CNA-V. HRD-S clarified CNA-V's original hire date was in October 2021, but then CNA-V was rehired on 9/1/22.On 6/24/26 at 3:06 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, director of operations-C, and regional nurse consultant-D that CNA-M and CNA-V did not have a BID, DOJ response, and IBIS letter completed every four years per state regulation.

Based on interviews and record review the facility did not ensure residents are free from unnecessary psychotropic or antipsychotic medications for 2 (R3 and R9) of 5 sampled residents.R3 had orders to decrease Abilify (Aripiprazole) which was incorrectly transcribed, resulting in an increase of the medication. Specific behaviors explaining the need for the medication and to justify the increase in the medication were not identified and documented.R9 had orders for Quetiapine Fumarate (Seroquel) scheduled at bedtime and every 12 hours PRN (as needed) upon admission to the facility. The scheduled dose was increased twice within 2 months with no evidence of behaviors to justify the increase in dosage and the PRN order extended beyond 14 days. In addition, Haloperidol PRN was ordered and extended beyond 14 days. There was no evidence of behaviors to justify use of the medication.Findings include:The facility policy titled Use of Psychotropic Medication(s) dated 1/1/26 documents (in part) . It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Chemical restraint refers to any drug used for discipline or that makes it more convenient (i.e., less effort) for staff to care for a resident and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however nonpharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to a resident's health and safety.2. Psychotropic medications are to be used only when a practitioner determines that the medication is appropriate to treat a resident's specific, diagnoses and documented condition and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication.5. The indications for initiating, maintaining, or discontinuing medication as well as the use of nonpharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions.12. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs.15. The resident's response to the medication, including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.16. Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record.b. PRN orders for antipsychotic medications shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.The facility policy titled Medication Reconciliation dated 1/1/26 documents (in part) . Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his or her stay.4. Daily process:c. Obtain and transcribe any new orders in accordance with facility procedures.1.) R3 was admitted to the facility on [DATE] and has diagnoses of vascular dementia, auditory hallucinations, Schizophrenia and major depressive disorder.Surveyor review of R9's January 2026 Medication Administration Record (MAR) documented the following order: Abilify (Aripiprazole) 2 MG - give 2 tablets by mouth one time a day for psychosis related to unspecified psychosis not due to a substance or known physiological condition - dated 4/4/25. R9's PMHNP (Psychiatric Mental Health Nurse Practitioner) note dated 7/29/25 documented: Staff report behaviors, such as wandering and attempting to elope. They report that this is typical behavior for her (R9), and she accepts redirection easily. They denied combativeness or aggression. They feel that the frequency of this behavior is at baseline. Surveyor located a form titled Pharmacy Note to Attending Physician/Prescriber dated 2/19/26 which documented: IDT (interdisciplinary) team review recommends at trial reduction of Aripiprazole 3 mg on Sundays and 4 mg all other days of the week. Rationale: Antipsychotic use in patient with dementia with no recent documentation of hallucinations. Physician/provider response: Check mark next to I agree with and endorse as my own the clinical rationale from the IDT team, please implement recommendation as written. Signed by physician dated 2/23/26.R9's PMHNP note dated 2/24/26 documented: We discussed decreasing Abilify today and she is agreeable to this. Writer will call power of attorney for approval. Staff deny any concerns with mood, behavior, or cognition. Plan: Decrease Abilify to 2mg daily for delusions/dementia, not currently distressed by psychosis. POA (power of attorney) notified.R9's Physicians order dated 2/24/26 documented: Abilify Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth one time a day.R9's February 2026 MAR included the following orders: Abilify oral tablet 2 mg - give 1 tablet by mouth one time a day for psychosis start date 2/25/26, AND an order for Aripiprazole 4 mg by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, Friday, Saturday - start date 2/24/26.Surveyor noted the Abilify dose was not decreased as ordered, it was increased. R9 was administered 2 mg daily in addition to 4 mg daily Monday through Saturday for a total of 6 mg. R9's March 2026 MAR included the following orders:Abilify 2 mg (Aripiprazole) 1 tablet by mouth one time a day - start date 2/25/26.Aripiprazole 4 mg by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, Friday, Saturday - start date 2/24/26.Aripiprazole 3 mg by mouth one time a day every Sunday - order date 3/1/26.Surveyor was unable to determine why Abilify 3 mg daily was ordered on Sunday. Surveyor noted that R9 continued to receive Aripiprazole 2 mg daily in addition to 4 mg daily Monday through Saturday and an additional 3 mg on Sunday through 3/25/26, which amounts to a total of 6 mg Monday-Saturday and 5 mg on Sunday.On 3/26/26 R9's Aripiprazole order was changed to 5 mg by mouth in the morning for schizophrenia.Surveyor review of R9's medical record revealed no evidence of behaviors except for wandering/exit seeking, which according to staff, per PMHNP notes, is typical behavior for her, and she accepts redirection easily. They deny combativeness or aggression and feel that the frequency of this behavior is at baseline. On 6/24/26 at 9:44 AM, Surveyor spoke with Chief Operations Officer (COO)-C. Surveyor told COO-C of concern regarding R9's Abilify. The psychiatry plan per 2/24/26 note was to decrease the dose. The dose was not decreased, but rather increased and in March the dose was increased again with no evidence supporting the increase. There is no documentation of behaviors aside from wandering (which is not unusual for R9). Surveyor and COO-C discussed the possibility of staff not realizing that Abilify and Aripiprazole are the same medication when transcribing the order on the MAR, which would explain why the medication is on the MAR multiple times with different doses. COO-C stated she understood the concern.2.) R9 was admitted to the facility on [DATE] and has diagnoses that included chronic kidney disease stage 3, senile degeneration of the brain and dementia. R9 was on Hospice until 6/30/25.R9's care plan dated 3/19/25 documented: The resident would like to remain LTC (long term care) in our facility. Patient will be on our secured unit to help with wandering caused by her dementia diagnosis.Demonstrates cognitive impairment related to Alzheimer's disease/dementia and experiences fluctuating participation and occasional restlessness. Benefits from structured, low-stimulation, sensory-based activity engagement and individualized approaches to support comfort, reduce anxiety, and promote quality of life - revised 4/9/26.Surveyor noted R9's Plan of Care (POC) behavior monitoring is generic and not specific to identified behaviors specific for R9. Surveyor review of R9's March 2025 Medication Administration Record (MAR) revealed the following orders:Quetiapine Fumarate Oral Tablet 25 mg - give 1 tablet by mouth at bedtime for mood disorder related to unspecified dementia, unspecified severity with other behavioral disturbance - start date 3/5/25.Quetiapine Fumarate Oral Tablet 25 mg - give 1 tablet by mouth every 12 hours as needed (PRN) for mood disorder - start date 3/5/25.Surveyor noted the PRN Seroquel did not include a stop date and was given 12 times before it was discontinued on 4/3/25.On 4/4/25 R9's Seroquel dose was increased to 25 mg in the morning and 50 mg at bedtime per hospice order.Surveyor noted there was no evidence of behaviors to justify the increase in dosage. There was no behavior monitoring documentation on the MAR, nursing notes documented occasional wandering and/or pacing and POC documented zero behaviors.On 5/12/25 R9's Seroquel dose was again increased to 100 mg at bedtime per hospice order.Surveyor noted there was no evidence of behaviors to justify the increase in dosage. There was no behavior monitoring documentation on the MAR, nursing notes documented occasional wandering and/or pacing and POC for April and May documented zero behaviors.On 5/9/25 Haloperidol 2 MG by mouth every 6 hours as needed for restlessness was ordered by hospice. Surveyor noted the order did not include a stop date and was administered 16 times in May and 7 times in June before it was discontinued on 6/17/25.Psychiatry initial evaluation dated 6/17/25 documented: Continues with decline in disease progress. Review of psychotropic medication use: Patient is stable and functioning at the highest practicable level on the current dose of medication. A reduction would be detrimental. The benefits of a reduction do not outweigh the risks and is clinically contraindicated at this time. Plan: Continue medications as ordered. Consider slow GDR (gradual dose reduction) of Seroquel in the future if able. On 6/30/26 at 9:11 AM, Surveyor spoke Assistant Director of Nursing (ADON)-R. She reported R9 has behaviors that include impulsiveness, exit seeking, restlessness and increased distress especially in the evening related to her spouse passing away. Surveyor told ADON-R that behavior monitoring specific to R9 was not implemented or completed and POC documentation indicated zero for behaviors. On 6/30/26 at 9:45 AM, Surveyor told Director of Nursing (DON)-B, Nurse Consultant-D and Chief Operations Officer (COO)-C of concern PRN Haldol was ordered without stop date and was administered beyond 14 days with no evidence of behaviors to support use of the medication. On 6/30/26 at 10:29 AM, Surveyor met with Director of Nursing (DON)-B, Nurse Consultant-D and Chief Operations Officer (COO)-C. Surveyor advised that R9's March nursing notes documented only occasional episodes of confusion/wandering. Seroquel was increased on 4/4/25 with no evidence of behaviors documented. Subsequent April and May progress notes documented occasional pacing, but no other behaviors. Seroquel was increased again on 5/12/25 with no evidence of an increase in behaviors documented. In addition, Haldol was ordered on 5/9/25 with no evidence as to why, as there was no documentation of increased behaviors, and it extended beyond 14 days without clinical indication for use. Nurse Consultant-D stated, I did notice that when I was reviewing, there weren't any other behaviors documented. I think there is a problem that the nurses believe if hospice orders medication, the facility does not have any other control regarding the order. COO-C added, I understand the concern, we have some work to do here.

Based on interviews and record review, the facility did not ensure 3 (R34, R4, and R46) of 5 residents with an allegation of abuse or involved in a resident-to-resident altercation were reported to the State Survey Agency within the required reporting timeframe. *R34 informed facility staff that Certified Nursing Assistant, (CNA)-Y, was rough with cares. This allegation of abuse was not reported to the State Survey Agency. *A resident-to-resident altercation involving R4 and R46 was not reported to the State Survey Agency within the required reporting timeframe. Findings include: The facility policy with a last reviewed/revised date of 2/25/26 and titled, Abuse Neglect and Exploitation documents, in part: . The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, State Agency and to all other required agencies. within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1.) R34 was admitted to the facility on [DATE]. R34's Quarterly Minimum Data Set assessment dated [DATE] documented that R34 is cognitively intact. R34 requires substantial/maximal assist for toileting hygiene and is always incontinent of bowel and bladder. On 6/22/26 at 10:04 AM, R34 informed Surveyor of an incident that occurred in April 2026. R34 stated that CNA-Y was being rough while providing incontinent cares. R34 stated that they told CNA-Y that CNA-Y was being too rough, but CNA-Y continued and stated, I'm sorry, but I need to get you clean. R34 stated that later on, CNA-Y was in R34's room. R34 asked for help getting a computer cord. R34 stated that CNA-Y refused to help because R34 won't allow CNA-Y to care for R34 anymore. R34 stated that they told facility staff that CNA-Y was rough when caring for R34. Surveyor noted R34 informed facility staff that sometime back in April 2026, CNA-Y was rough when providing cares to R34. Surveyor noted that this is an allegation of abuse. Surveyor reviewed the Facility Reported Incidents (FRIs) for the last 6 months. Surveyor noted that the facility did not have a FRI for R34's allegation of abuse. Surveyor reviewed the facility grievance log and noted a grievance filed by R34. The grievance report filed 5/18/26 and an incident date of 5/17/26, documented, in part: [R34] stated [they] do not want [CNA-Y] to provide cares to [R34] because when [CNA-Y] is cleaning [R34], [CNA-Y] is too rough when [they] clean. Included in the grievance report was a handwritten, undated statement from CNA-Y that documented: During my round when I was changing [R34's roommate], R34 asked me to plug [their] computer in for [them]. I told [R34] that I was in the middle of changing [R34's] roommate. As this was happening, I saw [CNA-Z], and I asked [CNA-Z] to help [R34]. Surveyor noted that the statement did not include the allegation of being rough with cares and only documented about CNA-Y not helping R34 with the computer cord. On 6/23/26 at 1:25 PM, Surveyor interviewed CNA-Y. Surveyor asked if CNA-Y recalls an incident when R34 told CNA-Y that they were being rough. CNA-Y stated yes. CNA-Y indicated that R34 had a bowel movement. CNA-Y stated that R34's bowel movements can get stuck and be hard to clean. While trying to clean R34, R34 told CNA-Y that they felt like CNA-Y was being rough. CNA-Y informed R34 that they had to get R34 clean, and CNA-Y continued cleaning. About 3 weeks after that is when CNA-Y was caring for R34's roommate and R34 asked for help with the computer cord. CNA-Y told R34 that they were helping the roommate. CNA-Y indicated a different CNA came to help R34 with the cord. Surveyor noted CNA-Y confirmed that R34 told CNA-Y that they were being rough, and CNA-Y continued cleaning R34. The grievance report contained a handwritten statement from Licensed Practical Nurse (LPN)-E dated 5/17/26 which documented: [R34] complained about [CNA-Y] being too rough, [they] never had prior complaints. [Writer] hasn't heard any other complaints about [CNA-Y]. [CNA-Y] did not work the weekend the complaint was made. [R34] stated [they] will let [CNA-Y] in the room but does not want cares from [CNA-Y]. On 6/23/26 at 1:13 PM, Surveyor interviewed LPN-E. Surveyor asked if LPN-E remembered an incident involving R34 and CNA-Y. LPN-E stated that R34 made a complaint about CNA-Y. LPN-E stated that CNA-Y is the best CNA and they work really well together. LPN-E stated that they asked CNA-Y about it. CNA-Y told LPN-E that R34's bowel movements get stuck and CNA-Y does have to wipe harder to get R34 clean. LPN-E stated that CNA-Y told them that is what happened. Surveyor asked if CNA-Y told them when this incident occurred. LPN-E stated No. Surveyor asked when R34 told LPN-E of the incident. LPN-E stated that R34 did not tell them. LPN-E stated that R34 told a different CNA, CNA-Z, who no longer works at the facility. CNA-Z told LPN-E on the weekend of 5/17/26 of R34's concern. LPN-E stated that they did not talk to R34 about the allegation of CNA-Y being rough, but LPN-E passed the information on to management. Surveyor noted that LPN-E stated that R34 informed CNA-Z of the allegation of abuse. CNA-Z then told LPN-E. Surveyor was unable to interview CNA-Z. CNA-Z was no longer employed by the facility. Surveyor noted the grievance report does not include a statement from CNA-Z. Surveyor noted multiple staff members were aware that R34 stated that CNA-Y being rough with cares. Surveyor noted that this allegation of abuse was not reported to the State Agency. On 6/24/26 at 9:11 AM, Surveyor interviewed NHA-A. Surveyor asked what is expected if a resident tells a facility staff member that a CNA was rough. NHA-A stated if it is a CNA then they should tell the nurse. The nurse will tell the Director of Nursing (DON)-B and DON-B will inform me. Surveyor asked if the allegation of CNA-Y being rough with cares was reported to the State Agency. NHA-A indicated that if the resident reports that staff was rough with cares, they would need to determine if the act is intentional and then determine if it needs to be reported. That is why there is a grievance about this incident. NHA-A stated that CNA-Y was not working at the facility on the weekend that R34 reported that CNA-Y was rough with cares. Surveyor asked if it was determined when the incident actually occurred. NHA-A did not have an answer. Surveyor informed NHA-A that the grievance report and statements did not include any information of when the incident occurred, just that it was reported to facility staff on 5/17/26. In addition, according to LPN-E, R34 told CNA-Z of the allegation of CNA-Y being rough. There is no statement from CNA-Z in the grievance report. NHA-A stated that they would look to see if there is a statement from CNA-Z. Surveyor shared the concern that R34 reported to facility staff that CNA-Y was rough with cares. This allegation of abuse was not reported to the State Agency. NHA-A stated that they understood. 2.) R4 was admitted to the facility on [DATE] with a diagnoses of severe vascular dementia with psychotic disturbance, traumatic brain injury, psychotic disorder with delusions and anxiety. R4's Significant Change in Condition Minimum Data Set (MDS) assessment, dated 11/18/2025, documented they have a Brief Interview for Mental Status (BIMS) score of 9, indicating they have moderate cognitive impairment. R46 was admitted to the facility on [DATE] with a diagnoses of schizoaffective disorder, bipolar and anxiety. R46's admission Minimum Data Set (MDS) assessment, dated 7/30/2025, documented they have a Brief Interview for Mental Status (BIMS) of score of 14, indicating they are cognitively intact. A progress note dated 2/6/26 at 14:19 (2:19 PM) in R46's record indicated: Behavior Note: Describe behavior, notifications: patient was observed having aggressive behaviors towards another resident. Nurse spoke to resident (R46) and he admitted to punching the other resident in the stomach. The patient who (R46) punched has no bruises and denies any pain at this time. (R46) was later seen smacking (sic) things from the same patient who (R46) punched. (R46) seems to be more aggressive than usual at this time. Completed by Licensed Practical Nurse (LPN)-E. The Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report was submitted to the State Agency on 2/7/2026 at 1:04 PM. On 06/23/2026 at 1:48 PM, Surveyor asked Director of Operations (DOO)-C what the expectation is for reporting abuse, and they stated within 2 hours of learning of the incident. Surveyor asked DOO-C when the facility was aware of the resident to resident altercation involving R46 and R4.DOO stated not until 2/7/26 when LPN-E had learned about the abuse and reported the abuse to Nursing Home Administrator (NHA)-A. On 06/24/2026 at 9:22 AM Surveyor asked NHA-A when did LPN-E know of the abuse between R46 and R4. NHA-A stated LPN-E reported it to NHA-A as soon as they knew on 2/7/26. Surveyor shared with NHA-A there is a progress note dated and time stamped on 2/6/2026 at 2:19 PM that documented aggressive behaviors were observed between R46 and R4 where R46 admitted to punching R4 in the stomach. Surveyor shared the note was written By LPN-E. NHA-A stated they were not aware LPN-E was aware of the potential abuse prior to LPN-E reporting it to NHA-A on 2/7/26. NHA-A stated they assumed when LPN-E reported the incident to NHA-A that LPN-E had just learned of incident. Surveyor informed NHA-A that there is a concern regarding the abuse not being reported timely.

Based on interviews and record review, the facility did not ensure an allegation of abuse and a resident-to-resident altercation was thoroughly investigated for 1 (R34) of 5 sampled residents reviewed for allegations of abuse.*R34 informed facility staff that Certified Nursing Assistant, (CNA)-Y, was rough with cares. This allegation of abuse was not thoroughly investigated.Findings include:The facility policy with a last reviewed/revised date of 2/25/26 and titled, Abuse Neglect and Exploitation documents, in part: . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: Identifying staff responsible for the investigation. Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and provide complete and thorough documentation of the investigation.R34 was admitted to the facility on [DATE].R34's Quarterly Minimum Data Set assessment dated [DATE] documented that R34 is cognitively intact. R34 required substantial/maximal assist for toileting hygiene and is always incontinent of bowel and bladder.On 6/22/26 at 10:04 AM, R34 informed Surveyor of an incident that occurred in April 2026. R34 stated that CNA-Y was being rough while providing incontinence cares. R34 stated that they told CNA-Y that CNA-Y was being too rough, but CNA-Y continued and stated, I'm sorry, but I need to get you clean. R34 stated that later on, CNA-Y was in R34's room. R34 asked for help getting a computer cord. R34 stated that CNA-Y refused to help because R34 won't allow CNA-Y to care for R34 anymore. R34 stated that they told facility staff that CNA-Y was rough when caring for R34.Surveyor noted R34 informed facility staff that back in April 2026, CNA-Y was rough when providing cares to R34. Surveyor noted that this is an allegation of abuse.Surveyor reviewed the Facility Reported Incidents (FRIs) for the last 6 months. Surveyor noted that the facility did not have a FRI for R34's allegation of abuse.Surveyor reviewed the facility grievance log and noted a grievance filed by R34.The grievance report filed 5/18/26 and an incident date of 5/17/26, documented, in part: [R34] stated [they] do not want [CNA-Y] to provide cares to [R34] because when [CNA-Y] is cleaning [R34], [CNA-Y] is too rough when [they] clean.Included in the grievance report was a handwritten, undated statement from CNA-Y that documented: During my round when I was changing [R34's roommate], R34 asked me to plug [their] computer in for [them]. I told [R34] that I was in the middle of changing [R34's] roommate. As this was happening, I saw [CNA-Z], and I asked [CNA-Z] to help [R34].Surveyor noted that the statement did not include the allegation of being rough with cares and only documented about CNA-Y not helping R34 with the computer cord. Surveyor noted a complete statement about the incident was not gathered by facility.On 6/23/26 at 1:25 PM, Surveyor interviewed CNA-Y. Surveyor asked if CNA-Y recalled an incident when R34 told CNA-Y that they were being rough. CNA-Y stated yes. CNA-Y indicated that R34 had a bowel movement. CNA-Y stated that R34's bowel movements can get stuck and be hard to clean. While trying to clean R34, R34 told CNA-Y that they felt like CNA-Y was being rough. CNA-Y informed R34 that they had to get R34 clean, and CNA-Y continued cleaning. About 3 weeks after that is when CNA-Y was caring for R34's roommate and R34 asked for help with the computer cord. CNA-Y told R34 that they were helping the roommate. CNA-Y indicated a different CNA came to help R34 with the cord.Surveyor noted CNA-Y confirmed that R34 told CNA-Y that they were being rough, and CNA-Y continued cleaning R34.The grievance report contained a handwritten statement from Licensed Practical Nurse (LPN)-E dated 5/17/26 which documented: [R34] complained about [CNA-Y] being too rough, [they] never had prior complaints. [Writer] hasn't heard any other complaints about [CNA-Y]. [CNA-Y] did not work the weekend the complaint was made. [R34] stated [they] will let [CNA-Y] in the room but does not want cares from [CNA-Y].On 6/23/26 at 1:13 PM, Surveyor interviewed LPN-E. Surveyor asked if LPN-E remembered an incident involving R34 and CNA-Y. LPN-E stated that R34 made a complaint about CNA-Y. LPN-E stated that CNA-Y is the best CNA and they work really well together. LPN-E stated that they asked CNA-Y about it. CNA-Y told LPN-E that R34's bowel movements get stuck, and CNA-Y does have to wipe harder to get R34 clean. LPN-E stated that CNA-Y told them that is what happened. Surveyor asked if CNA-Y told them when this incident occurred. LPN-E stated No. Surveyor asked when R34 told LPN-E of the incident. LPN-E stated that R34 did not tell them. LPN-E stated that R34 told a different CNA, CNA-Z, who no longer works at the facility. CNA-Z told LPN-E on the weekend of 5/17/26. LPN-E stated that they did not talk to R34 about the allegation of CNA-Y being rough, but LPN-E passed the information on to management.Surveyor noted that LPN-E stated that R34 informed CNA-Z of the allegation of abuse. CNA-Z then told LPN-E.Surveyor was unable to interview CNA-Z. CNA-Z was no longer employed by the facility. Surveyor noted the grievance report does not include a statement from CNA-Z.Included in the grievance report was a statement from Social Worker (SW)-H. The statement was dated 5/18/25 and documented: Writer met with [R34] [related to] a concern reported. [R34] stated [they] felt as if CNA was too rough when doing per cares. [R34] stated it occurred on a one-time basis and [they verbalized to CNA that [CNA] was rough. CNA acknowledged and [R34] stated there was no further concerns. [R34] stated [they] feel safe in the facility. No further concerns.On 6/23/26 at 1:39 PM, Surveyor interviewed SW-H. Surveyor asked how SW-H was made aware of R34's concern about CNA-Y. SW-H stated that Nursing Home Administrator (NHA)-A brought the concern to SW-H and that is when SW-H interviewed R34. R34 told SW-H that CNA-Y was a bit rougher than other CNAs when providing cares. Surveyor asked if other residents were interviewed to see if they had any concerns about CNAs being rough with cares. SW-H stated that typically, Administration will give SW-H interview questions to ask a percentage of residents if that is needed. SW-H stated that they did not recall Nursing Home Administrator (NHA)-A saying that SW-H needed to do that.Surveyor noted that other residents were not interviewed as part of the investigation to determine if any other residents had concerns about their care.On 6/24/26 at 9:11 AM, Surveyor interviewed NHA-A. Surveyor asked what is expected if a resident tells a facility staff member that a CNA was rough. NHA-A stated if it is a CNA then they should tell the nurse. The nurse will tell the Director of Nursing (DON)-B and DON-B will inform me. Surveyor asked about the allegation of CNA-Y being rough with cares. NHA-A indicated that there is a grievance about this incident. NHA-A stated that CNA-Y was not working at the facility on the weekend that R34 reported that CNA-Y was rough with cares. Surveyor asked if it was determined when the incident actually occurred. NHA-A did not have an answer. Surveyor informed NHA-A that the grievance report and statements did not include any information of when the incident occurred, just that it was reported to facility staff on 5/17/26. In addition, according to LPN-E, R34 told CNA-Z of the allegation of CNA-Y being rough. There is no statement from CNA-Z in the grievance report. NHA-A stated that they would look to see if there is a statement from CNA-Z. Surveyor asked if other residents were interviewed after this allegation from R34. NHA-A stated that they would typically interview other residents to see if that staff member is a concern to others. Surveyor shared the concern that R34 reported to facility staff that CNA-Y was rough with cares. CNA-Z, who took the initial report from R34, was not interviewed and did not provide a statement. Other residents were not interviewed. This allegation of abuse was not thoroughly investigated. NHA-A understood the concern.

Based on observation, interview and record review the facility did not ensure that residents received proper foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists for 1 of 1 (R34) residents reviewed for foot care.*Facility staff found that R34 had an ingrown toenail in August of 2026. R34 developed multiple infections due to the ingrown toenail. R34's Wound MD-W, R34's Nurse Practitioner (NP)-X and emergency room physicians all recommended that R34 be referred to a podiatrist for care and treatment. Facility staff did not always follow the doctor's recommendations for treatment and did not provide podiatry services until February 2026. Surveyor observed R34's toe nails to be long and unkept.Findings include:The facility policy dated 1/1/26 documents, in part: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. Residents requiring foot care who have complicating disease processes will be referred to qualified professionals such as a Podiatrist, Doctor of Medicine and/or Doctor of Osteopathy. Foot disorders which may require treatment include but are not limited to: . Nail disorders. Employees should refer any identified need for foot care to the nurse managers. The front desk or designee will assist residents in making appointments and arranging transportation to obtain needed services.R34 was admitted to the facility on [DATE] with diagnosis that include Morbid obesity and Peripheral Vascular disease.R34's Quarterly Minimum Data Set assessment dated [DATE] documents that R34 is cognitively intact. R34 requires substantial/maximum assistance for showering and bathing. R34 does not have any skin or wound concerns.R34's at risk for skin breakdown care plan initiated 12/13/24 documents the following pertinent interventions: Administer [treatments] as ordered and monitor for effectiveness. Skin checks on shower days.Surveyor reviewed R34's Comprehensive Care plan and did not find a foot care plan or any interventions in place for R34's feet or toes.On 6/22/26 at 10:04 AM, R34 informed Surveyor that they are concerned about R34's toe nails and toe nail care. R34 stated that it takes months to get their toe nails clipped. R34 stated that they had issues with an ingrown toenail, and it took a long time to get it taken care of. R34 stated that they did not think that they should have to wait so long to get an appointment for a podiatrist. R34 pulled the blankets up and showed Surveyor their feet. Surveyor observed R34's right great toenail to be long with black scabbing along both sides and the top of the nail. R34's other nails on R34's right and left foot were long and unkept.R34's SBAR note dated 8/2/25 at 9:21 PM documents, in part: . [Right] great toe has ingrown nail with slight bleeding, no swelling. Primary Care Provider responded with the following feedback: . Bacitracin ointment to [right] great toenail, cover with a band aid, and referral to podiatry for treatment of ingrown toenail.R34's MD order dated 8/2/25 documents, To see Podiatrist for treatment of ingrown toenail to the [right] great toe.Surveyor reviewed R34's Comprehensive care plan and noted when R34's ingrown toe nail was identified, a foot or toenail care plan was not initiated to prevent the worsening of R34's ingrown toe nail.On 6/29/26 at 12:51 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if R34 should have a foot/toe care plan after the development of the ingrown toenail wound. DON-B stated Absolutely.R34's Nurse Practitioner (NP)-X visit note dated 8/5/25, documents, in part: . [R34] reports on going issues of right great toe ingrown nail with tenderness and mild swelling started about 4 days ago. The area has no active drainage and signs of infection. She will be seen by in house podiatry this week.R34's Wound MD-W's note dated 8/7/25 documents, in part: . non-pressure wound of the right, first toe full thickness. Etiology: Trauma/injury. Further Etiology detail: Ingrown toenail. 2 x 0.3 x 0.1. 100% granulation. Patient requiring an increase in the level of care. Podiatry consult for ingrown toenail.R34 is seen by Wound MD-W weekly.On 8/25/25, R34 was sent to the emergency room (ER) for a concern unrelated to R34's ingrown toenail.R34's progress note dated 8/25/25 at 7:30 PM, documents, in part: [R34] returned from hospital, has new orders for [antibiotic] for toe infection.R34's hospital After Visit Summary dated 8/25/25 documents, in part: . Diagnoses: . Toe infection. Instructions: . Take antibiotics after food twice a day as prescribed. Follow-up with podiatry service for further care of your toes.R34's MD order dated 8/26/25 documents: Cefadroxil 500 milligrams. Give 1 capsule by mouth two times a day for infection to great toe for 7 days.Surveyor noted R34 was diagnosed with a toe infection and needed antibiotics to treat the infection. The ER physician recommended that R34 follow up with podiatry.Surveyor reviewed R34's medical record and did not find evidence that R34 was seen by a podiatrist for R34's ingrown toenail anytime during the month of August.R34's NP-X visit note dated 9/2/25 documents in part: . [R34] reports no new health issues aside from [the] right great toe that is less swollen. Right great toenail with swelling and tenderness, no drainage, no signs of infection. Refer to in house podiatry. open shoes. 8/25 ER visit, started Cefadroxil. To see podiatry. 9/02 less swollen. Contingency plan : if has signs for infection, start Bactrim. refer to podiatry for removal.Surveyor noted NP-X stated that R34 should use open shoes. Surveyor reviewed R34's care plan and did not see that this was added as an intervention.Wound MD-W continued to see R34 weekly. R34 did not see a podiatrist in the month of September 2025.R34's Wound MD-W visit note dated 10/2/25 documents, in part: non-pressure wound of the right, first toe full thickness. Etiology: Trauma/injury. Further Etiology detail: Ingrown toenail. 1 x 0.3. Wound progress: exacerbated due to infection. Infection assessment: One or more signs of clinical infection. Patient requiring an increase in level of care. Podiatry re-consult. Recommends oral antibiotics for cellulitis. Over the past month: podiatry re-consult. This month's approach: follow up with consult.Surveyor reviewed R34's medical record and noted no documentation that R34 saw podiatry or that R34 was started on antibiotics per Wound MD-X recommendations.On 6/29/26 at 11:26 AM, Surveyor interviewed Wound MD-W. Surveyor asked about the infection noted on 10/2/25. Wound MD-W stated that they recommended antibiotics. Wound MD-W stated that they typically will recommend the antibiotic, and the primary MD will say ok and/or order the medication. Sometimes Wound MD-W will order it. Surveyor asked if Wound MD-W was aware that R34 did not receive antibiotics after recommendation. Wound MD-X stated did not have an answer but stated that the toe did start looking better.R34's Wound MD-W visit note dated 10/9/25 documents, in part: non-pressure wound of the right, first toe full thickness. Etiology: Trauma/injury. Further Etiology detail: Ingrown toenail. 1 x 0.3. Wound progress: Improved evidenced by decreased infection.R34's NP progress note dated 10/9/25 at 11:15 documents, in part: . [R34] really wants to see podiatry secondary to elongated toenails. Will discuss with unit manager.Surveyor noted R34 requested to see podiatrist.R34 is seen by Wound MD-W weekly. On 10/24/25, R34 requested to go to the ER for an earache.R34's progress note dated 10/24/25 at 11:49 AM, documents, in part: [R34] returned from [Hospital]. [R34 has new orders. Started on . Bactrim for infected ingrown toe nail.R34's hospital After Visit Summary dated 10/24/25 documents, in part: . Take full course of antibiotics as prescribed for infection of ingrown toenail and schedule follow-up appointment with podiatry. Soak this toe in warm water for 15 minutes 3 times a day. Service to podiatry requested.R34's MD order with a start date of 10/24/25 documents: Sulfamethoxazole-Trimethoprim oral tablet. 800-160mg. Give 1 tablet by mouth two times a day for infection to right great toe for 5 days.Surveyor noted facility staff entered the antibiotic order for R34's infection but did not enter an order for podiatry referral or for toe soaks in warm water 3 times a day as recommended by the ER physician.Surveyor reviewed R34's medical record and noted R34 did not see a podiatrist in the month of October 2025.R34's Wound MD-W visit note dated 10/30/25 documents, in part: non-pressure wound of the right, first toe full thickness. Etiology: Trauma/injury. Further Etiology detail: Ingrown toenail. Wound progress: resolved.R34's NP-X visit note dated 11/5/25 documents, in part: . [R34] reports on going issues of right great toe ingrown inflamed and tender. She completed the 5 day [antibiotic] for toe infection. 10/24 sent to ER [due to] left ear pain, back to [facility] with [antibiotic] for right to ingrown infection- Podiatry coming this 10/31/25 per [Director of Nursing (DON)-B]. 11/4 completed [antibiotic]. Right great toenail dry and not inflamed. Podiatry did not arrive.Surveyor reviewed R34's medical record and noted R34 did not see a podiatrist in the months of November and December of 2025 or in January of 2026.Wound MD-W's visit note dated 1/22/26 documents, in part: non-pressure wound of the right, first toes. Ingrown toenail. Duration >1 day. 2 x 2. [R34] requiring an increase in the level of care. Podiatry consult.Surveyor noted that Wound MD-W began treating R34's toe again starting on 1/22/26.R34's NP-X visit note dated 2/4/26 documents, in part: [R34] has issues of recurrent right great toenail ingrown. will see podiatry this 2/11/26.On 6/29/26 at 11:13 AM Surveyor interviewed NP-X. Surveyor asked about R34's issues with R34's toe. NP-X stated that it started last year. R34 was being seen by Wound MD-W for treatment. NP-X had issues sending R34 to podiatry. NP-X stated there was something that happened with the facility and podiatry that paused the service. NP-X stated that usually podiatry comes quarterly. NP-X indicated that the delay of care and recurrent infections was partly because of the unavailability of podiatry and R34's refusal to be sent out to an outside podiatrist.R34's Podiatry note dated 2/11/26 documents, in part: [R34] is being seen for foot evaluation and treatment. Notable exam findings include severe ingrown right [big toe], dried blood drainage noted and tenderness along both sides of the nail. [R34] was able to tolerate a slant back removal of both sides of the nail, to reduce pressure caused and allow site to heal. [R34] will continue to be seen for at risk foot care every 2-3 months or sooner if needed.Surveyor noted that R34 was referred to podiatry on 8/2/25 and was seen by a Podiatrist on 2/11/26, over 7 months after the first referral. Surveyor noted that Podiatry wants R34 to be seen every 2 to 3 months.On 6/30/26 at 10:31 AM, Surveyor interviewed Podiatrist-CC. Surveyor asked when Podiatrist-CC first became aware of R34's need for podiatry. Podiatrist-CC stated that he first heard of R34's need in February of this year. Podiatrist-CC stated that they looked back at email correspondence and did not find any emails from the facility about R34. Podiatrist-CC stated that the facility was not on their radar for much of 2025 because of their name change. Podiatrist-CC stated that the facility will typically communicate when a resident needs to be seen. Podiatrist-CC stated that if they had known of R34's need, they would have been able to help R34 sooner. Surveyor asked about treating R34's ingrown toenail infections with antibiotics. Podiatrist-CC stated that antibiotics are effective for the infection, but they do not treat the problem. An ingrown toenail is like a splinter and until the splinter is removed, the process keeps repeating itself.R34's MD-W's visit note dated 2/19/26 documents that R34's ingrown toenail has resolved.On 6/24/26 at 1:25 PM, Surveyor interviewed the facility Wound Nurse, Registered Nurse (RN)-Q. Surveyor asked about RN-Q's ingrown toe nail. RN-Q stated that they and Wound MD-W started seeing R34 as soon as the ingrown toenail was found. Wound MD-W referred R34 to podiatry. After podiatry saw R34 the issues with R34's toe resolved. Surveyor asked why there was a delay in R34 seeing the podiatrist. RN-Q stated that typically podiatry comes to the facility every couple months. Unfortunately, the podiatrist did not know that the facility name changed and stopped coming to the facility for a while.On 6/29/26 at 11:26 AM, Surveyor interviewed Wound MD-W. Surveyor asked about R34's issues with the right great toe. Wound MD-W stated that R34 had an ingrown toenail and that they recommended that R34 see a podiatrist. Surveyor asked what the expected time frame for a podiatry consult would be. Wound MD-W stated that it varies. Wound MD-W stated that they would expect that they would see the resident the next time in the building. Surveyor asked if over seven months is an acceptable time frame. Wound MD-W stated that with the history of podiatrist it is expected. Wound MD-W stated that they would try to remove the area of concern but R34 would not want Wound MD-W to touch the toe. That is why Wound MD-W referred R34 to podiatry with the hopes that R34 would let them touch it.On 6/29/26 at 10:05 AM, Surveyor observed R34's feet. Surveyor noted that all of R34's toe nails look long and unkept. R34's right great toe has black scabbing on both sides and along the top R34's toe.Surveyor reviewed R34's medical record and noted R34 had not seen podiatry since 2/11/26 despite the podiatrist recommending foot care every 2-3 months.On 6/23/26 at 1:51 PM, Surveyor interviewed Receptionist-N, who takes care of appointments, travel to appointments and arranging in-house podiatry. Surveyor asked how podiatry is aware of who they need to see when they come to the facility. Receptionist-N stated that they communicate with the podiatry provider through email. Receptionist-N stated that they come to the facility every 2 to 3 months. Receptionist-N stated that podiatry was last at the facility in February of this year. Receptionist-N indicated that there was confusion and a period of time last year that the podiatrist was not coming to the building. The facility had changed their name, and the podiatrist thought that the facility had closed. On October 31st last year, Receptionist-N had email communication with the podiatrist making them aware that they are still open.On 6/29/26 at 12:51 PM, Surveyor informed DON-B of the concerns that facility staff identified that R34 had an ingrown toenail on 8/2/25. An order for a podiatry consult was entered. R34's toe got infected multiple times and required antibiotics twice. During this time, Wound MD-W, NP-X and ER physicians all recommended that R34 see podiatry, which was not completed until February of 2026. The facility did not follow After Visit instructions for toe soaks 3 times a day. The facility did not implement a care plan with resident centered interventions for R34's ingrown toenail. Surveyor observed R34's toenails to be long and unkept. R34's right great toe has black scabbing along the edges and over the top of the toe. DON-B indicated that they understood the concern and confirmed that there was a time that the podiatrist was not coming to the building.On 6/30/26 at 11:00 AM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the above concerns.

Based on observation, interview and record review, the facility did not comprehensively assess a resident after applying bed mobility devices for 1 of 1 sampled residents' (R7) reviewed for mobility devices.*R7 was assessed to have bed rails to aid in positioning. R7's use of bed rails was not included in R7's care plan. R7 did not have a physician order for the bed rails and R7 was not assessed quarterly for the continued need for the bed rails.Findings include:The facility's policy titled Proper Use of Bed Rails, dated 4/30/2025, documented It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail. The resident assessment must also assess the resident's risk from using bed rails. The resident assessment should assess the resident's risk of entrapment between the mattress and the bedrail or in the bedrail itself. The facility will assess to determine if the bed rail meets the definition of a restraint. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. The facility will continue to provide necessary treatment and care to the resident who has bed rails. This should be evidenced in the resident's records, including their care plan. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon significant change in status, or a change in the type of bed, mattress, or rail. The interdisciplinary team will make decisions regarding when the bed rails will be used or discontinued, or when to revise the care plan to address any residual effects of the bed rail.R7 was admitted to the facility on [DATE]. R7's diagnoses included paraplegia, profound intellectual disabilities, vascular dementia, and traumatic brain injury.R7's quarterly minimum data set (MDS) completed on 4/10/2026 documented R7 has a brief interview for mental status (BIMS) score of 15, indicating that R7 was cognitively intact. The physical restraint section of the MDS documented R7 does not have bed rails. R7 is dependent on staff for eating, hygiene, showering, bed mobility, and transferring. R7 required substantial assistance for dressing.On 6/29/2026, at 10:00 AM, Surveyor reviewed R7's electronic health record (EHR). Surveyor noted documentation of bed rails in R7's progress notes. Review of R7's plan of care and physician orders does not include documentation of bed rails for R7.On 1/14/2026, at 12:50 PM, R7's evaluation titled Positing Rail and Bar Evaluation documented R7 has no history of falls, R7 has impaired bed mobility, the bed rail does not prevent R7 from performing actions, the bars were added to assist R7 with bed mobility, the rails are not a restraint, and R7's power of attorney (POA) was informed of the risks and benefits and consented to the bed rails.Surveyor noted the facility's policy documents bed rail assessments to be completed at least quarterly. R7's last documented bed rail assessment was 1/14/26 with no further evidence of quarterly reassessments completed. On 6/29/2026, at 11:38 AM, Surveyor attempted to interview R7. R7 was unable to answer questions and did not understand the questions asked. Surveyor observed bedside rails on R7's bed.On 6/29/2026, at 11:45, Surveyor interviewed Certified Nursing Assistant (CNA)- F regarding R7's use of bed rails. CNA-F stated R7 cannot use the bed rails due to having hand contractures and they have never seen R7 use them while providing cares for R7.On 6/29/2026, at 11:47 AM, Surveyor interviewed CNA-I regarding R7's use of bed rails. CNA - I stated they have never seen R7 use the bedside rails and R7 requires staff to help reposition.On 6/29/2026, at 1:00 PM, Surveyor interviewed Licensed Practical Nurse (LPN) -O regarding the bed rail evaluation process and R7's use of bed rails. LPN-O stated the physical therapy department or the Director of Nursing (DON)-B can assess and initiate the use of bed rails for residents. After the initial assessment is completed, the unit managers will complete assessments quarterly to reassess the need for the use of bed rails. LPN-O stated R7 used the bed rails for repositioning initially, R7 now is no longer able to use the bed rails to assist in repositioning. LPN-O was unsure of when R7's decline occurred between January 2026 and June 2026.On 6/29/2026, at 1:05 PM, Surveyor interviewed Unit Manager (UM)-Q regarding the bed rail evaluation process and R7's use of bed rails. UM-Q stated initial placement of the bed rails is completed by DON-B or the physical therapy department. After the initial assessment is completed, the Unit managers are responsible for completing a quarterly audit of residents with bed rails. The audit is shared with the interdisciplinary team, and care plan changes are made if bedrails are started or discontinued. UM-Q stated R7 previously used the bed rails to aid in positioning but no longer can use them. UM-Q is unsure when the decline in bed rail use occurred for R7. UM-Q does not know when the last bedrail assessment was completed for R7.On 2/29/2026, at 1:16 PM, Surveyor interviewed DON-B regarding the bed rail evaluation process and R7's use of bed rails. DON-B stated they complete the initial assessment for bed rails. An order is placed in the residents' EHR, and the care plan is updated. After the initial assessment, the unit managers will continue to assess residents with bed rails to ensure the bed rails are still indicated for resident use. This assessment is uploaded into the forms tab. DON-B stated at the time of the initial assessment, R7 was able to use the bedrails to assist in repositioning. DON-B stated they were unaware of R7's physical decline and inability to use the bed rails. DON-B stated they should have been updated when the decline occurred so R7 could be reassessed. DON-B stated they were unable to locate an updated bedrail assessment for R7, physician orders, or updated care plan for bedrail use.On 6/29/2026, at 2:30 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, DON-B, Director of Operations (DOO)- C, and Nurse Consultant (NC)-D regarding R7 does not have an updated bed rail assessment, no physician order for a bed rail, and no care plan documentation for the bedrail.

Based on interview and record review, the facility did not ensure nurse staffing information included the actual hours worked by registered nurses, licensed practical nurse, or certified nurse aides.Review of weekend staffing schedules and required staff postings from 1/1/26 through 1/31/26 revealed 6 of 9 days had discrepancies between the documents. This resulted in inaccuracies with the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift.This deficient practice has potential to affect all 51 residents at the facility.Findings include:The facility policy titled Nurse Staffing Posting Information with implemented date 1/1/26 documents:Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to resident, staff, and visitors at any given time.Policy Explanation and Compliance guidelines: . The nurse staffing sheet will be posted on a daily basis and will contain the following information . the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: . Registered Nurses . Licensed Practical Nurses . Certified Nurse Aides .Surveyor reviewed the weekend schedules and staff postings from 1/1/2026 through 1/31/2026. Surveyor compared the actual staffing schedules with the staff postings and noted the following inaccuracies:1/10/26:PM SHIFT: Staff posting: 16 licensed practical nurse (LPN) hours, 30 certified nurse aid (CNA) hours; Staff schedule: 11.5 LPN hours, 27 CNA hours.1/11/26:PM SHIFT: Staff Posting: 22.5 CNA hours; Staff schedule: 18 CNA hours.1/17/26:PM SHIFT: Staff Posting: 30 CNA hours; Staff Schedule: 35.5 CNA hours.NOC (night) SHIFT: Staff posting: 22.5 CNA hours; Staff schedule: 20.5 CNA hours.1/18/26:PM SHIFT: Staff Posting: 30 CNA hours; Staff schedule: 27.5 CNA hours.1/24/26:PM SHIFT: Staff Posting: 24 LPN hours; Staff Schedule: 21.5 LPN hours.NOC SHIFT: Staff Posting: 7.5 med tech (MT) hours, 15 CNA hours; Staff schedule: 14.5 MT hours, 8 CNA hours.1/31/26:PM SHIFT: Staff Posting: 16 RN hours, 45 CNA hours; Staff Schedule: 13 RN hours, 37 CNA hours.Surveyor noted that the staffing total hours for all the dates indicated above were not accurate and that there were discrepancies in the staff schedules and staff postings for 6 of 9 weekend days reviewed between 1/1/26 through 1/31/26.Surveyor also reviewed staff schedules and staff postings between the dates of 5/22/26 through 6/22/26 and noted several discrepancies in the staffing total hours documented on the staff postings.In an interview on 6/29/26 at 11:13 AM, human resources director (HRD)-S confirmed they are responsible for completing the daily staffing posting. HRD-S stated they calculate the hours worked by counting the number of each RN, LPN, MT, and CNA on the schedule and multiplying the number by the hours worked on a typical shift for each role. HRD-S stated they do not calculate the actual hours worked on the staff posting if a staff member leaves early or comes in late and does not work the entire shift. Surveyor reviewed the January dates with discrepancies with HRD-S, and HRD-S stated yes, they should have put the actual hours worked on the daily postings for those days, but they likely did not have time to go through and update the staff postings to reflect the actual hours worked. Surveyor asked HRD-S if HRD-S continues to calculate the total staffing hours by using the number of hours worked on a typical shift for each role, and HRD-S stated yes, they are not going through and calculating actual hours worked to reflect when staff come in late or leave early as of this date.On 6/29/26 at 2:30 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, director of operations-C, and regional nurse consultant-D that the daily nurse staffing information did not reflect the actual hours worked by nursing staff.

Based on observations, record review, and interviews, the facility failed to support the residents' right to voice a grievance or complaint without discrimination or reprisal. The failure created the potential for residents not to file a grievance or complaint as there were no means to do so anonymously or without staff knowledge. This had the potential to affect a pattern of 54 residents who resided at the facility (R8, R9, R10, R11).Findings include:During a Resident Group Interview on 10/01/25 at 2:00 PM with four alert and oriented residents (Resident (R) 8, R9, R10, and R11), it was stated that the Resident Council had requested a Grievance Box be installed with Grievance forms attached so that the residents were able to file a grievance anonymously if desired. Review of the monthly Resident Council minutes revealed the following:06/14/25 - . Council Members, Residents, would like to know the grievance policy and would like grievance forms available at all times without having to ask the staff . Administrator informed Council Members and Residents forms will be placed at the nursing station .08/07/25 - . Council Members and Residents requested the installation of a complaint box to allow residents to submit written concerns . Administrator informed council and residents that this was ordered and will arrive 9/5 .During an interview on 10/01/25 at 4:20 PM, the Administrator stated, We don't have a grievance box. We have a suggestion box. That's what the residents wanted, a suggestion box. That's what we put up. The Administrator stated, Grievance forms are at the nurses' station.Observation of the Suggestion Box, on 10/01/25 at 4:35 PM revealed an unlocked box on a wall across from the nurses' station. Attached to the side of the box was a holder for Suggestions. The Suggestion card noted, My Suggestion Is, and My Suggestion Would Benefit. Observation of a locked glass cabinet, located across from the nurses' station, on 10/01/25 at 4:39 PM, revealed the Grievance Policy and Procedure was located behind the locked glass, not easily accessible to the residents.Observation of the Nurses' Station, on 10/01/25 at 4:45 PM revealed no Grievance Forms readily available to residents.During an interview on 10/02/25 at 10:03 AM, Register Nurse (RN1) said she had never seen any grievance forms at the nurses' station.During an interview on 10/02/25 at 10:12 AM, the Social Service Director (SSD) stated, They used to be around here. Used to be in a binder when asked to locate the grievance forms which were identified to be at the nurses' station.During an interview on 10/02/25 at 12:30 PM, R8, the Resident Council President, confirmed that the request for a Grievance Box with Grievance forms be available for residents to file a grievance anonymously. We shouldn't have to ask for a Grievance form from the nurse. We've been asking for several months for the box.Review of the facility's undated Resident and Family Grievance policy revealed, . Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. The facility will not prohibit or in any way discourage a resident from communicating with external entities including federal and state surveyors or other federal or state health department employees. Upon request, the facility will give a copy of this grievance policy to the resident .

Based on observations, record review, and interviews, the facility failed to ensure one of 12 sampled residents (Resident (R) 8) was free from misappropriation of property. The failure to prevent misappropriation of property created the potential for additional misappropriation to have occurred for other residents.Findings include:Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R8 was admitted on [DATE] with diagnoses that included flaccid hemiplegia affecting left nondominant side.Review of R8's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/20/25, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R8 was cognitively intact.During a resident group interview on 10/01/25 at 2:00 PM with four alert and oriented residents (R8, R9, R10, and R11), R8 said she had an antenna stolen from outside her room where it had been magnetically mounted. R10 stated, I witnessed the staff member (Wound Care Nurse/PM Supervisor, WCN/S) cut the wires and take the antenna. R8 said she reported the missing antennae to the Administrator who told her that he would replace it. R8 said she did not have the antennae, nor was it replaced by the Administrator. When asked when the incident occurred, R8 stated, A few months ago.During an interview on 10/02/25 at 12:30 PM, R8 stated, The antenna was taken when I was napping. I was in a room directly across from [R10]. The antenna was magnetically attached to the top of the doorframe on the outside of the door. The staff member cut the wire and took the antennae. I used it for my gaming.During an interview on 10/02/25 at 12:46 PM, the Administrator said the allegation of misappropriation of property was reported on 06/04/25. He stated that he did not have all of the investigation in the file. The Administrator confirmed that the misappropriation of property was not reported to the State of Wisconsin. The Administrator said the resident did not have a replacement antenna as he was unaware that Corporate cancelled the order he had placed until it was brought to his attention during the Complaint Survey. The Administrator stated, We don't know where it (antenna) went.During an interview on 10/02/25 at 2:10 PM, the accused staff member (WCN/S) stated, I wasn't even in the facility when the antenna was said to be taken. I don't know why I'm being accused. Review of the facility's undated Abuse, Neglect, Exploitation Policy and Procedure, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.

Based on interviews and record review, the facility failed to report an allegation of misappropriation of property for one of 12 sampled residents (Resident (R) 8). The failure to report allegations of misappropriation created the potential for additional misappropriation to have occurred for other residents.Findings include:Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R8 was admitted on [DATE] with diagnoses that included flaccid hemiplegia affecting left nondominant side.Review of R8's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/20/25, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R8 was cognitively intact.During a resident group interview on 10/01/25 at 2:00 PM with four alert and oriented residents (R8, R9, R10, and R11), R8 said she had an antenna stolen from outside her room where it had been magnetically mounted. R10 stated, I witnessed the staff member (Wound Care Nurse/PM Supervisor, WCN/S) cut the wires and take the antenna. R8 said she reported the missing antennae to the Administrator who told her that he would replace it. R8 said she did not have the antennae, nor was it replaced by the Administrator. When asked when the incident occurred, R8 stated, A few months ago.During an interview on 10/02/25 at 12:30 PM, R8 stated, The antenna was taken when I was napping. I was in a room directly across from [R10]. The antenna was magnetically attached to the top of the doorframe on the outside of the door. The staff member cut the wire and took the antennae. I used it for my gaming.During an interview on 10/02/25 at 12:46 PM, the Administrator said the allegation was reported to him on 06/04/25. He stated that he did not have all of the investigation in the file. The Administrator confirmed that the misappropriation of property was not reported to the State of Wisconsin. The Administrator said the resident did not have a replacement antenna as he was unaware that Corporate cancelled the order he had placed until it was brought to his attention during the Complaint Survey. The Administrator stated, We don't know where it (antenna) went.During an interview on 10/02/25 at 2:10 PM, the accused staff member (WCN/S) stated, I wasn't even in the facility when the antenna was said to be taken. I don't know why I'm being accused. Review of the facility's undated Abuse, Neglect, Exploitation Policy and Procedure, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.

Based on record review, interviews, and review of facility policy, the facility failed to ensure 13 residents [(R)4, R16, R17, R18, R19, R20. R21, R22, R23, R24, R25, R26, and R27] out of a census of 43 Resident reviewed for misappropriation was free from abuse in the sample of fifteen residents. This failure had the potential for psychosocial impairment from the loss of resident funds by a staff member. Findings include: Review of the facility's reported incident revealed that the former Business Office Manager (FBOM) was alleged to have been taking monies out of the resident trust for personal gain; at which time the BOM was immediately removed from the facility and all access to resident trust was suspended. The report also revealed that the facility reported the incident timely and conducted a thorough investigation identifying thirteen residents that had discrepancies with their trust account. The review also revealed that residents that maintained funds in the resident trust account had not had any issues with receiving money when requested. During an interview on 05/28/25 at 1:41 PM the Regional Director of Operations (RDO) stated in December 2024 an email was sent to corporate office for unauthorized use of facility credit card; the former business office manager (FBOM) was suspected of unauthorized use of the facility credit card. We immediately suspended the FBOM and started an investigation. We also suspended all access to any facility programs (banking, PCC, and intranet). At which time the Regional Business Office Consultant (RBOC) started an audit on the resident trust fund, the facility credit card and petty cash account. The facility notified the police and report completed. The FBOM quit working for the facility once the investigation started. The RDO also stated that a report filed with the Office of Inspector General (OIG) due to missing funds from resident trust accounts. The facility also notified the Social Security Administration (SSI) and notified residents that were identified of resident trust issues. There were residents interviewed about receiving money from their trust and none voiced concerns about receiving money when requested. During an interview on 05/28/25 at 2:30 PM the Registered Nurse Consultant (RNC) stated the FBOM employee record did not indicate any reason for concerns or indications that she would have done that. The RNC also stated that the facility contacted Social Security and they said that they would handle the missing funds from their end. The RNC also stated that the facility stays in contact with the District Attorney's Office for updates on the case. The day of 01/06/25 the FBOM submitted her resignation as soon as she was suspended and notified of the investigation. During an interview on 05/28/25 at 3:25 PM the Regional Business Office Consultant (RBOC) stated the she completed the audit on the resident trust and anything that did not look right she flagged. The RBOC also stated that facility surety bond amount was $50000 at the time and the resident trust was covered by the facility surety bond ensure that no residents went without being able to access their funds. The RBOC also stated that the facility has not denied any resident request for funds from the resident trust. Charges have been filed against the alleged perpetrator by way of the District Attorney's Office. The RBOC also stated that there were not any issues identified with the employee file that would have indicated the allegations. The RBOC also stated that the FBOM was good at hiding the movement of monies and making transactions look legitimate. The RBOC also stated that there has been an updated policy for the resident trust account and now no one person alone can access the resident trust account. During an interview on 05/29/25 at 2:00PM the Administrator stated that the FBOM had a clean background check and was very skilled at making transactions seem legitimate with the banking so that there was no suspicion or questions about the resident trust account arose. The Administrator also stated that there were no complainants voiced by any residents regarding their ability to request and receive funds from their account. There was a policy in place prior to the incident and the corporate went over transactions each month with the now terminated FBOM. Interviews conducted with residents throughout the survey process did not indicated any negative outcome form the FBOM allegedly taking monies from the resident trust. All residents interviewed voiced no concerns or issues with receiving money from their account when requested. Review of the facility's policy titled, Abuse, reviewed 06/15/2024, indicated, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. ln 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. This will be done by: conducting preemployment screening of employees and pre-admission screening of residents; orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property . 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 . Review of the facility's policy titled, Resident Trust Fund indicated that All Social Security and Supplemental income for which the facility is payee are deposited directly into the P/F account. A check (net of t/f amt) is written from the Trust Fund Account to the Operating Account for the room & board charges by the controller. Interest is posted monthly based on the ending savings amount by RFMS. All T/p disbursements are the responsibility of the Business Office Manager. l. Petty cash disbursements will be signed by the resident. If a resident is unable to sign, the disbursement will be witnessed by another person (not the BOM). 2. If resident is unable to go to banking, the BOM will go to the resident room with another employee to disburse funds. 3. Any personal needs item that is purchased (per resident and or guardian's request) can be reimbursed with proper receipts via checks. 4. Any resident with funds close to $1,800.00 will be notified not to exceed the Medicaid threshold of $2000.00 Any other procedures are to be followed by guidelines of Social Security Administration. A review of the current facility policy that was implemented 01/2025 titled Facility Resident Trust Disbursement of Funds Procedure indicated, It is the practice of this facility to ensure a proper documentation and accountability of the use of Resident Trust Funds. This procedure is to assist residents with management of their funds and to pay for expenses while in a nursing facility. To establish internal controls to protect against misappropriation of such funds and maintain an accurate accounting of the funds . Facility must act as a trustee of the resident's funds and hold, safeguard, manage, and account for all transactions completed . Funds cannot be disbursed to anyone without permission, in writing, from the resident or resident's assigned representative . The Business Office Manager, or his,/her designee will enter the withdrawal transactions in RFMS for each resident with the properly provided documentation as mentioned in Section 2. Employee entering the withdrawals as per Section 3.a. is Not to approve the payment and / or print the check for reimbursement. Payment approval and check issuance will be done by the facility Administrator or his, /her designee once all proper documentation for the fund's disbursement is provided. All such documentation is to be properly filed and stored on a monthly basis as designated by the Business Office Manager and the Administrator in a properly secured location for the amount of time as deemed applicable by law.

Based on observations, interviews, and record review, the facility did not ensure that 13 of 13 residents reviewed for smoking and/or vaping (R2, R3, R299, R36, R299, R14, R37, R34, R31, R32, R22, R31, R150, R38, R149, R43, and R36) and one resident reviewed for transfers (R199) were provided with an environment that was free of accident hazards and/or provided with appropriate supervision. R2 was allowed to vape (use an electronic cigarette) while using oxygen in her room instead of being restricted to designated smoking areas away from oxygen. In addition, the facility allowed charging of the e-cigarette in the resident's room. R3 is severely cognitively impaired. R3 was allowed to smoke without supervision and was allowed to smoke outside of the designated area. There was no safety equipment in the area where R3 was observed smoking. R299 smokes unsupervised. When R299 goes outside, R299 is unable to re-enter the building independently; he must wait for staff to come and let him back inside. Facility failure to ensure residents were provided with appropriate supervision and safety devices while smoking or vaping created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator), DON B (Director of Nursing), Regional Director of Operations, and Regional Clinical Consultant were notified of the finding on [DATE] at 12:49 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of G (actual harm/isolated) for R199 who was transferred in a Hoyer lift without a second person assisting in the transfer, resulting in a right and left proximal femoral fracture and at severity level 2 (potential for more than minimal harm) for the following examples related to smoking/vaping. R36, R299, R38, R34, and R18 smoke unsupervised and did not smoke in a designated smoking area. The area where the residents smoked did not have safety equipment (aprons, fire extinguisher, and/or fire blanket). Theses failures had the potential to cause serious adverse outcomes including serious injury, serious harm, serious impairment, up to and including death. R299 and R150 did not have an initial smoking assessment completed. R2, R3, R43, R31, R36, R38, R22, R14, R32, and R34 did not have quarterly smoking assessments completed. R150, R38, R2, and R22 did not have care plans developed related to smoking/vaping. R199 was to be transferred using a full body (Hoyer) lift and 2 staff assistance. On [DATE], CNA K (Certified Nursing Assistant) transferred R199 without a second staff person assisting. R199 fell and sustained a right and left proximal femoral fracture. Findings include: SMOKING/VAPING Review of the facility's policy titled, Vaping Safety Policy and Procedure, and dated [DATE], indicated, .To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Procedures: 1. Vaping is allowed in facility. 2. A smoking/vaping safety assessment will be completed to determine the level of assistance and supervision needed during vaping, the ability to carry and store vaping materials, in her/his own room. The plan of care shall reflect the results of this assessment. The assessment will be completed upon admission, quarterly and with significant change . Review of the facility's policy titled, Smoking Guidelines, dated ,d+[DATE], indicated, .1. Prior to, or upon admission, residents who smoke shall be informed about any limitations on smoking, including designated smoking areas and the extent to which the facility can accommodate their smoking preferences. 2. Smoking restrictions shall be strictly enforced in all nonsmoking areas . According to Public Safety Network (Agency for Healthcare Quality and Research), .the use of any ignition source in the presence of oxygen is potentially hazardous. This issue was addressed specifically by the British Compressed Gases Association, which stated, Electronic cigarettes are . a potential ignition source and, in the context of oxygen-rich environments, have the same fire risks as traditional cigarettes.(11) This opinion was supported by the Electronic Cigarettes Industry Trade Association, which agreed that in the context of oxygen use, it would be appropriate to describe electronic cigarette use as similarly hazardous to smoking.(11) Furthermore they suggest that if a patient needs oxygen, a nonheated source of nicotine such as NRT be considered . https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room 1. R2 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure. R2's Smoking Evaluation, dated [DATE] and provided by the facility, indicated, R2 is alert, exhibits safe smoking/vaping awareness .e-cigarette/vape .preferred type: disposable .Oxygen Usage: Is the resident able to remove all oxygen equipment before entering designated smoking areas? Not applicable. Review of R2's clinical record and facility provided documents revealed no further smoking evaluations for the resident. Review of R2's Physician Order, dated [DATE] and located under the Orders tab of the EMR, indicated, .Oxygen (two-four) liters/minute as needed PRN (as needed) for hypoxia . R2's quarterly 'Minimum Data Set (MDS) dated [DATE], indicated R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R2 was cognitively intact. R2's Care Plan, revised [DATE] indicated, .The resident is a smoker/vapes .Interventions: Assist with transportation to/from smoking area, Instruct resident about smoking/vaping risks and hazards and about smoking cessation aids that are available; Monitor oral hygiene; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy; and The resident can vape unsupervised. There was no documented evidence that the resident's care plan had been revised to include oxygen usage and vaping in her room. During observations on [DATE] at 11:00 AM, 5:00 PM, and 5:45 PM, a No smoking, oxygen in use sign was noted on the resident's door in the right upper corner. R2 was noted to have oxygen being administered via nasal cannula. During an interview on [DATE] at 5:45 PM, R2 stated that she vaped in her bedroom several times a day while wearing oxygen. R2 stated that she kept her e-cigarette in her room. During the interview, the surveyor observed R2 bring her white e-cigarette from under the covers in her left hand while she had oxygen going via nasal cannula. R2 stated that she had never had any burn incidents, and she had been vaping for the past two years. During an interview on [DATE] at 7:39 PM, R2 stated that the e-cigarette was rechargeable, and she charged it with her phone cord. E-cigarettes contain a heating element. Any heat source can cause oxygen to ignite, placing the resident at risk for burns. During an interview on [DATE] at 8:24 PM, DON B (Director of Nursing) stated it was the resident's right to vape in her room because it was important to maintain a homelike environment. During the interview, the surveyor and DON B observed R2 lying in bed, wearing her oxygen nasal cannula. R2 confirmed that she was receiving oxygen. DON B asked R2 if she wore her oxygen while she vaped, and R2 stated, Yes. During an interview on [DATE] at 8:35 PM, DON B stated she educated R2 about vaping with oxygen. DON B stated that she told R2 that she would need to have blood oxygen level taken after her oxygen was removed, and if they determined it was within normal limits, she could proceed with vaping. During an interview on [DATE] at 10:30 AM, DON B stated that R2 did not have oxygen anymore, and her blood oxygen levels were monitored every two hours to make sure they maintained normal levels. DON B stated R2 was allowed to continue to vape in her room and keep her own e-cigarette. DON B stated that if R2 needed her oxygen, then R2 would give her e-cigarette to staff. R2's Care Plan, located under the Care Plan tab of the EMR, revealed no documented evidence R2's care plan was revised to include vaping and oxygen usage. The DON confirmed the care plan had not been revised. During the interview on [DATE] at 11:55 AM, the DON stated that the smoking evaluation should be completed quarterly. She confirmed that there were no aprons, fire blankets, and/or fire extinguishers in the smoking area. The DON stated the electronic medical record was set up so that if you answered a question on the smoking evaluation, then the option for a smoking apron will come up, but the system would not allow a person to further elaborate. The DON stated that there was a fire extinguisher in the front of the building/reception area. During an observation on [DATE] at 12:00 PM, R2 was observed in her room with her vape; however, there was no oxygen in her room. 2. R3 was readmitted to the facility on [DATE] with diagnoses that included dementia. R3's Smoking Quarterly Review, dated [DATE] and provided by the facility, indicated, .No change to comprehensive smoking evaluation. Quarterly Planning and Interventions .instruct resident about the facility policy on smoking: locations, times, safety concerns .The resident can smoke unsupervised . Review of R2's clinical record and facility provided documents revealed no further smoking evaluations for the resident. Review of R3's quarterly MDS, dated [DATE] indicated R3 had a BIMS score of four out of 15, which indicated R3 was severely cognitively impaired. During an observation on [DATE] at 10:15 AM, R3 was observed sitting on the bench on the front porch. There was a sign posted in front of him that read, This is Not a Designated Smoking Area. R3's four-wheeled walker was positioned in front of him, and there were no staff members present. R3 was smoking a cigarette that had only one-half inch left to the filter line. Another cigarette, with approximately three quarters inch left, was under his left thigh. R3 removed the cigarette under his left thigh. Surveyor observed that the cigarette had been lit at some point. No burn marks were observed on R3's pants. The unlit cigarette fell to the ground in front of R3 while he still had the lit cigarette in his hand. R3 bent down to get the unlit cigarette, and the lit cigarette was observed to be close to R3's face. R3 placed the unlit cigarette in the storage seat of his walker and continued to smoke the lit cigarette which was close to the filter area. R3 was not wearing a smoking apron. There was no fire blanket, no fire extinguisher, or fireproof ash bucket noted. A regular trash can was observed. During an observation on [DATE] at 10:44 AM, R3 had returned inside the facility. A cigarette lighter was noted under the bench where R3 had been seated. The surveyor requested NHA A to come outside, and when he arrived, he picked up the lighter and stated that he wondered where it came from. Surveyor stated that there was a resident outside smoking a few minutes ago. NHA A stated he was unaware of any resident outside smoking on the front porch. During an interview on [DATE] at 11:28 AM, DON B stated that she would like R3 to smoke in the smoking area but was aware that R3 liked to smoke outside the front of the facility. DON B stated that they tried to redirect him. During the interview with the NHA A and DON B on [DATE] at 11:55 AM, NHA A stated that Life Safety surveyors had never said anything about the facility's smoking area. NHA A stated that the facility had just replaced the canister out in the smoking area with a fire rated canister. NHA A confirmed that there was no fireproof canister in front of the facility for the resident (R3) who smokes there. NHA A stated R3 often smoked by the road and confirmed that he liked to keep his cigarette butts. DON B and NHA A both stated that the bench on the front porch was fire rated and that there was a smoking blanket on the wall somewhere by the front reception area. During the interview on [DATE] at 3:55 PM, DON B stated that R3 had been re-evaluated by the social worker and was now deemed to be a supervised smoker. DON B stated that the facility would be keeping his smoking material. DON B indicated that R3's BIMS was completed again and was found to be a 6 out of 15 (still severely impaired). 51678 3. R299 was admitted to the facility on [DATE] with diagnoses that included spina bifida and paraplegia. R299's Care Plan, dated [DATE] revealed a focus area related to the resident smoking. A goal was that the resident would not suffer injury from unsafe smoking/vaping practices. Interventions included helping to and from the designated smoking area. R299's medical record did not contain any smoking assessments since their admission or readmission to the facility. R299's MDS, dated [DATE] revealed R299 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. During an observation on [DATE] at 5:10 PM, 2 Surveyors, who were in the conference room on the south side of the building, approximately 100 feet from the south door, heard someone banging and yelling at the south door of the building. This door led to the designated resident smoking area, and the door was locked. R299 was the resident banging on the door and yelling. Surveyors noted that the door swung outward towards the smoking area. R299 was seated in his wheelchair with his legs extended out on the pedals. In order for R299 to re-enter the building independently, he would have to put the code in to unlock the door, and then try to re-position his wheelchair so that he could open the door before the code expired. At 5:25 PM, R299 was noted to still outside of the south door and was banging and yelling to come in. Surveyors summoned the Activity Coordinator to come and help him in the building. She went and opened the door at 5:35 pm. R299 had to be instructed to move out of the way as the Activity Coordinator was unable to open the door. The Activity Coordinator brought R299 inside the building at 5:36 pm. He had a blanket around his shoulders. R299 had been attempting to re-enter the building for 26 minutes. Per weather.com, it was 50 degrees outside at 5:36 PM. During an interview on [DATE] at 5:38 PM, R299 was asked if someone had helped him get outside to the smoking area. R299 did not respond to the question. During an interview on [DATE] at 6:00 PM, CNA M (Certified Nursing Assistant) stated he had helped R299 out at 5:24 PM, and someone had brought R299 in at 5:38 pm. CNA M was informed of the surveyors' observations. CNA M maintained his statement that he took R299 out at 5:24 PM. During an observation on [DATE] at 11:00 AM, R299 was outside of the door that led to the smoking area. He was unable to get back in and was observed knocking on the door. A staff member assisted him in getting back into the building. He again had to move away from the door for the staff to help him in the building. He had a blanket draped around his shoulders. R299 was speaking in a loud voice and swearing at the staff. The temperature was 55 degrees Fahrenheit (F), and the wind speed was 11 MPH with gusts to 20 MPH from the WSW per weather.com. The wind chill temperature was noted to be 46 degrees. During an interview on [DATE] at 1:25 PM, DON B confirmed R299 should have been monitored and asked how long he wanted to stay outside. She confirmed he was unable to go out and come back into the building without assistance. Failure to ensure residents were provided needed supervision while smoking or vaping created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The jeopardy was removed on [DATE] when the facility completed the following. 1. The facility updated their policy and procedure to address safety in using e-cigarettes including their use only in designated smoking areas. 2. Assessments were reviewed and updated for all residents known to smoke/vape. 3. Based on the findings of the assessments, care plans were reviewed and updated for all residents known to smoke/vape. Appropriate interventions were put into place to ensure resident safety. 4. All staff were trained on the updated policy and procedure and location of the smoking area prior to beginning their next scheduled shift. The deficient practice continues at a scope/severity of G (actual harm/isolated) for R199 related to transfer and at severity level 2 (potential for more than minimal harm) for the following examples also related to smoking/vaping. 4. During an observation on [DATE] at 9:45 AM, when the survey team arrived at the facility, a plastic outdoor cigarette disposal container was found in the parking lot, approximately 15 feet from the south door of the building. No fire extinguishers, smoking aprons, or fire-proof containers were available. There was no staff supervision. There were signs on the building by the door that read, No Smoking within fifteen feet of the building. Further observations on [DATE] at 1:10 PM, 3:17 PM, 5:10 PM, and 9:15 PM, revealed residents exiting the south door without supervision. The residents would stand by the door and smoke, and others would go out to the cigarette disposal container in the parking lot. R3, R36, R299, R38, R34, and R18 were observed smoking in this area. 5. R14 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus with diabetic neuropathy, cerebral infarction due to unspecified occlusion or stenosis of basilar artery, and peripheral vascular disease (PVD). Review of R14's facility provided Smoking Evaluation (Comprehensive), dated [DATE], indicated, .R14 alert, oriented .exhibits safe smoking/vaping awareness .e-cigarette/vape .disposable .use a wheelchair .able to move about or remove lit material if it falls on them: yes, does the resident exhibit adequate fine motor skills to safely hold a lighted cigarette? Yes .Is resident free of smoking/e-cigarette/vaping related incidents? Yes .Planning and Interventions .Intervention: The resident can smoke unsupervised . Further review revealed no evidence of another quarterly smoking assessment completed after this assessment in [DATE]. Review of R14's clinical record and facility provided documents revealed no further smoking evaluations for the resident. During an observation and interview on [DATE] at 7:39 PM, R14 stated that they vaped outside; however, a rechargeable e-cigarette was observed on her bed. During an interview on [DATE] at 4:55 PM, DON B confirmed that R14's quarterly smoking assessment was late and should have been completed in [DATE]. During an interview on [DATE] at 8:50 AM, NHA A stated that vaping had not been a concern at the facility, but since the summer of 2024, there had been an increase in vaping at the facility. NHA A stated that this had always been a smoking building, and vaping was a new concern due to the younger population that the facility was admitting. 6. R37 was admitted on [DATE] with diagnoses that included chronic lymphocytic leukemia, chronic pain syndrome, adult failure to thrive, muscle spasm, and bipolar disorder. R37 had a Smoking Evaluation completed on [DATE] and [DATE]. The evaluations showed he was alert and oriented, had clear speech, and he used a disposable vaping device. The resident had been free of smoking/e-cigarette/vaping related incidents. Smoking Evaluations had not been completed for the first and second quarters of 2024. A smoking evaluation had not been completed until [DATE], after the beginning of the survey. R37's quarterly MDS, dated [DATE] revealed R37 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. During an observation and interview on [DATE] at 3:39 PM, R37 was observed in his room. R37 stated he uses a vaping device and kept it in his room with him. He stated he was instructed by NHA A that he should vape in his room rather than outside, as it would be easier for him due to his muscle spasms. He stated he usually only got out of bed in the afternoon. His vaping device was not in sight during the observation. During an interview on [DATE] at 8:30 PM, R37 stated his vaping device was rechargeable and could be disposed of when the nicotine liquid was gone. He stated staff did not supervise him when he used the vaping device, and he had no incidents from using the vaping device in his room. 7. R34 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, anxiety, and post-traumatic stress disorder (PTSD). Smoking Evaluations had been completed for R34 on [DATE], [DATE], and [DATE]. There was no documented evidence of a smoking evaluation for the fourth quarter of 2023 or the second quarter of 2024. It was revealed it had been greater than three months since the last smoking evaluation was completed for R34. R34's Care Plan, revised [DATE] and located under the Care Plan tab of the EMR revealed a focus of R34 being a smoker. It was recorded that the resident was independent with smoking and could smoke independently. During observations on [DATE], [DATE], [DATE], and [DATE], R34 was observed to go outside independently to smoke. He was observed to smoke independently, without supervision. 8. R32 was admitted to the facility on [DATE] with diagnoses that included anxiety and depression. Review of R32's Smoking Assessments, revealed only one smoking assessment, dated [DATE], had been completed for the resident. Review of R32's Care Plan, revealed a smoking focus had not been added to the resident's care plan until [DATE], even though they were admitted on [DATE]. The care plan interventions included instructing the resident about smoking/vaping risks and hazards and about smoking cessation aids that were available, the facility's policy on smoking/vaping, and to notify the charge nurse immediately if it was suspected the resident had violated the facility smoking policy. It was recorded that the resident could smoke unsupervised. R32 was observed smoking on [DATE] at 4:00 PM in the smoking area. 26446 9. R22 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, multiple sclerosis, and cerebral infarction. R22's Smoking Assessment, was last completed [DATE]. The most recent assessment was not completed timely. Review of R22's annual MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. R22's Care Plan, last revised [DATE], documented that the resident is a smoker/vaper. The interventions identified the resident as a safe vaper and instructed the resident about the facility policy on smoking/vaping, the locations, times, and safety concerns. During an interview on [DATE] at 7:12 PM, R22 stated that she vaped in her room when she had the money to have staff purchase a vape device for her. She stated she has not had one for a while, since she has not had the money to purchase one. 10. R31 was admitted on [DATE] with diagnoses including diabetes mellitus two, venous insufficiency, and epilepsy. Review of R31's Smoking Quarterly Review, revealed the last assessment was completed [DATE]. R31 was assessed as a safe smoker. The most recent quarterly smoking assessment was not completed timely. Review of R31's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. Review of R31's Care Plan, documented that the resident is a smoker. The interventions indicated the resident could smoke unsupervised. A new intervention, initiated [DATE] during the survey, stated to conduct a smoking safety assessment as necessary and to provide appropriate smoking management in accordance with the assessment. 11. R150 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus two, peripheral vascular disease, and hypertension. She was assessed as alert upon admission. R150's Smoking Evaluation, was completed [DATE]. R150 was assessed as a smoker, but not identified as safe or unsafe. Review of R150's Care Plan, was initiated on [DATE] as demonstrates compliance with safe smoking regulations. A baseline care plan was not developed timely. 12. R38 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypokalemia, and adult failure to thrive. R38's Care Plan, initiated [DATE], documented that the resident is a smoker. The interventions indicated the resident could smoke unsupervised, to instruct the resident about the facility policy on smoking/vaping locations, times, and safety concerns. The care plan did not identify the resident was a safe smoker until [DATE]. R38's Smoking Quarterly Review the last assessment was completed [DATE]. R38 was assessed as a safe smoker. The most recent quarterly smoking assessment was not completed timely. A delayed smoking assessment was completed [DATE] during the survey. Review of R38's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. 13. R149 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, hypertension, and epilepsy. R149's Care Plan, initiated [DATE], documented that the resident is a smoker. The interventions documented to conduct a smoking safety assessment as necessary and to provide appropriate smoking management in accordance with the assessment. It did not document if the resident was a safe or unsafe smoker. R149's Smoking Assessment, revealed the first assessment was completed [DATE]. R149's admission MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. 35690 14. R43 was admitted to the facility on [DATE] with diagnoses that included syncope and nicotine dependence. R43's quarterly MDS, dated [DATE] revealed R43 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident was independent for all activities of daily living. Review of R43's Care Plan, dated [DATE] revealed, The resident is a smoker. The Care Plan revealed a goal of Resident will not suffer injury from smoking/vaping practices through the review date. Interventions included instructing the resident about smoking and the facility policy. Interventions included, .The resident is able to manage his own smoking materials and smoke unsupervised . Review of R43's Smoking Evaluation, located in the EMR under the Focus tab and dated [DATE], 12 days after admission, revealed R43 did not require supervision for smoking. There was no evidence an evaluation had been completed since that time. On [DATE], during the survey, a Smoking Evaluation was completed for R43 which indicated R43 did not require supervision for smoking. 15. R36 was admitted to the facility on [DATE] with diagnoses that included alcoholic cirrhosis of liver with ascites. Review of R36's Smoking Evaluation, dated [DATE], revealed R36 did not require supervision for smoking. This was the only Smoking Evaluation located in R36's EMR. R36's annual MDS, dated [DATE] revealed R36 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident was independent for all activities of daily living. Review of R36's Care Plan located in the EMR under the Care Plan tab, revealed no care plan related to smoking had been developed for the resident until [DATE], after the beginning of the survey. TRANSFERS R199 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction and vascular dementia. R199's quarterly MDS, dated [DATE] indicated R199 had a BIMS of 13 out of 15, which indicated the resident was cognitively intact. The MDS recorded the resident was dependent on staff for all activities of daily living (ADLs). R199's Care Plan, dated [DATE], indicated, .Transfer: The resident requires Hoyer (mechanical) lift with assist of 2 staff . Review of an investigative file for R199 revealed: A hospital Progress Note, dated [DATE], recorded, .Closed fracture of left distal femur Date Noted: [DATE] Assessment: Patient was accidentally dropped from Hoyer (Mechanical) lift when she suffered subsequent left distal femur fracture .Oblique fracture of proximal right femoral shaft . A document detailing a phone interview with CNA K, dated [DATE], stated, I had a normal regular day [sic] [DATE] nothing happened out of the ordinary. I washed R199 up at 10:30 AM and then proceeded to transfer her with a full body sling. I transferred her by myself. The resident never fell . I took her to the day room. She ate lunch that I fed her about 1:30 PM. She asked me to lay her down. I took her to her room and laid her down by myself. An undated interview with LPN L recorded, [R199] was stating she was dropped by a black CNA. At that time R199 did not state from [Mechanical Lift]. I assessed ROM (range of motion) but could not complete, c/o (complaints of) pain with movement. Could not visualize any swelling or bruising. MD (Medical Doctor) updated STAT [immediate] Xray ordered. Res (resident) refused Tylenol when asked. Administrator updated immediately. Xray was completed STAT which was within four hours and as soon as results popped up Res sent to ER (emergency room ) and MD, POA (power of attorney) updated, POA did not answer. POA called again with no answer. POA called back and info provided. An investigation summary recorded, R199 sustained fractures of bilateral lower extremities that were discovered on [DATE] when she complained of acute left lower extremity pain. R199 is a . female with h/o (history of) CVA (cerebrovascular accident) with right sided hemiplegia, vascular dementia, epilepsy and osteoarthritis. She has a BIMs of 7 with a legal guardian .She has lived at (facility name) since [DATE]. She has been non-weight bearing since prior to her admission. She has not sustained any previous falls while a resident in this facility. R199 reports that she was dropped onto the floor during a full mechanical transfer. There was no reported fall or incident on [DATE] or any day previous to this. Her roommate has provided varying statements that include R199 herself attempting to stand then collapsing and R199 being dropped from the lift during a transfer. Staff interviews have resulted in no conclusive evidence of what event actually occurred. Based on the nature and severity of R199's injuries it is reasonable to assume that something happened during the day shift of [DATE] as the soft tissue swelling and abrupt pain onset are indicative of an acute injury. The nursing assistant who worked with R199 on [DATE] during the day shift was deceptive and dishonest during interviews. She did admit to completing a full mechanical lift without a second person present, violating our resident handling policy .Given R199's history of osteoporosis with previous fractures and hardware infection in left hip and long-standing history of non-weight bearing she was at high risk for fractures involving minimal trauma .The facility took action to identify any other residents who had the potential to be affected by this practice. There is no evidence that any other residents have had injuries as result of this deficient practice. Policies and procedures were reviewed. Education was in [TRUNCATED]

Based on observations, interviews, and facility policy review, the facility failed to ensure food was properly labeled and dated as to when they expired, and all expired foods were disposed of in accordance with professional standards for food service safety as required for 51 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: Review of a facility's policy titled, Food Storage, dated [DATE], revealed Food will be purchased in quantities that can be stored properly, and arranged in food groups for organized storage and inventory .Old stock is always used first .Food should be dated as it is placed on the shelves .Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat .All containers must be legible and accurately labeled and dated. During an initial kitchen observation with DA O (Dietary Aide) and DM P (Dietary Manager) on [DATE] from 10:29 AM to 10:50 AM, it was revealed: -The walk-in refrigerator had six one-quart cartons of heavy whipping cream. The best by dates were [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. DA O stated that the dietary staff tried to keep track of the use by dates in the refrigerator, confirmed the expired dates on the cartons, and stated they would be discarded. -The food preparation area had three large plastic containers. One container for breadcrumbs had posted dates of [DATE], with a use by date of [DATE]. The second container for oatmeal, had posted dates of [DATE], with a use by date of [DATE]. The third container for rice had posted dates of [DATE], with a use by date of [DATE]. DM P stated that he believed the posted dates were wrong but could not be sure when they were put in the three food containers. -Underneath the food preparation table contained a 25 lb. (pound) container of Ready Care Instant Food Thickener. It was opened and uncovered, with ,d+[DATE] dated on it. The DM stated that the facility had not used the thickening powder for a long time, and it needed to be thrown away. During an additional kitchen observation with DM P on [DATE] at 10:54 AM, it was revealed: -The walk-in refrigerator contained a box of approximately ,d+[DATE]oz (ounce) Ready Care Strawberry Shakes, thawed. The box documented to Keep Frozen. The cartons instructed to Use within 14 days after thawing. There was no observable thaw date marked on the shakes. DM P stated that he was not aware of the requirements to ensure shakes were dated when thawed. -The walk-in refrigerator had an opened one-quart Ready Care Thickened Dairy Drink, dated ,d+[DATE] and ,d+[DATE] with a best by date of [DATE].A second one-quart Ready Care Thickened Dairy Drink, was dated ,d+[DATE] with a best by date of [DATE]. The cartons instructed After opening, may be kept up to 7 days under refrigeration. -Additionally, the walk-in refrigerator had one opened 46 oz. Ready Care Thickened Apple Juice with ,d+[DATE] and ,d+[DATE] written on the carton. A second opened 46 oz. Ready Care Thickened Golden Fruit Punch with ,d+[DATE] and ,d+[DATE] written on it. The carton instructed After opening, may be kept up to 7 days under refrigeration. DM P stated that he was not aware of the special requirements for opening and dating thickened drinks and disposed of the opened drinks.

Based on observations, interviews, and facility policy review, the facility failed to ensure 6 of 28 resident rooms on 2 of 4 halls had been maintained in a safe and homelike manner. Findings include: Review of facility's policy titled, Safe and Homelike Environment, revised 11/19/24, revealed no procedure for the upkeep of the resident rooms. During an observation and interview on 11/16/24 at 11:00 AM, in room [ROOM NUMBER], an area of unpainted dry wall plaster was noted behind the resident's bed. R37 stated he did not remember how long the unpainted area had been there. He stated he would like the area painted. During an observation on 11/16/24 at 12:45 PM, room [ROOM NUMBER] was noted to have a hole in the wall to the left of the window. The hole was approximately four inches wide by two feet long. CNA F (Certified Nursing Assistant) and CNA G stated they had not noticed the hole in the wall. 26446 An observation and interview on 11/16/24 at 11:32 AM revealed wall damage in resident room [ROOM NUMBER]. There was a large spackled/patched area approximately 12 to 18 inches in circumference directly behind the headboard of bed 451B. The patched area was bumpy and unpainted. A second broken area of the wall was observed to the right side of the bed, near the window. This area was severely damaged, with visibly broken drywall approximately 12 to 18 inches in size. The curtain rod was visibly broken. R22 stated that the wall had been damaged for a long time. An observation on 11/16/24 at 12:05 PM revealed wall damage to the left side of bed 453B. There were long deep grooves visibly marked down the side of the wall, approximately 12 inches in length, at head height. During observations and interviews on 11/19/24 at 6:00 PM, NHA A (Nursing Home Administrator) and Maintenance Director (MntDir) stated they were aware of problems with the condition of the rooms and confirmed the observations as stated above. The MntDir stated he did not have enough time to fix everything. He stated he got notifications from staff on the room walls. He stated there had been no plan for repairs to the rooms.

Based on observation, interview, record review, the facility failed to ensure 1 of 1 resident (R3) reviewed for self-administration of medications out of a total sample of 31 had been assessed for self-administration of medications, had a physician's order for the self-administrator, and had care plan interventions identified and implemented related to 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: Review of the facility's policy titled, Self-Administration of Medications, revised January 2018, indicated, .In order to maintain the resident's high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the residents and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process .C. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition .D. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered . R3 was admitted to the facility on [DATE] with a diagnosis of dementia. R3's quarterly Minimum Data Set (MDS), dated [DATE] indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident was severely cognitively impaired. R3's Physician Orders, dated November 2024 included the following: ~Aspirin 81 milligrams (mg) give one tablet by mouth (PO) daily, ~Calcium antacid tablet chewable 500 mg give one tablet PO daily, ~Vitamin B-12 oral tablet extended release 1000 micrograms (mcg) PO daily, ~Vitamin D-3 oral tablet 50 mcg PO daily. Review of R3' medical record found no evidence of a physician's order for self-administration of medication; no facility assessment for self administration of medications and no care plan for self-administration of medications. During the initial tour on 11/16/24 at 11:15 AM, a clear medication cup containing one small round yellow pill with the number 5 imprinted on it, two white round pills, two small round pink pills, and one medium sized round light orange pill was noted on R3's overbed table. R3 stated he was unsure where the medications were from or who gave him the medication. During an observation and interview on 11/16/24 at 11:25 AM, CMT C (Certified Medication Tech) confirmed that she gave R3 the medications, and that the medications were still on R3's overbed table. CMT C was unable to identify the medication. During the interview, R3 took the medications. During an interview on 11/16/24 at 12:10 PM, DON B (the Director of Nursing) confirmed that medications should not be left at a resident's bedside unless the resident could self-administer their own medications. DON-B confirmed R3 could not self-administer his own medications.

Based on observations, interviews, and record review, the facility failed to ensure that 1 of 1 resident (R100) reviewed for suprapubic catheters was provided with appropriate care. The facility did not have an indication for the catheter and failed to ensure there were physician orders for catheter care. In addition, the facility failed to ensure that R100's care plan included the appropriate type of catheter, and that the catheter had a privacy bag. Findings include: R100 was admitted to the facility on [DATE]. R100's hospital Medicine Admission History and Physical, dated 11/08/24, included a history of .cystocele (prolapsed bladder) repair .suprapubic catheter, 09/23 . Review of hospital Patient Discharge Summary, dated 11/14/24 indicated, .Presenting for multiple days of progressive altered mental status per patient and family. Initial workup in the emergency department showed .a urinalysis concerning for possible UTI (Urinary Tract Infection) (patient does have a suprapubic catheter) .Urine culture 11/08/24 .candida (a yeast that normally lives in small amounts on the skin, in the mouth, and in the belly), Escherichia coli . R100's Physician Orders, did not contain orders for catheter care. R100's Care Plan, located under the Care Plan tab in the EMR, revised 11/15/24, indicated, .The resident has urinary catheter .Interventions: Catheter: The resident has a Foley catheter. Position catheter bag and tubing below the level of the bladder . There was no documented evidence of catheter care as an intervention. During an observation and interview on 11/16/24 at 11:45 AM, R100 was observed R100 in her wheelchair in her room. Her catheter bag, which had no privacy cover, was facing the door to the hallway. During the interview, R100 was not able to indicate why she had a suprapubic catheter. During observations on 11/17/24 at 10:30 AM and 1:00 PM, R100 was observed sitting up in her wheelchair with the catheter bag in her hands, facing the doorway. There was no privacy cover on the catheter bag. During an interview on 11/18/24 at 7:25 PM, the Director of Nursing (DON) confirmed that when a resident had a catheter, there should be physician orders for catheter care, an indication for the use of the catheter, the resident's care plan should include the appropriate catheter type, and the catheter bag should have a privacy cover. The DON confirmed that R100 did not have an indication for the use of the suprapubic catheter, no physician orders for routine catheter care, and her care plan did not include the appropriate catheter type. At 7:35 PM, the DON confirmed that R100 now had a privacy cover for her catheter bag.

Based on observations, interviews, and record review, the facility failed to ensure that 2 of 4 residents (R42 and R149) reviewed for pain management out of a total sample of 31 received pain medications consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. R42 rated pain at a 6.5 out of 10 and stated that anything over 4 was unacceptable for them. Nursing staff were alerted to R42's request for pain medication at 3:38 PM. R42 did not receive pain medication until 4:15 PM. During that time, R42 verbalized she had pain, and was observed to be moaning and rocking. R149 was experiencing pain rated at an 8 or 9 out of 10. R149 had requested pain medication and it took nursing staff over an hour to respond with the medication. When staff responded with the medication, R149's pain rating had increased to 10 out of 10. Findings include: Review of the facility's policy titled, Management of Pain, dated 10/12/22, indicated, .The purpose of this policy is to accomplish .an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhanced dignity and life involvement .Promptly and accurately assessing and diagnosing pain. Monitoring treatment efficacy and side effects .An immediate care plan will be initiated upon admission for any residents with orders for pain management .Document interventions and responses in the medical record as appropriate (i.e. medication administration record, treatment record, nursing progress notes, etc.) and/or on the pain flow sheet . 1. R42 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, bacteremia, amputation of 2 left toes, and a wound vacuum to a surgical wound on the left lateral leg. R42's admission MDS (Minimum Data Set) assessment dated [DATE] indicated R42 had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded that the resident received an opioid medication. R42's Physician Orders, dated 10/29/24, revealed R42 was to receive Oxycodone HCl (hydrochloride) Oral Tablet 5 mg, 1 tablet by mouth every 8 hours as needed for pain management. R42's Care Plan last revised 10/31/24, revealed R42 had complained of pain related to surgical wounds, amputation of two left toes, and a vascular graft infection. Interventions included administering medications for pain as ordered, to monitor/record pain characteristics, and to monitor/record/report to nurse resident complaints of pain or requests for pain treatment. R42's MAR (Medication Administration Record) indicated that R42 received oxycodone last on 11/15/24 at 3:35 PM for a pain level of 8. On 11/16/24 from 3:38 PM through 4:11 PM, Surveyor conducted a continuous observation and interviewed R42. At 3:38 PM, R42 stated she had asked a staff member for pain medication 5 minutes ago. She stated that the staff member had told her she would go tell the nurse. R42 stated that her current pain was a 6.5 out of 10 (with 0 being no pain and 10 being the worst pain experienced). R42 confirmed that any pain above a 4 was too much for her. She stated she would wait for the nurse. The resident was visibly moaning, rocking, and expressing she had pain in the left leg wound vacuum location. During this same time, Surveyor was also able to observe LPN H (Licensed Practical Nurse). From 3:40 PM until 4:00 PM LPN H was at nurses' station and speaking with coworkers. At 4:00 PM, R42 told Surveyor that no one had brought her pain medication. At 4:00 PM, LPN H was observed at her medication cart, pushing it down the 400 hall. LPN H stopped at 2 other resident rooms and administered medications to those 2 residents. At 4:11 PM, LPN H was observed placing the medication cart near R42's room. LPN H entered R42's and asked the resident about her pain level. R42 stated her pain was a 6.5 out of 10. LPN H exited the resident's room and stated to the Surveyor R42 was receiving an as needed pain medication. LPN H confirmed that she was notified earlier that R42 was in pain and needed medication. LPN H stated she had been busy getting medication counted and prepared. Review of R42's MAR, had received her dose of Oxycodone HCl on 11/16/24 at 4:15 PM. LPN H documented R42's pain was 5 out of 10 even though R42 had reported it to be 6.5 out of 10. Review of the MAR found that timing was not an issue as this was the first time R42 had received pain medication since 11/15/24 at 3:35 PM. During an interview on 11/19/24 at 2:45 PM, DON B (Director of Nursing) stated that if a resident had expressed pain, she expected the nurse to not delay in providing the medication. She confirmed that if a resident stated her pain was at a 6, the nurse needed to take care of it right away. She stated it was not acceptable to delay and was not aware that LPN H had documented an incorrect pain level. DON B was aware R42 had ongoing concerns with pain due to her leg wound. During an interview on 11/19/24 at 4:27 PM, CMT I (Certified Medication Technician) stated she was familiar with R42. She stated that if a resident or staff member tells her that a resident is having pain, she will go get the nurse to get pain medication if it is not available on the medication cart. She stated that she was aware that R42 had pain and could let staff know when they needed pain medication. CMT I said it was important to give residents their pain medication as soon as they were made aware. LPN H was not available for additional interviews. 2. R149 was admitted to the facility on [DATE] with diagnoses including wound vacuum to abdominal surgical wound. R149's MDS, dated [DATE] indicated R149 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. R149's Care Plan, last revised 11/13/24, revealed that the resident was at risk for pain related to a surgical wound. The interventions identified included administering pain medications as ordered, to monitor/record/report to the nurse the resident's complaints of pain or requests for pain treatment, and to monitor/record pain characteristics. R149's Physician Orders dated 11/12/24, indicated R149 was to receive oxycodone HCl, Oral Tablet 10 milligrams (mg), 1 tablet by mouth every four hours as needed for pain. During an interview on 11/16/24 at 5:19 PM, R149 stated that she currently had an abdominal wound vacuum for the healing of a surgical wound. She stated that when she asked for pain medication, the staff would sometimes not return for 30 minutes or longer. R149 stated staff just don't come back. She stated that her pain was often 8 or 9 out of 10, and she needed pain medication. During an interview on 11/18/24 at 1:45 PM, R149 stated she had requested a pain pill an hour ago from RN J, but RN J had not returned. R149's MAR indicated the last time R149 had Oxycodone HCl on 11/18/24 at 8:18 AM, more than 5 hours earlier. R149's order is for 1 tablet every four hours as needed. It was recorded that the resident's pain had been at 9 out of 10 and the medication had been effective. During an interview 11/18/24 at 2:03 PM, RN E stated that RN J had gone to the secure memory unit to provide one-on-one supervision for a resident. RN E stated that RN J was not currently providing medication administration from her medication cart. RN E reviewed the medication administration for R149 and confirmed that the resident had not received a pain pill since approximately 8:30 AM. RN E stated she would go speak with the resident. RN E stated that although RN J was the nurse providing medication for the 4 hall, staff had to take turns monitoring a specific resident on the secured unit for approximately an hour. R149's MAR revealed RN E administered a dose of Oxycodone HCl on 11/18/24 at 2:06 PM, nearly 2 hours after R149 had requested pain medication. It was recorded that the resident had rated her pain at 10 out of 10, which is higher than the original rating of 9, and the medication had been effective. During an interview on 11/18/24 at 2:35 PM, RN J stated that R149 had told her that she needed pain medication because she was actively in pain. She stated she was sorry, and that she had forgotten. RN J stated that she had been assigned to go to the secured unit to do one-to-one supervision for a resident from 1:30 PM to 2:00 PM. She stated that all staff, including staff working on the medication carts, might get assigned to go and do monitoring on the secured unit for the resident requiring one-on-one supervision. RN J stated that she had been scheduled for monitoring around the time she would be doing her second medication pass for residents. She confirmed that being assigned to provide one-on-one supervision on the secured unit had disrupted her second medication pass, and because of it, she had forgotten to give R149 the pain medication. She stated it was frustrating that it was at the time she needed to pass medications. During an interview on 11/19/24 at 4:59 PM, DON B stated that it was important to ensure residents received pain medication. She stated that resident safety was important, but so was pain management. DON B stated she was not aware there had been a delay in R149 receiving her pain medication, and that could exacerbate other conditions that they have.

Based on observation, record review, and interview, the facility did not ensure that staff accurately administered medications for 1 of 31 sampled residents (R9). CMT M (Certified Medication Tech) did not mix compounded insulin for R9 prior to administering it. Failure to do so could result in an inaccurate proportion of short or long acting insulin being given. Findings include: Review of the Novolog 70/30 manufacturer's instructions, provided by the facility, revealed 70/30 insulin was a .mixture of 70% intermediate-acting insulin (isophane) and 30% short-acting insulin (regular). Before using, gently roll the vial or cartridge, turning it upside down and back 10 times to mix the medication. Do not shake the container . Review of the facility's undated policy titled, Registered Nurse (RN) Delegating Tasks to Medication Aides stated, .the responsibility and authority to decide what the aide can and cannot do. The RN may decide to delegate a task that was not taught to the aide (insulin injections, for example). If so, the RN must ensure the medication aide is trained, competent, and supported whenever they need help . R9 was readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus. During an observation on 11/17/24 at 5:00 PM, CMT M prepared R9's insulin. She retrieved R9's Novolog 70/30 insulin from the medication cart. She sanitized the top of the vial, then drew up 35 units into the syringe, and injected the insulin into R9's right arm. She had not mixed the insulin prior to drawing up the insulin to R9. During an interview on 11/17/24 at 5:20 PM CMT M confirmed she had not mixed the 70/30 insulin. She stated she was not aware she should have mixed the insulin. Review of CMT M's Insulin Competency Checklist dated 07/11/24 and provided by the facility, revealed she had been marked as satisfactorily performing the task of insulin administration. The competency had included how to prepare any type of cloudy insulin prior to administration. During an interview on 11/17/24 at 6:00 PM, DON B (Director of Nursing) confirmed the 70/30 insulin vial should have been gently rolled to mix the two types of insulin. She stated if the 70/30 insulin was not mixed, the resident would not have received the correct dosage of either type of insulin, and that could have affected R9's blood glucose levels. During an interview on 11/19/24 at 10:04 AM with RN N (Registered Nurse) on the correct way to prepare 70/30 insulin, she stated the insulin vial would have to be rolled several times to mix the two types of insulin together.

Based on interview, observation, and record review, the facility did not ensure 2 (R9 and R7) of 6 residents reviewed for pressure injuries received the necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing. *R9 was identified to be at risk for pressure injuries. R9 developed a stage 2 pressure injury to the sacrum on 11/16/23. R9 was hospitalized on [DATE] returning to the facility on [DATE]. R9 was readmitted on [DATE] with a Stage 3 pressure injury to the sacrum on 11/23/23. The facility did not revise R9's care plan to implement pressure reducing devices such as wheelchair cushion, air mattress, or off-loading heels until 12/14/22 (22 days after readmission.) On 12/14/22, R9 was readmitted with a stage 3 pressure injury to the right heel at which time R9's potential for skin integrity care plan was updated. The area was noted to have a decline on 12/26/23 with no change in treatment and no revision to R9's care plan. On 3/2/23, R9 was readmitted with a deep tissue injury (DTI) to the right lateral foot. On 3/15/23, the right lateral foot wound bed was described as 100% eschar. The facility continued to stage this area as a DTI rather than an unstageable pressure injury from 3/15/23 through 6/18/23. No assessment of the pressure injury was conducted during the week of 3/6/23. The facility did not update R9's potential for skin integrity care plan to identify the unstageable pressure injury to the right heel and the DTI (unstageable) to the right lateral foot until 5/3/23. Even though R9's Minimum Data Sets indicate R9 has not exhibited refusal of cares, Surveyor noted a care plan which identified R9 refuses cares, and refuses repositioning (dated 7/26/19, 8/2/19, 12/7/22.) R9's care plans were not updated to reflect alternate ways to encourage compliance with cares and repositioning. There was no indication risks and benefits were discussed with R9 so that R9 could make an informed decision regarding his pressure prevention and treatment. There was no indication alternate measures to provide pressure relief that R9 may find acceptable was discussed and care planned for. On 6/26/23, the dressing on the right heel was observed to have serosanguinous drainage and the edge of the dressing was peeling and appeared dirty. On 6/27/23, R9 is observed to have the same dressing on his heel. According to R9, the nurse did not do a dressing change on 6/26/23 and a dressing change has not been completed in a number of days. On 6/27/23, the nurses signed as doing the dressing change which later was said to have been done by the wound Doctor whom R9 does not see. On 6/27/23, R9 was noted to have a pillow under his calves however R9's heel was not off loaded and was resting directly on the mattress. On 6/26/23 & 6/27/23, Surveyor observed no dressing covering the pressure injury on the right lateral foot. R9's right lateral foot went from a deep tissue injury to an unstageable pressure injury. *R7 was admitted to the facility 1/28/23 from the hospital with lower extremity pressure injuries. The hospital gave specific daily wound care orders that were not transcribed into R7's electronic medical record (EMR.) Wound care orders were entered into R7's EMR on 1/29/23 but did not follow the specific hospital recommendations. Example 1 regarding R9 rises to a scope and severity level of a G (harm/isolated.) Findings include: 1. R9's diagnoses includes chronic obstructive pulmonary disease, hypertension, atrial fibrillation, congestive heart failure, and diabetes mellitus. The potential for an impairment to skin integrity care plan initiated 10/1/19 & revised 7/20/22 has the following interventions: * Apply lotion to dry skin as resident allows/tolerates. Initiated 10/1/19. * Assist resident to keep skin clean and dry/incontinence per ADL POC (activity daily living plan of care). Initiated 10/1/19 & revised 10/15/19. * Assist with self cathing as needed. Initiated 10/1/19. * Educate resident/family/caregivers of causative factors and measures to prevent skin in jury as needed. Initiated 10/1/19 & revised 10/15/19. * Encourage to keep peri area dry, avoid moisture. Initiated 2/10/21. * Encourage appropriate placement of NEB and CPAP tubing (ie: out from under bare skin, out from under bony prominence's,etc). Initiated 10/1/19. * Identify/document potential causative factors and eliminate/resolve where possible. Initiated 10/1/19 & revised 10/15/19. * Monitor for s/s (signs/symptoms) further infection (right hip replacement site), update MD (medical doctor) as needed. Initiated 10/1/19. * Monitor for side effects of the ATBx (antibiotic), anticoagulants and pain patches: gastric distress, rash, or allergic reactions which could exacerbate skin injury. Update MD as needed. Initiated 10/1/19 & revised 10/15/19. * Implement pressure reducing device i.e. w/c (wheelchair) cushion, air-mattress, off-loading heels, etc. Initiated 12/14/22. R9 developed a sacrum pressure injury on 11/16/22 which was identified as a Stage 2 with measurements of 4.0 x 3.0 x 0.2. R9 was transferred to the hospital on 11/16/22 and returned on 11/23/22. Upon readmission R9's sacral pressure injury was identified as a Stage 3 with measurements of 8.5 cm x 6.0 cm x 0.2 cm. There was no revision in R9's at risk for potential for skin integrity care plan until 12/14/22 (22 days after readmission). R9's skin impairment/wound form on 3/27/23 & thereafter does not include a sacrum pressure injury which has healed. Surveyor also noted R9 has the following refusal care plans: Resident has hx (history) of self propelling backwards in wheelchair in facility and running into things. Resident has been asked to propel correctly but choose to propel backwards. Refuses to follow healthcare recommendations. Initiated 7/26/19 & revised 12/7/22. Resident displays conflictual, difficult behavior with other persons related to: refuses lab draws from facility, refuses all therapeutic interventions in room, resident puts call light on for assistance, then leaves room, denies putting call light on. Behavior symptoms are manifested by: refusing cares from nursing staff not familiar with resident refuses to see specialist md. Initiated 12/7/22 & revised 6/16/23. All interventions are dated 12/7/22. Resident is resistive to care - resident reuses to allow staff to apply sunscreen prior to going outside, refuses to offload from buttocks, refuses to allow staff to turn and reposition in bed, refuses air mattress. Initiated 8/2/19 & revised 11/16/22. All interventions dated 8/2/19. R9's refusal care plans were not updated to reflect alternate ways to encourage compliance with cares and repositioning. There was no indication risks and benefits were discussed with R9 so that R9 could make an informed decision regarding his pressure prevention and treatment. There was no indication alternate measures to provide pressure relief that R9 may find acceptable was discussed and care planned for. RIGHT HEEL The PPS 5 day Minimum Data Set (MDS) dated [DATE] assesses R9 as having a Brief Interview for Mental Status (BIMS) score of 14 which indicates R9 is cognitively intact with daily decision making skills. The MDS assesses R9 has needing extensive assistance with 2 staff for bed mobility. The MDS indicates R9 does not exhibit any rejection of cares. The MDS indicates R9 is at risk for pressure injuries and has 1 unstageable pressure injure with a wound bed covered with slough and/or eschar and had 1 pressure injury upon admission/reentry. The MDS indicates the use of a pressure reducing device for chair, bed and pressure ulcer care. R9's care plan continued to identify a potential for an impairment to skin integrity initiated 10/1/19 & revised 7/20/22 (as noted above) with interventions listed in part as: * Educate resident/family/caregivers of causative factors and measures to prevent skin in jury as needed. Initiated 10/1/19 & revised 10/15/19. * Encourage to keep peri area dry, avoid moisture. Initiated 2/10/21. * Encourage appropriate placement of NEB and CPAP tubing (ie: out from under bare skin, out from under bony prominence's,etc). Initiated 10/1/19. * Identify/document potential causative factors and eliminate/resolve where possible. Initiated 10/1/19 & revised 10/15/19. * Implement pressure reducing device i.e. w/c (wheelchair) cushion, air-mattress, off-loading heels, etc. Initiated 12/14/22. The skin impairment/wound form dated 12/14/22 documents for does the resident have a pressure injury, yes is answered, location is right heel, stage of pressure injury is Stage 3 and measurements are 0.5 x 2.5 x 0.2. The wound bed is 100% granulation. Surveyor noted an updated to R9's potential for skin intergrity dated 12/14/22 to implement pressure reducing device i.e. w/c (wheelchair) cushion, air-mattress, off-loading heels, etc The nurses note dated 12/15/22 documents Resident noted to have new wound to right heel pressure wound. Resident has been refusing cares, refusing meds, refusing positioning. Resident seen by [Physician's name] at [Name] wound clinic. Received new order from wound clinic. Recommendations for treatment not available in house. Called wound clinic, received new orders for silver alginate to wound bed, collagen sheet to sacral wound. Orders carried out. PCP (primary care physician) made aware. Surveyor noted R9's care plans were not updated to reflect alternate ways to encourage compliance with cares and repositioning. There was no indication risks and benefits were discussed with R9 so that R9 could make an informed decision regarding his pressure prevention and treatment. There was no indication alternate measures to provide pressure relief that R9 may find acceptable was discussed and care planned for. R9's treatment to right heel from 12/15/22 to 1/18/23 is clean with normal saline, pat dry, apply alginate with silver to base of wound, cover with dry dressing, change M, W, F (Monday, Wednesday, Friday) & PRN (as needed). The skin impairment/wound form dated 12/20/22 for location is right heel, stage of pressure injury is Stage 3 and measurements are 2.0 x 1.0 x 0.2 The wound bed is 100% granulation. The skin impairment/wound form dated 12/26/22 for location is right heel, stage of pressure injury is Unstageable and measurements are 2.0 x 1.0 x 0.2 The wound bed is 20% granulation and 80% slough. Surveyor noted a decline in the condition of the pressure injury with the wound bed now having 80% slough and an increase in measure measurement since 12/14/23, there was no change in treatment and no revision in R9's potential for skin integrity care plan and no revision to the care plan addressing R9's refusals. Surveyor noted weekly assessments for R9's right heel until 3/27/23. The skin impairment/wound form dated 3/27/23 for location is right heel, stage of pressure injury is unstageable, and measurements are 2.0 x 1.0 x 0.1. Surveyor noted there is no description of the wound bed. There are weekly assessment starting 4/3/23 with the most recent assessment dated [DATE] for location is right heel, stage of pressure injury is Unstageable and measurements are 0.7 x 0.7 x nm (not measured) The wound bed is 10% granulation and 90% slough. RIGHT LATERAL FOOT R9 was hospitalized from 2/25/23 to 3/2/23. Upon return to the Facility R9 was assessed as having a right lateral deep tissue pressure injury with measurements of 2.0 x 1.0 x nm. The treatment was skin prep. Upon readmission R9's potential for skin integrity care plan was not revised and an actual pressure injury care plan was not developed until 5/3/23. The skin impairment/wound form dated 3/6/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 2.0 x 1.0 x nm, the wound bed is intact non blanchable skin. The skin impairment/wound form dated 3/15/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 3.0 x 1.0 x 0.5, the wound bed is 100% eschar. R9's pressure injury is incorrectly staged as a wound bed with 100% eschar should be staged as unstageable. There was no revision in R9's potential for skin integrity care plan was not revised and an actual pressure injury care plan was not developed until 5/3/23. The skin impairment/wound form dated 3/22/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 3.0 x 1.0 x 0.5, the wound bed is 20% slough & 80% eschar. R9's pressure injury continues to be incorrectly staged. There is no assessment during the week of 3/26/23 to 4/1/23 for R9's right lateral foot pressure injury. The skin impairment/wound form dated 4/3/23 & 4/10/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 3.0 x 1.0 x 0.5, the wound bed is 20% slough & 80% eschar. R9's pressure injury continues to be incorrectly staged. The skin impairment/wound form dated 4/17/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 1.0 x 1.0 x nm, the wound bed is 10% granulation & 90% slough. R9's pressure injury continues to be incorrectly staged. The nurses note dated 4/25/23 documents Resident was readmitted to facility. Resident has new order of antibiotics Cefepime 1g (gram) every 12 hours for 7 days for Morganea Bacteremia MDR (multidrug resistant) and pseudomas UTI (urinary tract infection). Resident had been admitted to the hospital for sepsis on 4/11/23. Resident has open wound on RT (right) heel, RT lateral foot, BLE (bilateral lower extremities) scabs. Resident has PICC (peripherally inserted central catheter) LF (left forearm) arm. The skin impairment/wound form dated 4/25/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 1.0 x 1.0 x nm, the wound bed is 10% granulation & 90% slough. Barriers to wound healing documents Resident is a [AGE] year old male with history of obesity, cellulitis, covid 19, history of fungal infection to groin area. Resident incontinent of urine, wears pullups causing friction. Resident has difficulty in mobility. Non compliant with elevating legs, sits in w/c (wheelchair) for extended periods of time. Resident refuses to follow healthcare recommendations. Resident with recent hospitalization requiring surgical intervention due to abscess. Resident refuses to offload and turn and reposition. Surveyor noted the right lateral foot is incorrectly staged as a wound bed with 90% slough should be staged as unstageable. Although the MDS' indicate no rejection of cares, Surveyor noted no indication in R9's record of the facility have a discussion with R9 regarding the risks and benefits of R9's decisions to not follow healthcare recommendations pertaining to the prevention and treatment of pressure injuries such as R9's refusal to elevate legs, sitting in w/c for extended periods of time, refusing to offload and turn and reposition. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/27/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R9 is assessed as requiring extensive assistance with one person physical assist for bed mobility, transfer, & toilet use, does not ambulate, is always continent of urine & always incontinent of bowel. R9 is assessed as being at risk for pressure injuries and has one un-stageable - slough &/or eschar which was present upon admission/reentry and one deep tissue injury present upon admission/reentry. The MDS indicates R9 exhibits no rejection of cares. The skin impairment/wound form dated 5/1/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 1.0 x 1.0 x nm, the wound bed is 10% granulation & 90% slough. Surveyor noted the right lateral foot continues to be incorrectly staged as a wound bed with 90% slough should be staged as unstageable. The resident has an un-stageable pressure ulcer to his right heel and a DTI (deep tissue injury) to his right lateral foot care plan Initiated & revised on 5/3/23 has the following interventions: * Administer treatments as ordered and monitor effectiveness. Initiated & revised 5/3/23. * Air mattress on bed, settings based on weight. Initiated 5/3/23 & revised 6/13/23. * 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 MD. Initiated & revised on 5/3/23. * The resident requires supplemental protein as ordered to promote wound healing. Initiated & revised 5/3/23. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Initiated & revised 5/3/23. The at risk pressure injury care plan was not revised and a pressure injury care plan was not developed until 5/3/23. The skin impairment/wound form dated 5/8/23 & 5/15/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 1.0 x 1.0 x nm, the wound bed is 10% granulation & 90% slough. Surveyor noted the right lateral foot continues to be incorrectly staged. The skin impairment/wound form dated 5/22/23 & 5/30/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 0.5 x 0.5 x nm, the wound bed is 10% granulation & 90% slough. Surveyor noted the right lateral foot continues to be incorrectly staged. The skin impairment/wound form dated 6/5/23& 6/12/23 for location documents right lateral foot, stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 0.3 x 0.3 x nm, the wound bed is 10% granulation & 90% slough. Surveyor noted the right lateral foot continues to be incorrectly staged. The skin impairment/wound form dated 6/19/23 for location documents right lateral foot, stage is measurement is 0.2 x 0.2 x nm, the wound bed is 10% granulation & 90% slough. Surveyor noted the right lateral foot stage is Deep Tissue Injury: Persistent non blanchable deep red, maroon or purple discoloration, measurement is 0.2 x 0.2 x nm, the wound bed is 10% granulation and 90% slough. Surveyor noted the right lateral foot continues to be incorrectly staged. On 6/26/23 at 10:09 a.m. Surveyor asked R9 if he has any pressure injuries. R9 informed Surveyor he has a wound on his heel that hasn't been changed in a week. Surveyor asked R9 permission to observe cares for him with Med Tech/CNA(Certified Nursing Assistant)-X. R9 gave Surveyor permission. On 6/26/23 from 10:11 a.m. to 10:39 a.m. Surveyor observed morning cares for R9 and observed R9 transfer from the bed into the wheelchair using a slide board with Med Tech/CNA-X. During this observation at 10:25 a.m. Surveyor observed a dressing on R9's right heel. Surveyor observed on the outside of the dressing there is an area of serosanguineous drainage approximately the size of a nickel and the edge of the dressing was peeling up & appeared to dirty. There is an unstageable pressure injury on the right lateral side of R9's foot which is an approximate size of a dime and does not have a dressing. There were no concerns identified with Med Tech/CNA-X during this observation. The nurses note dated 6/27/23 at 3:16 a.m. documents Pt (patient) sleeping on this shift with no complaints of pain. Self cath for retention. Continues with no complaints of discomfort. Treatment done by wound care team. This note was written by RN (Registered Nurse)-W. On 6/27/23 at 7:55 a.m. Surveyor observed R9 in bed on his back wearing yellow gripper socks, a pillow under R9's calves, with R9's heels on the mattress. Surveyor asked R9 about the green pressure relieving boots in the chair and asked R9 if he wears these boots. R9 replied no and explained if he has a pillow it's okay. R9 informed Surveyor he has never had an infection in the bone. Surveyor asked R9 if the nurse did his treatment last night. R9 replied no it's the same one. Surveyor asked R9 if it would be alright for Surveyor to look at his foot later. R9 replied yes. On 6/27/23 at 8:04 a.m. Surveyor spoke to CNA-Y and informed CNA-Y Surveyor would like to look at R9's feet. CNA-Y informed Surveyor R9 wants to get up after breakfast around 9:30 a.m. On 6/27/23 at 9:30 a.m. Surveyor observed R9 sitting in a wheelchair dressed for the day. On 6/27/23 at 10:26 a.m. Surveyor asked CNA-Y if R9 wears pressure relieving boots. CNA-Y replied no he refuses in bed she will put a pillow so R9's heels are not on the mattress but he also refuses. Surveyor asked CNA-Y if she could accompany Surveyor to R9's room in order for Surveyor to look at R9's feet. On 6/27/23 at 10:28 a.m. CNA-Y removed R9's gripper sock from the right foot. Surveyor observed there is no dressing on R9's right lateral pressure injury and the dressing on the right heel is the same dressing as Surveyor had observed yesterday. Surveyor asked R9 if it would be alright if Surveyor went to get DON-B, asked CNA-Y not to place the sock back on and left R9's room to get DON-B. On 6/27/23 at 10:34 a.m. Surveyor asked DON-B to accompany Surveyor to R9's room and while walking to R9's room asked when wound rounds are done. DON-B replied Monday afternoon. Surveyor asked DON-B if R9 is seen by [Name of] wound doctor. DON-B asked RN-E, who is the Facility's wound nurse, if R9 sees [Name of] wound doctor. RN-E replied no he refused. On 6/27/23 at 10:37 a.m. Surveyor entered R9's room with DON-B and RN-E. Surveyor showed DON-B & RN-E R9's right lateral unstageable pressure injury which does not have a dressing and informed DON-B & RN-E there wasn't a dressing yesterday. Surveyor also informed DON-B & RN-E the dressing on R9's right heel is not dated and is the same dressing as Surveyor observed yesterday. R9 informed DON-B his dressing has not been done in a number of days. DON-B informed Surveyor R9 is alert and orientated. Surveyor informed DON-B there is a nurses note dated today which documents the treatment was done by the wound team. DON-B informed Surveyor she is going to speak to the nurse who wrote the note. On 6/27/23 from 10:42 a.m. to 10:48 a.m. Surveyor observed the treatment for R9's right heel & right lateral foot with RN-E. Surveyor noted RN-E completed the treatment to the right heel and lateral foot of cleanse area with normal saline, pat dry, apply silver alginate, cover with dry dressing. This treatment was ordered on 5/11/23 every Monday, Wednesday, Friday, and PRN (as needed). No concerns were identified during this observation. On 6/28/23 at 9:58 a.m. Surveyor asked RN-E who is responsible for skin integrity care plans. RN-E replied that is MDS. RN-E informed Surveyor he also meets with MDS and puts in care plans. Surveyor went over R9's care plan with RN-E informing RN-E there wasn't an actual pressure injury care plan until 5/3/23 and R9 returned from the hospital on 3/2/23 with a right lateral foot DTI. RN-E replied wow I did not know. Surveyor asked RN-E why he kept staging R9's right lateral foot as a DTI when the wound bed became 100% eschar then granulation with slough. RN-E informed Surveyor he probably did not change it but it's unstageable. Surveyor informed RN-E on 3/27/23 the right heel assessment was not completed and there is no assessment for the right lateral pressure injury during the week of 3/26/23 to 4/1/23. RN-E informed Surveyor he was not working at the Facility during this time explaining he left at the end of the month for a few days and then they brought him back. On 6/28/23 at 10:05 a.m. Surveyor asked DON-B if she was able to speak with RN-W. DON-B informed Surveyor RN-W got the information from R9, she didn't check the pressure injury or follow up. Surveyor asked why RN-W initialed the treatment as being completed. DON-B informed Surveyor R9 told RN-W it was completed by [Name of] wound doctor. Surveyor asked DON-B if RN-W did the treatment. DON-B replied no. Surveyor informed DON-B R9 was readmitted on [DATE] with a right lateral DTI, which then was unstageable and a care plan wasn't developed until 5/3/23. DON-B informed Surveyor she will check into this. On 6/28/23 at 1:40 p.m. DON-B provided R9's care plans to Surveyor. Surveyor reviewed this set of care plans and noted they are the same care plans Surveyor had. R9's pressure injury care plan was not developed until 5/3/23. 40533 2. R7 was admitted on [DATE] to the facility with diagnoses that included Uncontrolled Type 2 Diabetes Mellitus, Congestive Heart Failure, Chronic Kidney Disease, Peripheral Artery Disease and Morbid Obesity. Surveyor reviewed the Admission Minimum Data Set (MDS) with an assessment reference date of 2/4/23 for R7. Documented under Section C, Cognition was a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Documented under Skin Conditions was Risk of Pressure Ulcer/Injuries was 1. Yes. Documented under number of unstageable pressure ulcers due to coverage of wound bed by slough or eschar was 3. Surveyor reviewed R7's Hospital Patient Discharge Summary with a date of 1/28/23. Documented under Discharge Instructions was Wound Care: Continue per wound care recommendations below. Right Leg: paint with iodine, cover with gauze, rolled gauze, and tubigrip, change [daily]. Left Leg: santyl (necrotic tissue only), hydrofera blue, gauze rolled gauze, and tubigrip change [daily.] Surveyor reviewed MD orders for R7. The hospital discharge wound care orders were not entered into R7's EMR. Surveyor reviewed R7's admission assessment documented by Registered Nurse (RN)-M on 1/28/23. RN-M did not enter R7's wound care orders. On 6/28/23 at 7:35 AM Surveyor interviewed RN-M. Surveyor asked who oversees putting wound care orders in on admission. RN-M stated Wound RN-E would put in the wound care orders. Surveyor reviewed R7's wound assessment documented by Wound RN-E on 1/28/23. RN-E did not enter R7's wound care orders. On 6/28/23 at 7:50 AM Surveyor interviewed RN-E. Surveyor asked who oversees putting wound care orders in on admission. RN-E stated the admission nurse unless he is in the building and then sometimes he will. Surveyor noted RN-E did the admission wound assessment but no orders had been put in. RN-E was unsure why and stated weekends are hectic. RN-E stated he or RN-M should have entered them and another nurse should have verified the orders. Surveyor reviewed R7's Progress Notes. Documented on 1/28/23 was Resident admitted from [hospital] at 1240 . Weeping wounds on [both lower] extremities noted, dressing reinforced . Surveyor reviewed R7's MD orders entered on 1/29/23. Documented was Change [bilateral lower extremities] kerlix, wash, pat dry and apply kerlix [twice daily] for weeping . This order did not follow the specific wound care orders from the hospital and did not include antiseptic or chemical debriding agent to aid in healing and preventing infection. On 6/28/23 at 9:36 AM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked who oversees putting wound care orders in on admission. DON-B stated the RN doing the admission or RN-E if it is a significant wound. Surveyor noted no one put in the wound care orders from the hospital on 1/28/23. DON-B stated RN-M or RN-E should have put the orders in. DON-B stated they should have communicated better.

Based on interview, observation and record review, the facility did not ensure 1 (R300) of 3 residents sampled received treatment and care in accordance with professional standards of practice. The facility did not do wound care and dressing changes as ordered. R300's lower extremity wounds worsened and caused increased pain to resident. The facility did not always updat the resident's Physician on changes to the wound. Resident's care plan was not updated and pain reassessments were not completed. Resident was transferred to the hospital from wound clinic after wounds were found to be infected. Findings included: On 2/27/2020 a complaint was received by the Southeastern Regional Office for The Division of Quality Assurance alleging residents admitted for wound care do not have dressings changed as ordered, residents are in pain from wounds and wounds have become infected requiring hospitalization . Surveyor reviewed facility's Management of Wounds policy with a revision date of 7/25/16. Documented under Policy was 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; -Promote the healing of pressure injuries that are present; -Providing education to residents, families and caregivers; and -Improving the quality of care and clinical outcomes through quality improvement programs 2. Assessing the Local Wound Condition It is the policy of this facility to use a uniform wound assessment that will provide a consistent means of wound evaluation. This assessment will facilitate continuity of care and communication among staff. 5. Providing Local Wound Care It is the policy of this facility to treat the wound according to the guidelines of the Agency for Healthcare Research (AHRQ), National Pressure Advisory Panel (NPUAP), and current standards of clinical practice. Surveyor reviewed facility's Care Plan policy with no revision date. Documented was The care plans are updated at least every 90 days or with a significant change of the resident by the team member initiating the care plan. R300 was admitted to the facility on [DATE]. Surveyor reviewed R300's Hospital Discharge Paperwork with a date of 1/15/20. R300 was admitted to hospital from 1/8/20 to 1/15/20 after having fallen and having laid 4 hours on the floor in his residence. Documented was Mid lateral wound with surrounding [MEDICAL CONDITION], [DIAGNOSES REDACTED]. Clear drainage on dressing per nursing. Right lower extremity wound (more than) 2 months. Began after scraping leg. Had been applying 'nuskin' without improvement. Increased redness and drainage for past 2 weeks. Documented on 1/12/20 was Workup showed an infected RLE (right lower extremity) ulcer with [MEDICAL CONDITION]. R300's [DIAGNOSES REDACTED]. Surveyor reviewed R300's 1/15/20 Admission Assessment. Documented was Reason for admission - he is here for wound (treatment) and deconditioning . Skin assessment - RLL front: Resident right lower leg medial calf blister with 15 x 22 cm. RLL rear: Maceration noted to the entire leg and with peeling open leaking skin. Leg circumference is 60 cm. Check all that apply: reddened, moist, [MEDICAL CONDITION] (right foot [MEDICAL CONDITION]). Surveyor reviewed R300's Baseline Care Plan with a start date of 1/15/20. Documented was Skin Integrity Planning: Focus: The resident has potential/actual impairment to skin integrity. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of [REDACTED]. Turn and position as necessary. Surveyor reviewed R300's 1/15/20 Admission Pain Comprehensive Evaluation. Documented under Description was Right lower leg with pain to calf and blistered areas. Entire right lower leg with pain described as burning and cramping/spasms. Two further Pain Comprehensive Evaluation assessments were completed on 1/16/20 and 1/21/20 documenting pain to RLE remains unchanged. Surveyor reviewed R300's admission MD orders for RLE wound. Documented with a start date of 1/16/20 and end date of 1/22/20 was Cleanse with soap and water, pat dry, apply nickel thick [MEDICATION NAME], change (twice daily (BID)). Surveyor reviewed MD orders for pain medication for R300. Documented was [MEDICATION NAME] Tablet 500 mg Give 2 tablets by mouth every 6 hours as needed for pain/fever. Surveyor reviewed R300's Care Area Assessment (CAA) for 16. Pressure Ulcer/Injury with an assessment reference date of 1/20/20. Documented under Care Plan Considerations was .Patient also has [MEDICAL CONDITION] of right lower extremity. Education will be provided to the resident r/t prevention of [MEDICAL CONDITION] and about [MEDICAL CONDITION]. Antibiotics will be administered as ordered. Dressing changed as ordered. Side effects of the antibiotics will be notified to the Physician. Weekly treatment documentation will be measured. Surveyor reviewed CAA for 19. Pain that documented Triggered pain r/t presence of pain scale of 7, relieved with medication and position change. Medications will be administered as ordered and effectiveness of interventions will be documented. Causes of pain will be monitored and documented. Physician will be notified if pain relief is not adequate. Surveyor reviewed R300's Treatment Administration Record (TAR) and Progress Notes for 1/16/20 through 1/21/20 for wound care. Wound care was not verified completed on 1/17/20 AM shift, 1/18/20 AM shift, 1/19/20 AM shift and 1/20/20 AM shift. No noted changes in wound were documented in Progress Notes or Skin Assessments. Surveyor reviewed R300's Comprehensive Care Plan with an initiation date of 1/21/20. Documented was Care Plan: The resident has [MEDICAL CONDITION] of the right lower extremity r/t infection. The resident will have no complications resulting from the [MEDICAL CONDITION] through the review date . Give antibiotics for infection and mild [MEDICATION NAME] to relieve discomfort as prescribed by Physician. Monitor/document side effects and effectiveness. Monitor /document healing of the [MEDICAL CONDITION]. Any new or worsening symptoms should be reported to MD. Monitor/document and report to MD the following symptoms of [MEDICAL CONDITION]: Red, Swollen, Tender Skin, May be accompanied by a fever, Reddened area begins to spread, Small red spots that appear on the reddened skin, Small blisters which may form and burst, Swollen lymph glands .Weekly treatment documentation to include measurement of each area of skin [MEDICAL CONDITION] width, length, color and exudate and any other notable changes or observations. Documented under Pain Management with a start date of 1/21/20 was .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Surveyor reviewed MD visit note from 1/22/20 performed by Wound Physician (MD)-I in facility. Documented was Wound #1, RLL is acute full thickness burn, 3rd degree and has received a status of not healed. Initial wound encounter measurements are 25cm length X 31 cm width X 0.1 cm depth with a area of 775 sq cm and a volume of 77.5 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is moderate amount of serous drainage noted which has no odor. The patient reports a wound pain of level 0/10. Wound bed has 51-75% [MEDICATION NAME], 1-25% slough, no granulation, no eschar. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The temp of the periwound skin is WNL. Periwound skin does not exhibit signs or symptoms of infection. (MD-I) debrided the wound with post debridement measurements of: 25cm x 31cm x 0.3cm with an area of 775 sq cm and volume of 232.5 cubic cm. MD-I changed the wound dressing to Cleanse with Normal Saline. Apply: xeroform, ABD, Kerlix BID and PRN. Surveyor reviewed R300's TAR and Progress Notes for 1/22/20 through 1/28/20 for wound care. Wound care was not verified completed on 1/26/20 PM shift. No noted changes in wound were documented in Progress Notes or Skin Assessments. On 1/28/20 R300 visited Wound Clinic at Aurora Health Care. Documented in Outpatient Wound Care Progress Note was Chief Complainant: Right leg ulcer. Additional Wound Category: Venous leg ulcer: [MEDICAL CONDITION] ulcer, lower extremity, RLE . Medical Decision Making: 1/28/20 RLE with ongoing wounds that have progressed to scattered open wounds circumferentially. Right lateral leg with full-thickness open wounds/ (discontinue) xeroform . No signs and symptoms of wound infection. Wound care was changed to Begin [MEDICATION NAME] or iodosorb to right lateral leg wounds followed by ABD followed by Visco/Cotton/Coban 3x/week. Add oil [MEDICATION NAME] gauze PRN to prevent sticking. No updates to care plan were made. On 1/30/20 R300's Skin Impairment/Wound Form documents the wound type as Burn(s) (second or third degree) and has measurements of 36 X 49 X 0.2 cm. The wound bed was described as 70% [MEDICATION NAME], 30% granulation. Surveyor reviewed the revised Comprehensive Care Plan with revision date of 2/3/20. Documented was Administer [MEDICATION NAME] as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. The resident prefers to have pain controlled. There were no further updates or revisions to the care plan or pain assessments completed. Surveyor reviewed R300's TAR and Progress Notes for 2/3/20 through 2/12/20 for wound care. Wound care was not verified completed on 2/10/20 shift. Documented on TAR was 10: Other/See Progress Notes. No noted changes in wound were documented in Progress Notes or Skin Assessments. No wound care was completed per TAR since 2/7/20. On 2/7/20 R300's Skin Impairment/Wound Form documents the wound type as Burn(s) (second or third degree) and has measurements of 35.2 X 45 cm. The wound bed was described as 80% granulation, 20% slough. There is no documentation of MD being updated of slough in wound or evidence that staff updated the care plan. Surveyor reviewed MD visit note from 2/12/20 performed by Wound Physician MD-I in facility. Documented was Procedure Note: The wound was cleansed with normal saline and anesthesia was achieved with topical [MEDICATION NAME]. Then with clean surgical technique, 15 blade was used to surgically excise 42.90 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissue were removed at a depth of 0.9 cm and healthy bleeding tissue was observed. The wound was measured at 13 X 5.5 X 0.8 cm and wound base was described as 40% granulation, 60% slough. Also noted was This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm. Wound care was changed to Dakins solution apply twice daily for 30 days: ½ strength wat to moist; ABD pad non sterile apply twice daily for 30 days. Gauze roll non sterile (kerlix) apply twice daily for 30 days. There was no update to the care plan. On 2/13/20 at 5:12 PM, Progress Notes documented Received order from (MD) for PRN ([MEDICATION NAME]) 5/325 due to wound pain. Resident informed of new order. MD order was completed but there was no revised Comprehensive Pain Assessment completed and no update to care plan. TAR indicated pain level of 8/10 and 1 tablet [MEDICATION NAME] administered at 5:07 PM and effective. On 2/14/20 at 12:48 PM, Progress Notes documented Treatment to right lower extremity per MD orders. Large amount of tan drainage with small amount of bloody (drainage) noted on old (dressing.) Resident tolerated it well. 2/15/20 at 5:20 PM, Progress Notes documented Resident dressing to right leg done BID, large amount of slough noted to wound base. Resident with increased pain to area, started on [MEDICATION NAME] prn for pain with moderate success. TAR indicated pain level of 6/10 to 8/10 and doses of [MEDICATION NAME] administered at 8:10 AM, 2:00 PM, 6:25 PM and 10:50 PM with 6:25 PM dose documented as ineffective. No further updates on pain, wound or other assessments were noted. On 2/16/20 at 5:25 PM, Progress Notes documented Wound care done BID with dakins dressing. Wound pain increased now, continues on [MEDICATION NAME] prn with moderate success. There is no documentation of MD being updated on pain management or Comprehensive Pain Assessment being completed. TAR indicated pain level of 4/10 to 8/10 and doses of [MEDICATION NAME] administered at 3:15 AM, 7:34 AM, and 10:30 PM. 1000mg Tylenol was also administered at 11:28 PM. On 2/17/20, TAR indicated pain level of 8/10 and doses of [MEDICATION NAME] administered at 1:15 AM and 5:15 AM. At 11:28 PM 1000 mg Tylenol was given for 6/10 pain. R300's MD orders documented on 2/17/20 an order for [REDACTED]. No patch was placed on R300 on 2/17/20 for pain management. Per TAR, documented at 10:09 PM was 10: Other/ See Progress Notes with no notes in chart. Surveyor reviewed Care One Pharmacy delivery slip for [MEDICATION NAME] delivery on 2/18/20. 12 MCG/HR patches were delivered for R300 at 7:10 AM. On 2/18/20 at 11:46 AM, Progress Notes documented (Resident) left for wound clinic appointment at 7:40 AM. Writer received a call from the clinic stating that resident has been sent to (Emergency Department (ED)) for worsening wound condition. There is no documentation that [MEDICATION NAME] was placed on R300 on 2/18/20 before leaving for wound care appointment. On 2/18/20 at 5:24 PM, Progress Notes documented Resident admitted to aurora hospital for [MEDICAL CONDITION]. Surveyor reviewed hospital paperwork from admission on 2/18/20 directly from wound clinic. Documented under History of Present Illness was .presented to the ED for evaluation of right lower leg ulcer. Patient was admitted to the hospital approximately 1 month and a half ago and it was noted he had lower leg [MEDICAL CONDITION]. He was called by wound care and is told that his skilled nursing facility should be performing specific dressing changes, patient self-reports that sometimes these dressing changes or instructions were not followed. He then saw wound care today and it was noted that his leg now has a ulcer and has worsened. Patient was sent into the emergency department for further evaluation. He denies any recent fever. He does report he has pain in the lower leg. Documented under Reason for Admission was .(Patient (Pt)) notes that his wound care was often skipped and often incorrect. He presented to the wound care follow-up without any compression and without the prescribed wound care dressings . Over the last several days, the patient has noted increased [MEDICAL CONDITION], pain, [DIAGNOSES REDACTED] and has had difficulty with ambulation. He has been taking Tylenol routinely to help with the pain. He denies any fever or chills. None of this was communicated to the wound care team. When seen for the follow-up with the wound care today, 2/18/20, he was noted to have significant advancement all with new open wounds with [DIAGNOSES REDACTED], warmth, and suspected underlying abscess to fluctuance and active drainage. Wound care sent him to the ED for further evaluation and monitoring. Documented in hospital discharge summary with a date of 2/25/20 was Hospital Course: He was admitted to the medical unit. (Infectious Disease (ID)) and wound care consulted. (Intravenous (IV)) [MEDICATION NAME] started and [MEDICATION NAME] was added. Wound cultures show ([MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA)) strep pyogenes and pseudomonas. Eight days of [MEDICATION NAME] and seven days of [MEDICATION NAME] were completed. Wound gradually improved and wound care recommended [MEDICATION NAME] with visco/[MEDICATION NAME] lite changed - 1/3 x week based on discharge. He was evaluated by therapy and mobility had improved to the point where he was cleared for discharge home. ID [MEDICATION NAME] for two weeks at discharge . Review of Systems: Right leg pain improving, able to ambulate much easier. Pain controlled on oral meds. On 2/28/20 at 9:59 AM, Surveyor interviewed Registered Nurse Supervisor (RN)-E. Surveyor asked what the wound looked like on admission. RN-E stated there was a large blister on the back of the leg and the rest of the leg was [MEDICAL CONDITION] and weeping. There was no large wound, only small peeling areas that were being treated with silvadine. Surveyor asked when the wound was reassessed. RN-E stated the following week. Surveyor asked what the wound looked like the week after admission. RN-E stated it looked a lot different than at admission and MD-I debrided that wound due to the change and slough was noted. Surveyor asked why the wound was classified as a burn. RN-E stated MD-I classified it that because the resident noted at home he had burned himself with using over the counter wound treatments when he was trying to heal it himself prior to hospitalization . On 3/2/20 at 2:35 PM, Surveyor interviewed RN-H. Surveyor asked if he assessed the wound on admission. RN-H stated no but he saw it shortly after admission. Surveyor asked what the wound looked like. RN-H stated it had drainage, the blister had popped and there was an ulcer noted. Surveyor asked what the wound looked like after the 1/28/20 wound care appointment. RN-H stated there was no [MEDICAL CONDITION] but the redness was worse, the ulceration was also getting bigger. RN-H stated this is why MD-I saw him on 2/12/20. Surveyor asked if the MD was updated on the changes to the wound. RN-H stated MD-I was updated on 2/11/20 at the request of the patient. Surveyor asked about R300's increased pain with wound treatments. RN-H stated he was having complaints of pain with dressing changes so the Medical Director was updated and ordered [MEDICATION NAME]. Surveyor asked if the [MEDICATION NAME] was effective. RN-H stated it had varying effectiveness and was somewhat effective. Surveyor asked why he switched to the [MEDICATION NAME]. RN-H stated the Tylenol was effective at first but as the wound got worse the Tylenol was not effective. On 3/3/20 at 9:58 AM, Surveyor interviewed RN-F. Surveyor asked when the wound started to worsen. RN-F stated he went to the wound clinic and after that the wound worsened. RN-F stated it was sloughy, oozing and the resident had increased pain. Surveyor asked what interventions were put in place for this. RN-F stated [MEDICATION NAME] was ordered for the pain but he still had pain during wound treatments even when pre-medicated. On 3/3/20 at 11:19 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked when the MD should be updated on a wound. DON-B stated if the wound had changed in any way. DON-B added if the resident has a temperature or a deterioration in the wound itself had happened. Surveyor noted the instances in January and February when R300's wound had changed. DON-B stated yes, the MD should have been notified. Surveyor asked about R300's increased pain. DON-B stated the facility ordered [MEDICATION NAME] for the pain. Surveyor asked what should be done if a resident has increased pain. DON-B stated MD should be notified and a new pain assessment should be completed. Surveyor asked if the care plan should have been updated and new pain assessment completed after the 2/3/20 order of [MEDICATION NAME] for increased pain with wound treatment. DON-B stated yes. Surveyor asked why the [MEDICATION NAME] was ordered. DON-B stated she was not sure but assumed the [MEDICATION NAME] was not totally effective. Surveyor asked when the [MEDICATION NAME] was ordered and when if should have arrived. DON-B stated on 2/17/20 and it should have been delivered that evening. Surveyor asked if the [MEDICATION NAME] was ever put on. DON-B stated that she would get back to Surveyor. On 3/3/20 at 2:28 PM, Surveyor interviewed MD-I. Surveyor asked why the wound was classified as a burn. MD-I stated by looking at the wound and the resident's recollection of how the wound developed it was most likely a burn. Surveyor asked what the wound looked like on 1/22/20 when he first assessed it. MD-I stated small amounts of slough and clusters of wounds including 2 smaller strips of dead wounds. Surveyor asked about the large 25 X 31 X 0.1 cm measurement. MD-I stated he measured the whole area including the skin areas from top to bottom. Surveyor asked about the 15 X 5 X 0.8 cm measurement and the size difference. MD-I stated that was one ulcer and the wound had deteriorated and needed a large amount of debridement. On 3/3/20 at 3:07 PM, Surveyor interviewed RN Nurse (Consultant)-C. Surveyor asked if the [MEDICATION NAME] was ever put on the resident. Consultant-C stated according to the narcotic sign out sheet, no. There was no further documentation provided verifying wound treatments completed.

Based on interview and record review, the facility did not ensure that sufficient nursing staff were provided to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being of 5 residents (R1, R52, R101, R400, and R500) at risk for elopement from a census of 62 residents. * R1 was restless throughout the night of ,[DATE] and [DATE]. Staff working indicated they were short one certified nursing assistant (CNA) and that it was difficult to supervise R1. R1 eloped from the facility due to inadequate staffing to provide proper supervision, fell outside in the patio area and subsequently died as a result of her injuries. This deficient practice has the potential to affect 4 additional residents (R52, R101, R400 and R500.), residing at the facility during the time of the survey, whom required sufficient nursing staff to assure resident safety and were also at risk of elopement. The facility's failure to provide sufficient staff to ensure adequate supervision to prevent elopement and R1's subsequent fall created a finding of Immediate Jeopardy that began on [DATE]. Senior Administrator-G and Director of Nursing-B were notified of the immediate jeopardy on [DATE] at 2:08 p.m. The immediate jeopardy was removed on [DATE] when the facility implemented a removal plan. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: On [DATE], R1 eloped from the facility, fell outside and subsequently died due to her injuries. Cross reference F689 for further details regarding the fall, R1's injuries, and weather conditions outside at the time * Staffing Hours The facility is composed of four units and had a census of 62 residents on the night of [DATE] into the early morning of [DATE]. According to the Resident Censure and Condition Report (CMS Form 672) for the facility on [DATE], provided and verified by Senior Administrator-G, the facility's residents on [DATE] had the following personal care needs: Bathing: Assist of 1 or 2 staff - 36 residents Dependent - 21 residents Dressing: Assist of 1 or 2 staff - 47 residents Dependent - 7 residents Transferring: Assist of 1 or 2 staff - 34 residents Dependent - 18 residents Toilet use: Assist of 1 or 2 staff - 44 residents Dependent - 10 residents Eating: Assistant of 1 or 2 staff - 35 residents Dependent - 4 residents On [DATE] at 1:44 p.m., Surveyor interviewed Scheduler-DD regarding the staffing levels on the night of [DATE] into [DATE]. Surveyor asked Scheduler-DD how the facility determines the amount of staffing needed to meet resident's needs. Scheduler-DD informed Surveyor that the facility determines the amount of staffing needed to meet resident's needs based on the census of residents residing at the facility at that time. Scheduler-DD informed Surveyor that the facility does increase staffing if DON (Director of Nursing)-B informs her of the need to schedule more staff due to an increase in acuity. Surveyor asked Scheduler-DD how the facility is normally staffed on nights. Per Scheduler-DD, the facility at a minimum staffs the following number of nurses and CNAs (Certified Nursing Assistants) as follows: Third Shift (night shift): 3 CNAs & 2 Nurses Scheduler-DD informed Surveyor that the above number of CNAs is the minimum number of CNAs required to meet each resident's needs. On [DATE], Surveyor reviewed the actual facility staffing levels from [DATE] to [DATE]. Surveyor noted that the facility's actual staffing levels from [DATE] to [DATE] usually reflected a minimum of 5 nursing staff scheduled and or working on the night shift. Based on the minimum staffing levels provided by Scheduler-DD, Surveyor noted that the facility was short of nursing staff the following days: - [DATE]- night shift- Actual Staffing: 2 nurses and 2 CNAs (short 1 CNA) - [DATE]- night shift- Actual Staffing: 2 nurses and 2 CNAs (short 1 CNA) On [DATE] at 8:54 a.m., Surveyor informed Scheduler-DD of the above findings. Scheduler-DD confirmed that the facility normally staffs a total of five nursing staff members on the night shift. Scheduler-DD confirmed that on the night shift of [DATE] into [DATE] the facility was short staffed and that only 4 nursing staff members were working as opposed to the usual 5. * Written Statements The facility's investigation into R1's elopement and fall dated [DATE] and titled Four Point Plan Of Correction Agenda and Summary documents: Root Cause (Five Ways/Opportunity for Improvement: (Please Describe) Problem Statement ----- Resident was in a wheelchair on 5 dining room and was found outside . Why ---- Resident was up all shift and attempting to ambulate independently . Root Causes(s) ---- 1. Resident was previously independent in ambulation 2. Resident was in the dining room unsupervised (emphasized) 3. Was able to exit the facility egress alarming door Under the Falls Occurrence Report section, written by LPN (Licensed Practical Nurse)-P documents: Detailed Description of event: 0500 (5 AM) Writer was at wing 4 doing medpass. (R57) informed writer that R1 was outside by the dining room (wing 5). Resident was lying on the left side, assisted by 2 staff to her wheelchair, hematoma to her left forehead was noted, and ice pack was applied. Resident alert complaining of left hip pain, 911 was called, left 5:20 AM to hospital; Probable cause of Fall: Lost balance; What could have prevent fall: Needs 1:1 monitoring (emphasized). LPN-P's witness statement dated [DATE] documents, Where was the resident found: Wing 5 dining room, outside by the door; What was the resident trying to do: Per (R57), who witnessed the fall, she (R1) was knocking the door and end up to the ground; When was the resident last checked on: 0435 (4:35 AM); What most likely caused the fall: WANDERS, walked by herself; What could have prevented the fall: 1:1 supervision for fall safety (emphasized). CNA-Q's witness statement dated [DATE] documents, On Friday Feb. 14 2020. I (sic) was only two CNA's in the building at 4:00 (AM) (emphasized). The two CNA's begin during (sic) rounds on wing 5 so we changed (R1) and set her at the main nurse's station because the (LPN-D) was sitting at the computer, we went on to finish rounds and at 4:30 (AM) we noticed that (LPN-D) had pushed (R1) down to the day Room on wing 5. * Interviews On [DATE] at 12:11 p.m., Surveyor interviewed LPN-P regarding R1's fall on [DATE]. LPN-P informed Surveyor that she was assigned to units 4 and 5 the night of [DATE] into [DATE]. LPN-P informed Surveyor that on the night on [DATE], she observed R1 be wandering and restless and that she had been previously placed at the main nursing station with LPN-D due to her wandering behaviors and refusal to go to bed. LPN-P informed Surveyor that she was aware that R1 needed to be closely monitored due to her high fall risk and not due to elopement behaviors. On [DATE] at 11:34 a.m., Surveyor interviewed CNA-CC regarding R1's fall on [DATE]. CNA-CC informed Surveyor that she had observed R1 previously throughout the night and that R1 had been restless, wandering and refusing to go to bed in her room. CNA-CC informed Surveyor that on the night of [DATE] into [DATE], the facility was short staffed and that she was unable to watch R1 as she was busy providing cares to another resident. On [DATE] at 12:45 p.m., Surveyor interviewed LPN-D regarding R1's fall on [DATE]. LPN-D informed Surveyor that the facility was short staffed that night and that the two CNAs were working as a pair due to short staffing. LPN-D informed Surveyor that it was common knowledge that R1 needed to be kept in high traffic areas so that R1 could hear staff voices which would calm R1. LPN-D informed Surveyor that it was known that R1 would become restless if she did not hear staff voices and feel isolated, causing R1 to attempt to get out of her wheelchair and wander. On [DATE] at 11:41 a.m., Surveyor interviewed CNA-Q regarding R1's fall on [DATE]. CNA-Q informed Surveyor that she had observed R1 at the main nurse's station with LPN-D earlier in the night and that she had observed R1 to be restless and wandering throughout the night of [DATE]. CNA-Q informed Surveyor that the facility was short staffed and that she was unable to watch R1 as she was busy providing cares to another resident. On [DATE] at 2:39 p.m., Surveyor interviewed R57 regarding R1's fall on [DATE]. R57 informed Surveyor that when he observed R1 fall outside, he went searching for staff in his motorized wheelchair and was initially unable to locate any staff (emphasized) until he saw LPN-D. R57 informed Surveyor that after LPN-D responded he circled the main nursing station two times, yelling for additional staff assistance. R57 informed Surveyor that it took approximately 6 to 7 minutes before he could locate LPN-P and CNA-Q on wing 4 so that they could assist LPN-D with getting R57 inside (emphasized). * Other Residents at Risk At the time of R1's elopement from the facility on [DATE], the following residents were at risk for elopement per the facility's wandering book and assessments: R52, R101, R400 and R500. Based on interviews and a review of the actual staffing levels for the night of [DATE] into [DATE], Surveyor noted that the facility was short staffed and did not have the minimum amount of staff required, per the facility's staffing guidelines, to provide adequate supervision and meet resident's needs. The facility's failure to provide sufficient staff to provide adequate supervision to prevent elopement and R1's subsequent fall created a finding of Immediate Jeopardy that began on [DATE]. Senior Administrator-G and Director of Nursing-B were notified of the immediate jeopardy on [DATE] at 2:08 p.m. The immediate jeopardy was removed on [DATE], when the facility completed the following: - Review staffing levels, nursing and non-nursing, either prior to or at the daily morning meeting for the current day - Review anticipated staffing levels for at least the following day. - Provide education to the Team regarding staffing review, interventions and expectations for when staffing levels are below minimums or barriers are met to meeting resident needs with the current staffing level. - When the minimum staffing level is not met after normal business hours or staff cannot meet resident needs with the current staffing level, the DON and/or Administrator must be notified and if issue is not resolved timely the DON and Administrator shall go to the facility to offer support. - Generate and implement a nurse manager rotation for covering direct care staff openings when indicated. -When unable to adjust staff schedules or immediately illicit coverage, implement the following staffing crisis protocols: When nursing staffing levels falls below the minimum within the facility: 1) Nursing Management will be notified and required to remain in the building (or return to the building) until resolution is achieved. Resolution may be achieved by Nursing Management working as a direct care staff member. Assign non-nursing personnel to units to assist with call lights, transporting residents . and non-nursing requests. 2) Licensed/certified staff members will be contacted and offered a monetary bonus to cover openings. 3) Sister facilities will be contacted to seek additional assistance from licensed/certified staff in covering openings. 4) Notify the VP of Clinical Services. Any licensed/certified corporate team member will be deployed to assist in covering openings. - Defer new referrals/new admissions when staffing issues are anticipated in meeting required staffing levels. - Review and revise recruitment and retention efforts.

Based on interview and record review, the facility did not ensure that 1 (R1) of 6 residents reviewed had adequate supervision and assistance devices in place to prevent accidents. * R1, who had been restless throughout the night, eloped from the facility due to inadequate supervision at a time when the temperature outside was 19 degrees and winds were 15 mph. R1 fell outside in the patio area and subsequently died as a result of her injuries. The facility's failure to provide adequate supervision to prevent elopement and R1's subsequent fall created a finding of Immediate Jeopardy that began on [DATE]. Senior Administrator-G and Director of Nursing-B were notified of the immediate jeopardy on [DATE] at 2:08 p.m. The immediate jeopardy was removed on [DATE] when the facility implemented a removal plan. The deficient practice continues at a scope and severity (s/s) of a E (potential for harm/pattern) as the facility continues to implement their action plan. Findings include: The facility's Elopement Policy dated [DATE] and titled, Elopement Prevention documents: POLICY STATEMENT: It is a policy of this facility that all residents are afforded adequate supervision to meet each resident's nursing and personal care needs. All resident will be assessed for behaviors or conditions that could potentially place them at risk for elopement. All residents so identified will have these issues addressed in their plan of care. PREVENTATIVE MEASURES: Routine Procedures for the Prevention of Missing Residents and Elopements: - Upon admission, re- admission or the development of elopement behaviors, all resident will be assessed for elopement risk utilizing the Elopement Risk Assessment form. Residents identified as at risk for elopement will be reassessed quarterly and with significant change of condition in conjunction with the MDS schedule - Any resident identified as at risk to elope will have a picture taken and placed at the reception desk - A comprehensive elopement prevention plan of care will be developed for each resident identified as at risk for elopement - Unless otherwise specified in a plan of care will be developed for each resident identified as at risk for elopement who leave the facility property shall be accompanied and the responsible party shall sign the resident out of the facility on a resident sign- out sheet - Should an alarm on one of the exits to the outside of the facility be sounded, staff shall immediately respond to and determine the cause of the alarm. All facility staff members are responsible for responding to an exit alarm - After the facility investigated an exit alarm, if no reason can be found for the sounding of that alarm, if no reason can be found for the sounding of that alarm, the Nurse Manager shall be notified and an account of the all residents. IN THE EVENT A RESIDENT IS NOT LOCATED, PROCEED TO THE RESIDENT IS NOT LOCATED, PROCEED TO THE RESIDENT ELOPEMENT PLAN. If, after all at-risk residents are accounted for, the cause of the alarm is still undetermined a reasonable investigation to determine the cause of the alarm shall continue. Environmental Considerations for the Prevention of Missing Residents and Elopements: - Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility - A Wander guard safety device that will notify facility staff when the resident has left the building without supervision; and/or - Door alarms on facility exits; and/or - Staff supervision; either by visual contact or closed circuit television, of the facility exits - As part of the facility's Preventative maintenance Program, all Wander guard safety devices and door alarms shall be maintained and tested in accordance with the manufacturer's instruction. The regular testing of all the Wander Guard safety devices and door alarms shall be documented and included as part of the Preventative maintenance Program. On [DATE], an anonymous complaint was filed with the Southeastern Regional Office that alleged R1 had eloped from the facility, had fallen outside and died at the hospital. * Resident Background R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Hospital Discharge documentation from the hospital that was provided to the facility upon R1's admission to the facility on [DATE] documents, Neurological Assessment: Disoriented to situation, forgetfulness, poor judgement, poor safety awareness, short term memory loss. R1's Admission MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 3, indicating that R1 had severe cognitive impairment. Section E (Behavior) documents that R1 did not display Wandering behavior during the MDS (Minimum Data Set) look back/assessment period. Section G (Functional Status) documents that R1 required extensive assistance and a one person physical assist for her bed mobility and transfer needs. Section G also documents that R1 had total dependence on staff and required a one person physical assist for her locomotion on and off the unit. Section P (Restraints and Alarms) documents that no elopement/wandering alarms were used for R1. R1's Falls CAA dated [DATE] documents under the Care Plan Considerations section, Triggered falls r/t (related to) history of falling, only able to stabilize with staff assistance for toileting, moving from seated to standing position. Call light will be kept within reach. Safety reminders will be given. Activities will be encouraged. Appropriate footwear will be worn. Therapy will evaluate and treat as needed. Surveyor was unable to locate any CAA (Care Area Assessment) in R1's medical record that documented any wandering type behaviors. R1's Fall Risk assessment dated [DATE] documents a score of 16, indicating that R1 is at high risk for falls. R1's Falls care plan dated [DATE] documents under the Interventions section, Keep call light in reach and use of appropriate footwear. R1's Elopement assessment dated [DATE] documents a score of 7, indicating that R1 is at risk for elopement. R1's Elopement care plan dated as initiated on [DATE] documents under the focus section, The resident demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming related to the [DIAGNOSES REDACTED]. Under the interventions section it documents, Post a picture of the resident at/near the front desk and/or nursing station in a discrete place identifying possible elopement risk. Notify staff of risk potential; Make rounds/room checks per facility protocol to minimize chances of unauthorized leave. Surveyor noted that R1's Elopement intervention did not list a specific time interval or how often facility staff were to make rounds/room checks for R1. R1's CNA (Certified Nursing Assistant) Kardex documents under the Safety section, Make rounds/room checks per facility protocol to minimize chances of unauthorized leave. Surveyor noted that R1's CNA (Certified Nursing Assistant) Kardex did not list a specific time interval or how often facility staff were to make rounds/room checks for R1. Surveyor was unable to locate any documentation that R1 had a Wanderguard placed during her stay at the facility, even thought R1 was assessed as being at risk of elopement on [DATE]. Surveyor reviewed the facility's elopement binder and could not locate a picture of R1 in the elopement binder that would alert facility staff to R1's elopement risk. On [DATE] at 9:13 a.m., Surveyor asked DON (Director of Nursing)-B if R1 had a Wanderguard placed on her per the facility's Elopement policy. DON-B informed Surveyor that R1 did not have a Wanderguard placed on her because she believed R1 was not at risk for elopement. Surveyor asked DON-B if R1 had her picture placed in the elopement binder to alert staff of her elopement behavior per the facility's Elopement policy. DON-B informed Surveyor that R1 did not have her picture placed in the elopement binder because she believed R1 was not at risk for elopement. * Elopement/Fall Event R1's nursing note dated [DATE] documents, Note Text: 0500 (5 AM): Writer was doing medpass (medication pass) at wing 4, R57 came to informed, that R1 was on the ground, writer responded right away, resident was lying to her left side, outside the door by wing 5 dining room, assisted by three staff to her wheelchair, hematoma to left forehead noted, icepack applied, neuro (neurological) check WNL (within normal limits),verbalized pain to her left side of the hip, VS (vital signs) was check, BP (blood pressure) ,[DATE], P (pulse) 75, R (respirations) 22, T (temperature) 98.9, called 911, report was given, 0520 (5:20 AM) left the building going to hospital, DON (Director of Nursing) was paged, family was informed about the incident, Dr. (doctor) was informed at around 0715 (7:15 AM). R1's hospital admission documentation dated [DATE], from when R1 was admitted to the emergency room , documents, admitting [DIAGNOSES REDACTED]. Hospital Course: This is a [AGE] year old female who presents to the emergency department after an unwitnessed fall where she hit her head and fractured her left hip .Apparently since being at the nursing home she was more confused, which is likely contributors to the fall. Her children chose to not undergo hip repair during this hospitalization and she was instead made comfort measures and placed on a [MEDICATION NAME] drip due to her significant paint. Ultimately, she expired at 2:12 (AM) on [DATE]; Discharge Condition: Expired. The facility's investigation into R1's elopement and fall dated [DATE] included witness statements from staff that was working that night and from R57. R57's witness statement dated [DATE] documents, Had gotten up, dressed, and gone to the front to grab a newspaper. I came back to my room to read it in my chair. I heard an alarm sounding near my room. So, I went out to investigate. On the way, the alarm doubled, and I realized it was by my (wing 5) dining room. I looked and saw (R1) standing outside by the door, coming back in. I slowly opened the door and reached for her hand, but as I did she fell down. I can't lift her myself so I raced down and got (LPN-D) and the girls and they immediately got her up. LPN-P's witness statement dated [DATE] documents, Where was the resident found: Wing 5 dining room, outside by the door; What was the resident trying to do: Per (R57), who witnessed the fall, she (R1) was knocking the door and end up to (sic) the ground; When was the resident last checked on: 0435 (4:35 AM); What most likely caused the fall: WANDERS, walked by herself; What could have prevented the fall: 1:1 supervision for fall safety. CNA (Certified Nursing Assistant)-CC's witness statement dated [DATE] documents that she (CNA-CC) was providing cares to another resident on wing 5 and did not observe or participate in R1's fall in anyway. LPN-D's witness statement dated [DATE] documents, (R57) came over to me @ (at) W5 (wing 5) while I was passing medication. He reports that (R1) was outside. I sought the help of other staff. We went to check on it. (R1) was found on the ground, face down. CNA-Q's witness statement dated [DATE] documents, On Friday Feb. 14 2020. I (sic) was only two CNA's in the building at 4:00 (AM). The two CNA's begin during (sic) rounds on wing 5 so we changed (R1) and set her at the main nurse's station because the (LPN-D) was sitting at the computer, we went on to finish rounds and at 4:30 (AM) we noticed that (LPN-D) had pushed (R1) down to the day Room on wing 5. The (CNA-CC) begin (sic) getting up a resident that had to go to the [MEDICAL TREATMENT] and I continued to do more rounds on wing 4. As I came out (sic) a room on (wing) 4 I seen (R57) racing down in his scooter to (LPN-D) and telling him (R1) was outside. I raced down to see about (R1). (LPN-P) and I picked her up put her in the wheelchair and called 911. Surveyor completed interviews of staff and of R57. On [DATE] at 2:39 p.m., Surveyor interviewed R57 regarding R1's fall on [DATE]. R57 confirmed to Surveyor his above statement. R57 informed Surveyor that when he observed R1 fall outside, he went searching for staff in his motorized wheelchair and was initially unable to locate any staff until he saw LPN-D. R57 informed Surveyor that after LPN-D responded he circled the main nursing station two times, yelling for additional staff assistance. R57 informed Surveyor that it took approximately 6 to 7 minutes before he could locate LPN-P and CNA-Q on wing 4 so that they could assist LPN-D with getting R57 inside. R57 informed Surveyor that R1 was not wearing a jacket when he observed her outside and that he was concerned about R1 and the cold temperature outside. On [DATE] at 11:34 a.m., Surveyor interviewed CNA-CC regarding R1's fall on [DATE]. CNA-CC informed Surveyor that she had observed R1 previously throughout the night and that R1 had been restless, wandering and refusing to go to bed in her room. CNA-CC informed Surveyor that she was providing cares to another resident on wing 5 and did not observe or participate in R1's fall in anyway. CNA-CC informed Surveyor that she did not hear any alarm in the building going off as she was in another resident's room when R1 eloped from the facility. CNA-CC informed Surveyor that on the night of [DATE] into [DATE], the facility was short staffed and that she was unable to watch R1 as she was busy providing cares to another resident. On [DATE] at 11:41 a.m., Surveyor interviewed CNA-Q regarding R1's fall on [DATE]. CNA-Q informed Surveyor that she was working on unit 4 with LPN-P and that she did not hear any door alarm or wandering alarm sound as she was in another resident's room when R1 went outside and fell . CNA-Q informed Surveyor that R57 had notified her that R1 had fallen outside and that she responded with LPN-P and assisted LPN-P to get R1 off the ground and into her wheelchair. CNA-Q informed Surveyor that R1 was not wearing a jacket or winter clothing so she had assisted LPN-P place R1 into the wheelchair because it was cold outside the morning of [DATE]. CNA-Q informed Surveyor that she had observed R1 at the main nurse's station with LPN-D earlier in the night and that she had observed R1 to be restless and wandering throughout the night of [DATE]. CNA-Q informed Surveyor that R1 was not wearing a Wanderguard on her body at the time when she found R1 outside the morning of [DATE]. CNA-Q confirmed her above statement to Surveyor and informed Surveyor that she had last observed R1 around 4:30 a.m. and that on the night of [DATE] into [DATE], the facility was short staffed and that she was unable to watch R1 as she was busy providing cares to another resident. On [DATE] at 12:11 p.m., Surveyor interviewed LPN-P regarding R1's fall on [DATE]. LPN-P informed Surveyor that she was assigned to units 4 and 5 the night of [DATE] into [DATE]. LPN-P informed Surveyor that on the night on [DATE], she observed R1 be wandering and restless and that she had been previously placed at the main nursing station with LPN-D due to her wandering behaviors and refusal to go to bed. LPN-P informed Surveyor that she was aware that R1 needed to be closely monitored due to her high fall risk and not due to elopement behaviors. LPN-P informed Surveyor that she was on wing 4 doing medication pass and that she was alerted by R57 that R1 had fallen outside. LPN-P confirmed her above statement to Surveyor and informed Surveyor that she had placed R1 into her wheelchair after she fell outside because it was cold outside and that R1 was not wearing jacket at the time of her fall. LPN-P informed Surveyor that she did not hear any door alarm or wandering alarm sound as she was on another unit when R1 went outside and fell . LPN-P informed Surveyor that the facility was short staffed that night and that she last saw R1 sleeping in her wheelchair and had felt the CNAs would supervise R1, as the CNAs were working in pairs that night. LPN-P informed Surveyor that R1 was not wearing a Wanderguard on her body at the time when she found R1 outside the morning of [DATE]. On [DATE] at 12:45 p.m., Surveyor interviewed LPN-D regarding R1's fall on [DATE]. LPN-D informed Surveyor that he was assigned to units 1 and 2 the night of [DATE] into [DATE]. LPN-D informed Surveyor that on the night on [DATE], he observed R1 wandering and standing out of her wheelchair between 11:30 PM and 12:00 AM. LPN-D informed Surveyor that because of this, he brought R1 to the main nursing station with him so that he could supervise R1 as he charted. LPN-D informed Surveyor that it was common knowledge that R1 needed to be kept in high traffic areas so that R1 could hear staff voices which would calm R1. LPN-D informed Surveyor that it was known that R1 would become restless if she did not hear staff voices and feel isolated, causing R1 to attempt to get out of her wheelchair and wander. LPN-D informed Surveyor that around 2 AM, he was done charting at the main nursing station and brought back R1 to wing 5, where LPN-P was assigned. LPN-D informed Surveyor that he informed LPN-P that R1 needed to be supervised and that LPN-P had instructed him (LPN-D) to prop R1 up against the dining room table. LPN-D informed Surveyor that he did as LPN-P asked and placed R1 against the dining room table and left the unit. LPN-D informed Surveyor that at approximately 5 AM, he was standing in front of room [ROOM NUMBER] on wing 2, when R57 came in his motorized wheelchair and began yelling 'R1- she's outside, she's outside.' LPN-D informed Surveyor that he then responded to the wing 5 dining room and observed R1 outside on the ground. LPN-D confirmed his above statement to Surveyor and informed Surveyor that he was unable to bring R1 inside by himself and had waited for LPN-P and the CNAs to arrive to get R1 inside, as he (LPN-D) was concerned about the cold temperature outside. LPN-D informed Surveyor that he did not hear any door alarm or wandering alarm sound as he was on another unit when R1 went outside and fell . LPN-D informed Surveyor that R1 was not wearing a Wanderguard on her body at the time when she found R1 outside the morning of [DATE]. LPN-D informed Surveyor that the facility was short staffed that night and that the two CNAs were working as a pair due to short staffing. On [DATE] at 12:42 p.m., Surveyor asked Maintenance Director-EE if he had a log that documented the testing of the Wanderguard system and door alarms as documented in the facility's Elopement policy. Maintenance Director-EE informed Surveyor that he had just started working at the facility and that he did not have a log that documented that the Wanderguard system and door alarms were being tested as documented in the facility's Elopement policy. * Environmental Factors Surveyor noted that per interview statements, staff members and R57 were concerned about the weather outside when R1 eloped from the facility on [DATE]. According to the National Oceanic & Atmospheric Administration, the weather in Kenosha at 4:53 AM on [DATE] was 19 degrees Fahrenheit with 15 mph (mile per hour) winds. Per the National Oceanic & Atmospheric Administration, it only takes 30 minutes for frostbite to develop. According to the National Institute of Health, Older adults are especially vulnerable to hypothermia, which can be deadly if not treated quickly.Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes (which this resident had) and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature. http://www.nih.gov/news/health/jan2009/nia-16.htm According to http://www.livescience.com/6008-person-freeze-death.html, A drop in body temperature prevents critical organs from working properly - including the brain and heart, according to the Mayo Clinic. Improper functioning of the heart results in reduced blood flow to many organs, putting the body in a state of shock and increasing the risk of conditions like liver failure and kidney failure . The very young and the very old are at greater risk for hypothermia because they generally have weaker heart muscles, he said. In addition, older people are more likely to take medications such as beta blockers that can slow heart rate, which further increases their risk of developing hypothermia in the cold .Symptoms of mild hypothermia, such as shivering, weakness and confusion, set in when core body temperature reaches about 95 F (Fahrenheit). After that, 'as you start dropping (in core body temperature), bad things happen .At 91 F (33 C), you can experience amnesia. At 82 F (28 C) you can lose consciousness. Below 70 F (21 C), you are said to have profound hypothermia and death can occur. The above source notes that fingers and toes are more prone to frostbite, because those areas will have reduced blood flow in cold temperatures, as your body tries to keep its core warm and that the length of time it takes for frostbite to develop depends on the conditions. According to the National Weather Service Wind Chill Chart, an individual could get frostbite in about 30 minutes at the temperature noted here. This could, however, occur sooner for someone who is elderly and who has diabetes. Frostbite has four stages. In first-degree frostbite, the affected area of skin usually becomes white and feels numb. If treated quickly, the skin usually recovers fully. In fourth-degree frostbite, there is damage to the full thickness of the skin and also the underlying tissues such as muscle, tendons and bone. Tissue damage and loss can be permanent and amputation of fingers or toes may be needed to remove dead tissue. Surveyor noted that due to the facility's star shaped layout, staff members working on other units did not have a direct visual path of sight of R1 when R1 eloped from the facility on [DATE]. On [DATE] at 12:42 p.m., Surveyor and Maintenance Director-EE tested the wing 5 dining room door alarm from which R1 eloped through on [DATE]. A surveyor located on wing 4 during this time was unable to hear the alarm emanating from the wing 5 dining room door. On [DATE] at 9:10 a.m., Surveyor and Maintenance Director-EE tested the wing 5 dining room door from which R1 eloped through. Surveyor noted that the door immediately starts alarming when pushed and releases due to fire code regulations after 15 seconds of constant pressure. Surveyor observed that this initial door alarm, [MEDICATION NAME] 15 seconds, only alerts locally and does not alert at the main nurses station, which after measuring with Maintenance Director-EE is 225 away from room [ROOM NUMBER], on wing 5, where LPN-D was located when R1 left the building and left on [DATE]. Surveyor noted that after 15 seconds, a secondary alarm begins ringing at the main nursing station, which per Maintenance Director-EE is 40 feet away from away from room [ROOM NUMBER], on wing 5, where LPN-D was located when R1 left the building and left on [DATE]. A review of the facility's actual staffing levels from [DATE] to [DATE] documents that the facility normally staffs a total of five facility staff members. A review of the staffing levels for the night on [DATE] into [DATE] reveals only four facility staff members scheduled and working the night of [DATE] into [DATE]. Cross reference F725. The facility's failure to provide adequate supervision to prevent elopement and the subsequent fall created a finding of Immediate Jeopardy that began on [DATE]. Senior Administrator-G and Director of Nursing-B were notified of the immediate jeopardy on [DATE] at 2:08 p.m. The immediate jeopardy was removed on [DATE], when the facility completed the following: -All staff were educated on the elopement prevention policy and the elopement policy. -All staff were educated on prompt response to alarms and supervision of residents at risk for accidents or incidents -All staff were educated to notify the nurse in charge regarding any resident with exit seeking behaviors and implementation of immediate interventions to minimize risk -Nursing staff were educated on the process for notification to Administrator/DON/designee regarding staffing review, interventions and expectations for when staffing levels are below minimums or barriers are met to meeting resident needs with the current staffing level. All staff in the facility were educated on [DATE]. All staff will be educated prior to their next working shift. - Licensed staff assessed each resident on admission, readmission, quarterly or with new unsafe wandering behaviors or exit seeking behaviors and an immediate intervention will be implemented to minimize risk. - Residents who have been determined to be at risk for elopement will not be kept in an area near an exit without supervision on the night shift. -Elopement drills were conducted quarterly on all shifts. -Staff were educated on procedures when the minimum staffing level is not met after normal business hours or staff cannot meet resident needs with the current staffing level, the DON and/or Administrator must be notified and if issue is not resolved timely the DON and Administrator shall go to the facility to offer support.

Based on observation, interview and record review the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 3 (R39) residents reviewed for accident hazards. R39 received 2nd [MEDICAL CONDITION] a result of spilling hot chocolate on himself. A thorough investigation as to the cause of the burn and interventions specific to R39 to prevent [MEDICAL CONDITION] not initiated after the accident. Findings include: R39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R39's Quarterly Minimum (MDS) data set [DATE] was reviewed and indicated R39 had a Brief interview for Mental Status Score of 8 (severely impaired cognition) and required setup and supervision with eating. R39's diet included mechanical soft consistency with thin liquids. On 1/13/20 at 8:30 AM R39 was observed drinking hot chocolate out of a 2 handled, covered cup independently; no staff were observed to be in R39's direct area while he was drinking the hot chocolate. On 01/13/20 at 1:01 PM R39's Power of Attorney for Healthcare was interviewed and indicated R39 burned himself with hot liquids last week and she feels someone should be watching him while he drinks hot liquids. On 1/13/20 R39's progress notes were reviewed and Surveyor noted there is no indication in the progress notes that R39 was burned by hot liquids. R39's physician wound note dated 1/8/19 was reviewed and indicated: Wound #3 Proximal (near the center of the body) Abdomen is an acute partial; thickness burn 2nd degree. Measurements are 5 centimeters (cm) length by 10 cm width with no measurable depth, reabsorbing fluid blister. Wound #4 Distal (away from the center of the body) is an acute partial thickness burn 2nd degree. Measurements are 2 cm length by 16.4 cm width with no measurable depth, reabsorbing fluid blister. Wound #5 Abdomen right lower quadrant acute partial thickness skin tear type 2. Measurements are 5 cm length by 12 cm width by 0.1 cm depth, reabsorbing fluid blister. Orders for Xeroform and a dry protective dressing to all the abdominal wounds were made on this note. On 1/14/20 at 7:43 AM RN-F was observed completing treatments to R39's wounds. RN-F completed the treatment to R39's heel and then removed the cover over R39's abdomen. 3 large red areas, 2 with scabbed areas in the middle were observed. R39 indicated the areas itch at times but do not hurt. On 1/14/20 the facility's investigation dated 1/8/20 involving [MEDICAL CONDITION] R39 was reviewed and indicated: Writer (RN-F) interviewed (R39) on 1/7/20 regarding the areas on his abdomen. R39 stated he did spill hot chocolate on his stomach but he was not able to recall the date, location or shift it happened. Staff were interviewed and the timeframe was narrowed down to second shift on 1/6/20. Surveyor noted review of the staff interviews indicate no staff shared observations of R39 having hot chocolate or admitted to preparing hot chocolate for R39 as R39 could not make hot chocolate himself. The investigation indicates, based on staff interviews, it is suspected that R39 had hot cocoa and accidentally spilled on himself. Again the investigation does not conclude who provided hot chocolate to R39, or details such as whether staff obtained a cup from the kitchen for R39. Surveyor noted the investigation does not ask staff if they cleaned up R39 following a spill. Further review of the investigation indicates the facility investigation does not include an interview with LPN-M. There is no explanation what R39's condition was related to a possible spill when LPN-M worked with R39 and first saw the burn areas. Surveyor noted the investigation is not thorough to help establish a plan of care to prevent future burns. On 1/15/19 a rehabilitation screening form dated 1/8/19 was reviewed and read: reason for screen: follow up determine current level of functioning. The results were: decreased safety recall. (R39) requested to upgrade diet. Recommend speech therapy to determine safe, least restrictive diet, Physical therapy for positioning and occupational therapy for adaptive equipment independence with meal consumption. No mention of the risk of burning himself on hot liquids was mentioned in the screen. Review of R39's care plan for nutrition dated 9/15/19 indicates: resident uses 2 handled cup. Allow to feed self if desired regardless of skill. R39's care plan for risk for injury related to unaware of safety needs/cognitive/memory deficit, Cardiovascular accident with left sided [MEDICAL CONDITION] dated 10/7/19 was reviewed and did not contain any new interventions for prevention of burning himself with hot liquids. The only mention of R39'[MEDICAL CONDITION] his abdomen was an entry under the altered skin integrity care plan on 1/6/20 which read: burn to abdominal area. No interventions to prevent [MEDICAL CONDITION] addressed in R39's comprehensive plan of care. Review of R39's Skin impairment documentation written by RN-F on 1/14/20 indicates: (R39) is to have covered type sip cup for beverages. Education provided to resident: instructed to only accept drinks in a cup with a cover and sip device. Do not accept drinks in a paper, Styrofoam or uncovered cup. R39 did verbalize understanding. Surveyor noted according to R39's cognitive assessment he has severely impaired cognition and his care plan indicated he is unaware of his safety needs. Surveyor also noted this was completed during the survey and approximately 7 days after R39 sustained the burn. On 01/14/20 at 1:06 PM Registered Nurse (RN) Supervisor- F (who conducted the investigation regarding the burns) to R39 was interviewed and indicated she wasn't aware of [MEDICAL CONDITION] R39 until she came in the morning of 1/7/19 when Licensed Practical Nurse (LPN)-L told her about it from what she was told by LPN- M, who was the first to see the burns. RN-F indicated she didn't talk to LPN-M as part of the investigation and it was told to her LPN-M didn't think that the areas [MEDICAL CONDITION] she saw them. RN-F indicated LPN-M should have completed SBAR (situation, background, assessment and recommendation) documentation and did not. RN-F indicated she did not make any changes to R39's care plan as a result of him sustaining injuries from hot liquids. On 1/14/20 at 1:23 PM the Surveyor interviewed LPN-M who indicated on 1/7/20 at about 4:00 AM she was helping Certified Nursing Assistant (CNA)-Q change R39's brief and noticed he had red areas. LPN-M indicated R39 said he had a burn. LPN-M indicated she faxed R39's doctor about the areas before she left that night. LPN-M indicated she did not complete SBAR documentation for R39 in regards to the burn areas. LPN-M indicated she notified the oncoming nurse of R39's areas. Surveyor noted there is no indication of an RN assessment of the areas at the time R39'[MEDICAL CONDITION] discovered. Review of the fax to R39's doctor, dated 1/7/20 at 6:18 AM written by LPN-M indicates: new skin issue noted on (R39's) abdomen. Redness in the right upper quadrant 14 cm by 6 cm. Right lower quadrant 10 cm by 2.5 cm, fluid filled blister. Left upper quadrant 10 cm by 6.5 cm, opened blister was scabbed over. No pain noted. R39's doctor responded on 1/7/20 at 8:57 AM with an order for [REDACTED]. On 1/15/20 at 5:35 AM CNA-Q was interviewed and indicated that on 1/7/19 at about 12:00 AM she was in R39's room with LPN-M when [MEDICAL CONDITION] observed. CNA-Q shared R39 indicated he burned himself when he spilled hot chocolate on himself. On 1/14/20 the facility's January 2020 log for hot beverage temperatures was reviewed and indicated on 1/6/20 the hot beverage temperatures for breakfast, lunch and dinner were 140 degrees. There were no temperatures documented for supplemental liquids offered. On 1/15/19 Nurse Consultant-C was interviewed and indicated that the facility had done some things systematically after R39 was burned and provided documentation to the surveyor with an action plan and step which included: Dining room will be supervised for each meal by licensed staff, list of adaptive equipment will be provided to managers and licensed staff, staff assigned to dining room will review that all residents have appropriate adaptive equipment. Hot liquids will be temped before serving prior to leaving the kitchen, dining room supervision will monitor that residents are being assisted as needed, therapy will screen as requested for identified resident needs. Dietitian audits 2 x a weekly for diet accuracy, dietary staff educated regarding temps, adaptive equipment, diet accuracy. Surveyor noted while the facility initiated a potential plan, the details on how R39 was able to burn themselves was not determined through a thorough root cause analysis and a preventative care plan was not established for R39 that takes into account all factors regarding R39 to prevent the likelihood of future spills/burns. The above findings were shared with the Administrator and Director of Nurses on 1/14/20 at 2:30 PM. On 1/24/20 the facility's self report was received by the state agency. Within the report it is noted R39 indicated, when questioned, it was kitchen staff that provided R39 with the hot chocolate that R39 spilled. Surveyor noted this detail provided by R39 to the facility was not specifically noted in investigations and interviews provided to Surveyor during the survey.

Based on observation, record review and interview, the facility did not ensure pressure injuries were assessed or treated per standards of practice for 1 (R16) of 4 residents reviewed for pressure injuries. R16 developed a Stage 4 pressure injury to the left elbow 1/3/2020 and was not assessed by a Registered Nurse or physician until 1/8/2020. A new treatment order on 1/8/2020 was not followed until 1/15/2020 when it was entered into R16's medical record. Findings include: The facility policy and procedure entitled Handout A: Pressure Ulcer Prevention dated 10/17/2008 states: Risk Assessment Tools: The facility should use a pressure ulcer risk assessment tool (Braden Plus) to determine the amount of risk, and the degree to which mobility and activity levels are limited. The risk assessment should identify which factors can be removed or modified. All risk factors should be addressed even if the total risk score does not place the resident at risk for developing pressure ulcers. Skin Care and Early Treatment: Systematic Skin Assessment. An integral part of any skin care program is a systematic skin assessment. It is through these inspections that early skin problems can be detected and interventions started. Assessments must continue on a daily basis for all residents that are at risk for skin breakdown. Staff should evaluate skin condition for color, moisture, temperature, integrity, and turgor. It can be done by a licensed nurse or CNA and should pay special attention to bony prominences. Slouching in the chair may cause ulcers of the spine, scapula, or elbow. These same residents should also have pressure-reducing devices placed in the wheelchair. These chair bound residents should have written positioning plans for their wheelchairs as well as in bed. R16 was admitted to the facility 3/28/2019 with [DIAGNOSES REDACTED]. R16's admission Braden score on 3/28/2019 was 17 indicating R16 was at risk for skin breakdown. R16's Skin Impairment Care Plan was initiated 4/3/2019 with the following interventions: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocols for treatment of [REDACTED]. R16's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R16 as needing limited assistance with all Activities of Daily Living (ADLs). R16's Braden score on 10/26/2019 was 19 indicating R16 was not at risk for skin breakdown. On 11/17/2019, R16 was admitted to the hospital for [MEDICAL CONDITION] of the lower extremities and a urinary tract infection. R16 returned to the facility 11/20/2019 and began occupational and physical therapy due to increased need for assistance with cares and difficulty in walking. R16's Braden score on 11/20/2019 was 10 indicating R16 was at high risk for skin breakdown. R16's Skin Integrity Care Plan was not revised. R16's quarterly MDS assessment dated [DATE] coded R16 as needing extensive assistance for bed mobility, dressing, eating and toilet use, and complete assistance for transfers, hygiene and bathing. Surveyor noted the facility did not initiate a significant change MDS for R16 despite multiple areas of decline for R16. As a result of not initiating a significant change MDS a Care Area Assessment (CAA) was not triggered and completed including initiating potential revisions to R16's care plan. On 12/16/2019 in Occupational Therapy (OT) Treatment notes, the therapist charted R16 would benefit from a Broda chair due to poor positioning in a wheelchair. On 12/17/2019 in OT Treatment notes, the therapist charted R16 received a 30 inch wide Broda chair that fits R16 in length and weight, but measures 4-5 inches wider than hips potentially contributing to an increase in R16's lateral lean. On 12/20/2019 in OT Treatment notes, the therapist charted positioning was discussed with R16 encouraging R16 to lean to the right side for pressure relief. R16 was unable to follow instructions. On 12/27/2019 in OT Treatment notes, the therapist charted R16 was repositioned in Broda chair to alleviate pressure on the bottom. On 12/27/2019, R16's Activities of Daily Living Care Plan was revised to include the intervention: When in Broda, (R16) should be positioned with my chair back/fully reclined and my legs elevated. Except for meals. In an interview on 1/14/2020 at 3:08 PM, Senior Administrator-G stated R16 received a smaller Broda chair on 12/27/2019. On 1/2/2020 in OT Treatment notes, the therapist charted therapeutic activities were placed to the right side of R16 to strengthen the right side and decrease the left lean. In an interview on 1/14/2020 at 3:08 PM, Senior Administrator-G stated R16 received the third Broda chair on 1/3/2020 that was smaller than either of the previous Broda chairs. On 1/3/2020 at 5:29 PM in the progress notes, Registered Nurse (RN)-H charted a new open area was found on R16's elbow. A treatment order was obtained to cleanse the left elbow with normal saline, pat dry, apply skin prep to the peri wound, apply xeroform to the left elbow wound and cover with a border dressing daily and as needed. No documentation of R16's left elbow pressure injury was found. R16's Skin Integrity Care Plan was revised 1/3/2020 with the following interventions: -educate (R16/R16's) family/caregivers of causative factors and measures to prevent skin injury -identify/document potential causative factors and eliminate/resolve where possible -implement pressure reducing devices off-loading heels, etc. -keep skin clean and dry, use lotion on dry skin -monitor/document location, size and treatment of [REDACTED]. -pad bed rails, left wheelchair arm or any other source of potential injury if possible -provide pressure relieving devices -turn and position as necessary R16's Skin Integrity Care Plan was revised 1/14/2020 with the following interventions: -be careful when turning R16 to side that the fingers don't press into arm. -daily skin check and report any and all new areas to nursing management staff -keep bed remote clipped to top of bed In an interview with Director of Nursing (DON)-B on 1/14/2020 at 3:08 PM, Surveyor shared the concern no documentation was found of R16's left elbow open area in R16's medical record. R16's electronic health record indicated R16's Skin Impairment/Wound Form for 1/3/2020 was still in progress and Surveyor was unable to see the documentation. DON-B provided a copy of the Skin Impairment/Wound Form dated 1/3/2020 and the wound physician notes dated 1/8/2020. R16's Skin Impairment/Wound Form dated 1/3/2020 documented R16 had a pressure injury to the left elbow measuring 1 cm x 1.2 cm x 0.8 cm with moderate serous drainage. The treatment order was to cleanse the left elbow with normal saline, pat dry, apply skin prep to the peri wound, apply xeroform to the left elbow wound and cover with a border dressing daily and as needed. The current intervention per the form stated: Treatment in place. Arm rest cushion on chair. The form was not signed or completed: no stage of the pressure injury was given and no description of the wound bed was documented. On 1/14/2020 at 3:38 PM in an interview, Licensed Practical Nurse (LPN)-L stated the documentation on the Skin Impairment/Wound form dated 1/3/2020 was initiated by LPN-L, but LPN-L didn't complete the form. No other documentation of R16's left elbow wound was found in R16's medical record on 1/3/2020. R16's wound physician's note dated 1/8/2020 stated this was the initial encounter for this wound. The left elbow was a Stage 4 pressure injury measuring 1 cm x 1 cm x 0.5 cm with moderate serous drainage. The wound bed was 70% slough, and 30% granulation. On 1/14/2020 at 12:27 PM, Surveyor observed R16's dressing change to the left elbow performed by RN Supervisor-F and assisted by LPN-L. The dressing was removed with moderate amount of yellow drainage on the dressing revealing a wound measuring approximately 1 cm x 1 cm with a depth of approximately 0.5 cm. The wound base was 100% yellow slough with bubbles in the indented space. RN Supervisor-F cleansed the left elbow wound with normal saline, applied Santyl to the wound base, and covered the area with border gauze. RN Supervisor-F stated the wound was a Stage 4 pressure injury caused by R16 leaning in the Broda chair; sheepskin was observed on the left armrest of R16's chair and on the left enabler on the bed and a padded armrest was observed on top of R16's dresser. On 1/14/2020 at 2:57 PM in an interview, RN Supervisor-F stated on 1/3/2020 the wound was thought to be a Stage 3 pressure injury, but when the wound physician saw R16 on 1/8/2020 it was determined the wound was a Stage 4 pressure injury because of the location of the wound. RN Supervisor-F stated when wound rounds are done with the wound physician, wound measurements are written down on a piece of paper and when time allows, the wound documentation is put into the resident's medical record in the computer. RN Supervisor-F stated R16's wound measurements were on the paper from wound rounds on 1/8/2020 and hadn't been put into R16's medical record. RN Supervisor-F stated R16 leans to the left and pillows are put on R16's left side to prevent leaning. RN Supervisor-F stated R16's left elbow wound was found on 1/3/2020 by RN-H who is wound care certified. On 1/14/2020 at 3:08 PM in an interview, RN-H stated LPN-L found the area on R16's elbow and that information was communicated at change of shift report. RN-H stated he did not get measurements and didn't see the wound because it was already covered with a dressing. On 1/14/2020 at 3:38 PM in an interview, LPN-L stated on 1/3/2020 R16 had yellow drainage on the left armrest of the Broda chair and saw the wound to R16's left elbow. LPN-L stated she measured the wound and called the physician and got a treatment right away. LPN-L stated the wound base was yellow slough color and R16 did not have a pillow on the left side. LPN-L stated R16 moves around a lot and did not recall R16 leaning to either side. On 1/15/2020 at 8:46 AM in an interview, Physical Therapist (PT)-Z stated the facility tried several different Broda chairs with R16 to get a better fit because R16 leaned to the left. PT-Z stated she observed the wound 1/3/2020 during R16's physical therapy session and reported it to nursing. PT-Z stated the wound didn't look infected, just open, but was surprised at how deep it was. PT-Z stated the wound wasn't bleeding or red. PT-Z stated an arm cradle was put on R16's left arm rest to provide padding, but R16 was able to push it off the armrest; many different positioning pads were tried but R16 would disassemble any device they tried. PT-Z provided a copy of Physical Therapy notes from 1/3/2020: R16 was noted to have a wound at L (left) elbow. Nursing notified and L soft support provided to cover L arm rest on broda chair and elbow protector requested from nursing. CNA (Certified Nursing Assistant) educated on new positioning as new broda chair to be provided today due to leg rest not functioning well on current broda (2nd broda chair trial) and CNA will need to re-apply soft support. On 1/15/2020 at 9:39 AM in an interview, LPN-L stated RN Supervisor-F was told about R16's new pressure area on 1/3/2020, but didn't know if RN Supervisor-F saw it or not. LPN-L stated LPN-L did the charting on the wound on 1/3/2020. On 1/15/2020 at 9:49 AM in an interview, Surveyor asked RN Supervisor-F if R16's left elbow pressure injury was assessed on 1/3/2020 by RN Supervisor-F after LPN-L told RN Supervisor-F about R16's new pressure injury. RN Supervisor-F stated no, RN Supervisor-F did not see the wound. On 1/15/2020 at 9:42 AM in an interview, Nurse Consultant-C was asked how orders were entered into the computer. Nurse Consultant-C stated phone orders are put directly into the computer when they are received and faxed orders are entered into the computer and the fax is disposed of. Surveyor asked Nurse Consultant-C how the facility would know about an order, either over the phone or a verbal order by a physician in the facility. Nurse Consultant-C stated orders are reviewed on a daily basis and any order that looks suspicious is clarified. On 1/15/2020 at 9:49 AM in an interview, RN Supervisor-F was asked about the Santyl that was observed being put on R16's wound on 1/14/2020. The order in the computer for R16's left elbow wound treatment was the order written on 1/3/2020 - cleanse the left elbow with normal saline, pat dry, apply skin prep to the peri wound, apply xeroform to the left elbow wound and cover with a border dressing daily and as needed. RN Supervisor-F reviewed the order in the computer and agreed the treatment order did not include Santyl to be applied to the wound. RN Supervisor-F stated on 1/8/2020 when the wound physician was doing rounds, the wound physician changed the order to Santyl and RN Supervisor-F wrote the order down on the paper the wound measurements were written on, but did not put the order in the computer. Surveyor shared the interview of RN Supervisor-F with Nurse Consultant-C. Nurse Consultant-C agreed the physician order [REDACTED]. Surveyor reviewed R16's Treatment Administration Record for 1/8/2020 through 1/14/2020. The treatment to R16's left elbow was to be completed in the evening and was signed out as being completed 1/8/2020-1/11/2020, and 1/14/2020. 1/12/2020 had no initials potentially indicating the treatment was not completed. 1/13/2020 had documentation R16 refused the treatment. None of the initialed boxes were signed out by RN Supervisor-F. On 1/15/2020 at 1:34 PM, RN Supervisor-F stated she had been flustered the day before and had not been accurate in her statements. RN Supervisor-F stated she had seen R16's left elbow pressure injury on 1/3/2020 and the measurements that were documented had been the measurements she had obtained. RN Supervisor-F stated she remembered seeing the wound at that time and it had a completely yellow wound base. RN Supervisor-F stated she didn't document the assessment in R16's record. RN Supervisor-F stated R16's wound treatments are completed almost every day by RN Supervisor-F so R16 had been getting the Santyl treatment as ordered since 1/8/2020, but forgets to sign them out. On 1/15/2020 at 1:45 PM, Surveyor discussed the above findings with Nursing Home Administrator-A, DON-B, Nurse Consultant-C, and Senior Administrator-G. R16 needed extensive assistance with bed mobility and repositioning after returning from the hospital 11/20/2019 as indicated on R16's 11/27/2019 quarterly MDS assessment. R16 had a significant lean to the left that was being addressed by occupational and physical therapy and was placed in a Broda chair on 12/16/2019 that was too large. A smaller Broda chair was provided on 12/27/2019 with a care plan intervention of R16 being placed in a fully reclined position at all times except for meals. A third Broda chair which was smaller than the first or second was provided 1/3/2020, the same day the Stage 4 pressure injury was identified. When R16 was in the Broda chair with a significant lean to the left, R16's skin on the left side was not being monitored for pressure. An RN did not assess and document R16's Stage 4 pressure injury on 1/3/2020. The first complete assessment of R16's left elbow pressure injury was on 1/8/2020 by the wound physician. On 1/8/2020, the wound physician ordered a new treatment to R16's left elbow Stage 4 pressure injury that wasn't put into R16's Treatment Administration Record until 1/15/2020 so R16 did not receive the ordered treatment for 1 week. No further information was provided at that time. On 1/16/2020, the facility forwarded the wound physician's documentation from 1/15/2020. R16's left elbow Stage 4 pressure injury measured 1 cm x 1 cm x 0.5 cm with undermining from 1 o'clock to 12 o'clock with a maximum distance of 2 cm. The wound bed was 50% slough and 50% granulation with moderate serous drainage. R16's wound measurements were the same, but did not previously have undermining.

Based on observation, interview and record review the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 3 of 3 (R3, R4 and R8) residents reviewed for accident hazards. R3 was not advised of medication side effects which increased her risk of sunburn. R4 did not have a thorough investigation as the the cause of his falls. R8 did not have a mat on the floor as his care plan indicated. Findings include: 1.) R3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 8/8/19 during the initial interview, R3 reported she was started on [MEDICATION NAME] (Cipro) for a UTI and sustained a severe sunburn. R3 stated: They never told me about photosensitivity while on Cipro. R3 reported she went outside with therapy in the afternoon and decided to stay outside for about 2 hours and got sunburned. Surveyor asked if she was wearing sunscreen. R3 stated she was not wearing sunscreen because, I'm Sicilian. I never burn. I never have had to wear sunscreen. It's never, ever been a problem before. I'm Sicilian. R3 reported she then Googled the side effects [MEDICATION NAME] saw photosensitivity and stated: If I had known about that side effect I would not have gone outside. I wanted to stay outside, but only because I didn't [MEDICATION NAME] increase my risk for sunburn. Surveyor reviewed R3's medical record and located an order dated 5/17/19 which documented: Start [MEDICATION NAME] 500 mg (milligrams) BID (twice daily) for 10 days for UTI. R3's (MONTH) 2019 Medication Administration Record (MAR) indicated [MEDICATION NAME] started the evening of 5/17/19 and taken orally through the morning of 5/27/19. On 8/12/19 at 9:30 AM Surveyor spoke with Pharmacist-P who stated: A side effect [MEDICATION NAME] photosensitivity which means more sensitive to sunlight than normally would be. Surveyor asked if drug side effects are sent or explained to the patient. Pharmacist-P reported the medication side effects are not listed on the electronic MAR and do not usually fit on the label of the medication cards. She stated she would have the facility pharmacy consultant (Pharmacist-Q) call surveyor. On 8/13/19 Surveyor spoke with Pharmacist-Q who stated the nurses would be responsible for informing patients of side effects of medications, adding: Any drug reference has a list of side effects. On 8/12/19 at 10:10 AM Surveyor spoke with Certified Occupational Therapy Assistant (COTA)-O. Therapy notes documented the day in question as 5/23/19 when R3 was taken outside for therapy session. COTA-O reported she and R3 went outside to do exercises with the other therapist who was working with another resident. COTA-O believed the time to be around 1 or 2 PM. COTA-O reported after the session, R3 wanted to stay outside, so she did her documentation outside. COTA-O believed R3 was outside for an hour or so, but was not sure. COTA-O reported R3 had a sheet to cover her legs, but she said she was Sicilian and wanted to tan. COTA-O reported the resident then went inside with the therapists because the door from therapy locks, and she would not have been able to get back in. COTA-O reported she was not informed of R3 having been [MEDICATION NAME] was not aware of the side effect of photosensitivity. She reported therapists have since been inserviced by the therapy manager about asking the nurse before taking residents outside. Surveyor noted the temperature in Kenosha on 5/23/19 had a noon high of 73 degrees and sunny. Surveyor located an incident report completed by Registered Nurse (RN)-F dated 5/25/19 which documented: Incident description: Client presented with blistering burn to lower legs and upper body. Therapists had taken client outside for an extended period of time while on antibiotic therapy. Immediate action taken: Cool compress applied by floor nurse. Resident taken to hospital? N Other information: Was outside in sun for extended period of time while on antibiotic therapy. On 8/13/19 at 8:15 AM Surveyor spoke with RN-F who stated she remembered she found out about the sunburn on 5/25/19 and did an incident report. Surveyor reviewed R3's medical record and located and order dated 5/25/19 for silver [MEDICATION NAME] cream 1% apply to BUE (bilateral upper extremity), left leg and upper topically three times a day for burn. Surveyor noted there was no documentation in the nursing progress notes about the sunburn. Surveyor attempted to contact the nurse who administered the first dose of Cipro, but did not receive a return call. Surveyor was advised by the scheduler that the nurse in question only works on an as needed basis and is often difficult to reach. Surveyor spoke with Licensed Practical Nurse (LPN)-R who administered the medication during the course of treatment. She stated she did not recall advising R3 of the side effect of Cipro. Surveyor noted R3 was seen by her Primary Medical Doctor on 5/29/19 who ordered: Apply [MEDICATION NAME] to left leg twice a day. Use [MEDICATION NAME] dressing. According to Mayo clinic: https://www.mayoclinic.org/drugs-supplements/silver-[MEDICATION NAME]-topical-route/proper-use/drg- 819?p=1; Silver [MEDICATION NAME] cream is used to prevent and treat wound infections in patients with second- and third-degree burns. Patients with [MEDICAL CONDITIONS] a large area of the body must be treated in a hospital. Silver [MEDICATION NAME] is an antibiotic. It works by killing the bacteria or preventing its growth. Surveyor spoke with R3 who stated: It hasn't affected me emotionally. I'm just pissed that they didn't tell me about the side effect before I went outside. It would have influenced my decision of whether or not to go out or how long I would have stayed outside. Surveyor was unable to locate any documentation the facility advised R3 of the photosensitivity side effect while on Cipro, which increased her risk for sunburn. Unaware of such information, R3 spent an extended period of time outside and sustained a sunburn which subsequently blistered and required treatment. On 8/14/19 Surveyor spoke with Director of Nursing (DON)-M and Nurse Consultant-B and advised them of the above information. No further information was provided. Surveyor noted as of the current date, R3's left leg continues to require treatment related to the sunburn. (Cross reference F684) 2.) R4's medical record was reviewed by Surveyor for a complaint concern regarding falls in the facility. R4's Fall Investigations were reviewed for (MONTH) and June. R4's Progress Notes were reviewed in addition to the Fall Investigations conducted by the facility. * On 6/27/19 at 11:13 PM R4 was observed on the floor mattress next to the bed. R4 had no injuries and was transferred into a Broda chair and brought out to the nurses station. The Fall Investigation does not include staff statements for events leading up to the fall. There is no details into what R4 was trying to do or what they were doing prior to the fall. * On 6/29/19 at 6:10 PM R4 was observed on the floor next to the bed. R4 was administered anti-anxiety medication and placed back into bed. The Fall Investigation does not include staff statements for events leading up to the fall. There is no details into what R4 was trying to do or what they were doing prior to the fall. On 8/12/19 at 11:55 AM Surveyor requested any additional information from RN-F (Registered Nurse). RN-F is part of the Interdisciplinary Team that reviews the residents falls. On 8/12/19 at 12:18 PM RN-F provided the facility's internal Fall Investigations. The Fall Investigations did not contain any additional information pertaining to the circumstances of R4's falls. On 8/13/19 at 2:33 PM Surveyor shared R4's concerns with Administrator-A and NC-B (Nurse Consultant). There was no additional information provided related to the above 2 falls. 3.) Surveyor reviewed R8's medical record. R8 admitted into the facility on [DATE]. R8's Nursing: Admission Data Collection and Baseline Care Plan dated 5/16/19 indicates in part; R8's speech is clear, his comprehension is quick, oriented yes, disoriented to time, place an person. R8 is noted to be at risk for falls, with fall planning including interventions of: be sure call light is within reach and encourage resident to use it for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure resident is wearing appropriate footwear, follow facility fall protocol. Resident requires limited assistance with bed mobility and 2 plus person physical assistance. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 5/23/19 documents a Brief Interview for Mental Status (BIMS) score of 15 which indicates R8 is cognitively intact for daily decision making skills. R8 requires extensive assistance with two person physical assistance for bed mobility and transferring. The MDS indicates R8 has had 2 falls since admission with no injury. The Care Area Assessment (CAA) dated 6/11/19 indicates that Falls will be care planned with the objective to minimize risks. The rationale for the care planning decision indicates in part, . admitted post hospitalization .is receiving therapy for rehab, is able to make needs known, provide extensive assistance with ADLs at this time .has poor safety awareness .has had several falls since admission . The current Certified Nursing Assistant (CNA) Kardex dated 8/14/19 documents: * 5/16/19 fall mat on floor, * Provide frequent checks on resident and keep in populated are when resident is disoriented and offer resident things to do. * Resident's preference is to be on floor, states floor is more comfortable, likes to crawl on floor. This is r/t (related to) psych diagnosis (keep bed in lowest position with mat next to bed for easy transfer from bed to floor) * Clip bed control to blanket . R8's care plan includes, The resident is at risk for falls initiated on 5/17/19. The goals are: The resident will be free of injury through the review date. Target Date: 8/25/19. Side effects of psychoactive drugs, anti-hypertensives, and diuretic contributing to gait disturbance, balance disturbance, movement disorders and increasing the resident's fall risk will be reduced by the review date. Revision on: 5/17/19 Target Date: 8/25/19. Interventions include: * Fall Mat on floor 5/16/19 * Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. 5/17/19 * Follow facility fall protocol (not dated) * Provide frequent checks on resident and keep in populated area when resident is disoriented and offer residents things to do. (not dated) * PT evaluate and treat as ordered or PRN/as needed (not dated.) * Resident's preference is to be on floor, states floor is more comfortable, likes to crawl on floor. This is r/t (related to) psych diagnosis (keep bed in lowest position with mat next to bed for easy transfer from bed to floor. Not dated) * The resident needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, the bed in low position at night with safety mat at bedside; Side rails as ordered, handrails on wall, personal items within reach. 5/17/19. Surveyor reviewed R8's progress notes and incident/accident checklists which indicated the following: On 5/16/19 at 21:03 (9:03 pm,) resident was observed on the floor in his room next to his bed. A floor mat was added to R8's care plan at this time. On 5/17/19 at 0250 (2:50 pm) Resident was noted to be sitting upright on safety mat leaning against the bed . On 5/17/19 09:51 am, Resident new to facility, admitted same day of fall. Has history of falls. Has multiple [DIAGNOSES REDACTED]. Intervention: floor mat placed on floor and bed moved closer to wall. On 05/17/19 progress note 10:12 am indicates, (R8) new to facility, has history of falls. Second fall within 24 hours since admission. Was found sitting on mat on floor next to bed leaning against bed. Immediate Intervention: was resident was brought out in populated area for staff visualization. Care plan provide frequent checks on resident and keep in populated area when resident is disoriented and offer resident things to do. On 5/17/19 22:59 (10:59 pm) Resident was in dining room in wheelchair watching TV with staff monitoring as resident places self on floor at 1935 (7:35 pm) . On 6/24/19, Resident was trying to reach for bed control and fell out of bed. Immediate intervention: have maintenance put clip on bed control for easy access. On 8/14/19 at 12:50 pm, Surveyor observed R8 in bed. R8's bed did not appear to be a low position and no mat was on the floor next to the bed, as per R8's At risk for falls care planned intervention dated 5/16/19 and 5/17/19. On 8/14/19 at 12:54 pm, Surveyor interviewed the assigned Certified Nursing Assistant (CNA) N regarding R8 being in bed without a floor mat and questioning as to whether the bed was in low position. CNA N stated, when (R8) first got here his bed was low and he had a floor mat. CNA N stated, since admission (R8) has changed from using a Hoyer lift to a 1 person assist . when (R8) was first here he had falls but then had therapy and has had no further falls. Surveyor questioned CNA N as to why the CNA Kardex continues to indicate the use of a floor mat and low bed. CNA N stated, we cannot change the care plans, we let them know, the (former) DON J is no longer here, I know we let them know if something (regarding care plan changes) but if something happens if falls back on us. The fall mat is no longer applicable, we make sure the call light is next to him, grippy socks on, he still won't wear shoes. We may have removed the mat due to safety measures with him getting out of bed. We follow the fall protocol for falls. He usually is up and wheels himself around but he is in bed today because he is not feeling well. On 8/14/19 at 1:15 pm, Surveyor discussed R8's fall care plan interventions with RN I. Surveyor shared with RN I that R8's care plan addresses fall preventions with a low bed and mat on the floor however, R8 presently is in bed with no mat on the floor. Surveyor asked RN I who updates care plans and whether the fall interventions were still applicable. RN I stated we do not update the care plans, R8's behaviors change daily, he gets himself up. RN I stated having the fall mat place would be valid to keep it there. On 8/14/19 at 1:15 pm, Surveyor observed R8 still in bed with no fall mat in place and his bed did not appear to be in low position. On 8/14/19 at 1:20 pm, Surveyor informed Administrator A, DON M and Nurse Consultant B that R8 is presently in bed and the care planned fall prevention interventions of the mat on the floor and low bed were not implemented.

Based on observation, interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 2 (R3) residents reviewed for treatments. * R3 did not consistently receive treatment for [REDACTED]. Findings include: R3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 8/8/19 during the initial interview, R3 informed Surveyor that staff is not changing the dressing on her left leg for treatment of [REDACTED]. Surveyor reviewed R3's medical record and located an order dated 5/25/19 for silver [MEDICATION NAME] cream 1% apply to BUE (bilateral upper extremity), left leg and upper topically three times a day for burn. Surveyor noted there was no documentation in the nursing progress notes about the sunburn. Surveyor noted R3 was seen by her Primary Medical Doctor on 5/29/19 who ordered: Apply [MEDICATION NAME] to left leg twice a day. Use [MEDICATION NAME] dressing. R3 was seen again on 7/31/19 and the physician ordered: Silver [MEDICATION NAME] cream apply to left leg topically every day shift for burn. Cover with [MEDICATION NAME] only. Wrap with ace bandage. According to Mayo clinic: https://www.mayoclinic.org/drugs-supplements/silver-[MEDICATION NAME]-topical-route/proper-use/drg- 819?p=1; Silver [MEDICATION NAME] cream is used to prevent and treat wound infections in patients with second- and third-degree burns. Patients with [MEDICAL CONDITIONS] a large area of the body must be treated in a hospital. Silver [MEDICATION NAME] is an antibiotic. It works by killing the bacteria or preventing its growth. On 8/12/19 at 11:50 AM Surveyor spoke with Registered Nurse (RN)-L about the coding numbers on the Medication Administration Record [REDACTED]. RN-L informed Surveyor the number above the nurse initials would be a code why the medication or treatment was not given for some reason. RN-L stated: The number 10 indicates other/see progress notes, which means the medication or treatment was not given and the nurse should document in the progress notes as to why. Surveyor noted the number 4 indicated refused. Surveyor reviewed R3's TAR's from (MONTH) - (MONTH) 2019 which revealed several dates with no initials to indicate the treatment was completed, the numbers 10 (indicating the treatment was not completed) and 4 (indicating refusal): May: 8:00 AM - 2 days = no initials. 2:00 PM - 2 days = no initials. 8:00 PM - 2 days = 10 and 1 day = no initials. Surveyor noted there was no documentation in R3's progress notes why the treatment was not completed. June: 8:00 AM - 14 days = no initials. 3 days = 4. 2 days = 10. 8:00 PM - 4 days = no initials. 1 day = 10 and 7 days = 4. Surveyor noted there was no documentation in R3's progress notes documenting why the treatment wasn't completed and no documentation the physician was updated on the resident's refusal. July: 8:00 AM - 7 days = no initials. 1 day = 4. 8:00 PM - 1 day = 10 and 6 days = 4. Surveyor noted there was no documentation in R3's progress notes documenting why the treatment wasn't completed and no documentation the physician was updated on the residents refusal. Surveyor noted there was not a treatment on the TAR for (MONTH) 19th through the 31st. August: Day - 9 days = no initials from 8/1 - 8/11 to indicated the treatment was completed. On 8/12/19 at 1:07 PM Surveyor spoke with Unit Manager-C and reviewed the missing documentation and refusals on R3's TAR's. Unit Manager-C was unable to explain the missing documentation as to why the treatments were not completed or why the physician was not updated. Unit Manager-C reported he has not been informed by any nurse that R3 has or is refusing treatment to her left leg. Unit Manager-C stated: I thought the treatment was being done like it was supposed to. On 8/12/19 at 1:15 PM Surveyor spoke with Licensed Practical Nurse (LPN)-R who stated they were using [MEDICATION NAME] cream, and sometime right before her rotator cuff surgery she started to refuse because it was healing. Next thing I knew, it opened up again and then the treatment was ordered daily in the morning. I haven't seen it since. Surveyor asked why there was no documentation in the nurses notes regarding her initials of 10. LPN-R stated: I thought I did. Surveyor asked if LPN-R notified the supervisor or physician of R3's refusal of treatment. LPN-R stated: I don't remember. Surveyor review of R3's medical record revealed the sunburn occurred on 5/23/19 which was after her rotator cuff surgery (on 5/1/19) and not before as reported by LPN-R. On 8/12/19 at 2:30 PM Surveyor spoke with the facility wound care nurse, Registered Nurse (RN)-K about R3's wounds on her left leg. RN-K stated: I don't measure her wounds, she goes out to see someone for her lower extremity. Surveyor review of R3's medical record revealed no documentation of an assessment or measurements of R3's wounds. There was no evidence of R3 going to an outside entity for treatment or measurements of her wounds. On 8/14/19 at 9:45 AM Surveyor advised Director of Nursing (DON)-M of the inability to locate any documentation of an assessment, measurements or monitoring of the progression of wounds for R3. Surveyor informed DON-M of RN-K advising he does not measure or follow R3's wounds. Surveyor reviewed the TAR documentation with DON-M. DON-M stated she expects staff to initial the TAR when the treatment is completed and expects the nurses to assess the wound and chart on it in the nurses notes. Surveyor asked DON-M for any documentation the facility has on R3's wounds and documentation the dressing changes are being consistently completed. DON-M stated: Unfortunately we don't have any documentation of the wound or measurements. Surveyor asked DON-B if any nurse has assessed the wounds or measured them. DON-M stated the facility can't find any documentation. Surveyor asked DON-M how the facility knows if the wounds have improved or declined. DON-M stated: I don't know. Surveyor asked what was the expectation regarding wound care. DON-M stated: I would expect the nurses to have been doing the treatment and monitoring its progress. They should communicate if it was getting better or worse. Unfortunately if appears as though no one was officially monitoring her wounds. No additional information was provided. On 8/14/19 at 11:00 AM Surveyor observed wound care of R3's left leg performed by LPN-S with Nurse Consultant-B present. Upon removal of the old dressing (which was not dated), Surveyor noted 3 separate open areas on R3's shin. There was light green drainage from the superior wound. All areas were cleansed with normal saline and revealed clean, red granulation tissue. Nurse Consultant-B measured all 3 wounds: Upper - 5 x 6 x 0.1 cm (centimeters), middle - 4 x 3 x 0.1 cm and lower 3.2 x 2.6 x 0.1 cm. Surveyor noted no concerns with the completion of the dressing change or infection control. During the dressing change, R3 stated: It hasn't been changed since Saturday PM (8/10/19). I made them give me a shower because it forces them to change the dressing. Even though it's supposed to be done on days, I asked PM's to do it because it never gets done. (RN-K) told me it needs to be changed every day, but they don't do it. It's not healing because they're not taking care of it. Surveyor advised Nursing Home Administrator (NHA)-A, Nurse Consultant-B and Director of Nursing (DON)-M of R3 sustaining a sunburn on 5/23/19 which blistered and opened. Surveyor advised there is no documentation of when the blisters opened, no comprehensive assessment of the wounds, no documentation the treatments were consistently completed, and no ongoing monitoring of progression of the wounds. Surveyor was advised the facility is unable to locate such documentation. No additional information was provided. (Cross reference F689).

Based on observation, interview and record review, the facility did not provide adequate supervision and assistive devices to prevent accidents for 1 (R57) of 7 residents reviewed for falls and the facility did not ensure a safe environment in 2 of 4 bathing rooms, where unlocked chemicals were observed. This deficient practice related to unlocked chemicals had the potential to affect 3 of 17 residents (R56, R40, R42) with confusion/dementia on unit 4 and 3 of 16 residents (R1, R31, R212) with confusion/dementia on unit 5. R57 had 2 falls from bed, 2/8/18 and 3/20/18. The fall on 3/20/18 resulted in a [MEDICAL CONDITION] metatarsal. R57 did not have all fall interventions implemented to prevent future falls. Findings include: 1.) R57 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R57's Change of Condition Minimum Data Set (MDS) assessment, dated 9/28/18, indicates that R57 has severe cognitive impairment, a Staff Assessment of Mood score of 12, indicating R57 has moderate depressive symptoms and no behavior concerns of resisting care from staff. R57 requires total assist of 1 staff person for bed mobility, total assist of 2 staff persons for transfers and is always incontinent of bowel and bladder. R57's Care Plan, dated 2/2/15, with a target date of 10/12/18, states: At risk for falls/injury r/t (related/to) [MEDICAL CONDITION], Hx (history) of falls, weakness, severe [MEDICAL CONDITION], poor vision, DJD ([MEDICAL CONDITION] Joint Disease), cognitive deficits. Interventions include: bed next to the wall room change matt to floor, d/c (discontinue) 4-4-18, low bed 3-16-15 wall padded w/ (with) mat; 6/30/15 house mattress, refused body pillow, scoop mattress (resolved). Reinitiated scoop air (Adriatic) mattress 4/3/17; 7/18/16: reapproach when agitated; 8/10/16: sleep study; 9/6/16: 2 persons with cares, add targeted behaviors, staff discipline; 9/22/17: assess wheelchair; 9/30/17: bolsters to bed; 12/8/17: visual prompt; 4/4/18: full mattress to floor next to bed; anticipate and meet needs; 3/3/15: offer to lay down after lunch. Resident often refuses. Resident education provided and staff to continue to offer; be sure call light is within reach and encourage resident to use it for assistance as needed; bed next to wall to allow more space for mobility in room when out of bed; educate resident/family about safety reminders and what to do if a fall occurs; ensure that resident is warm gripper socks or non skid footwear when mobilizing in w/c (wheel chair); keep needed items, water, etc. (etcetera) in reach; provide safe environment with: even floors free from spills; and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position at night; and personal items within reach; resident often requested to be positioned on the edge of the bed; 10/17/16: Adriatic bed to aide with comfort, protection from injury due to contractors; add bolsters to bed; 12/13/17: psych ([MEDICAL CONDITION]) med (medication) review; provide visual prompts to ask for help; 7/24/15: reassess of B&B (Bowel and Bladder), resident educated on using call light; reattempt use of body pillow, 2/8/18; 2/12/18: staff education; 3/16/18 reassess brief size; supervision: maybe outside independently. R57's Fall Scene Investigation Report, dated 2/8/18, documents: Intercepted fall (resident was lowered to the floor) in her room at 9:50 PM. R57 stated she was attempting to turn over in bed and was documented to be more agitated than usual just prior to the fall. R57 was documented to have bare feet and was last assisted with toileting at 9:30 PM. R57 was assisted to bed at 7:00 PM and was repositioned several times during the shift and R57 continued to reposition self in bed. The root cause of the fall was documented to be: R57 repositioned self in bed near the edge of the bed. Aide had attempted to reposition R57 away from the edge when the resident fell from the edge and was lowered to the ground. Interventions to prevent future falls: position R57 away from the edge of the bed and encourage body pillow. Summary of the team meeting and conditions that may have contributed to the fall: R57 heard yelling out. When staff entered the room R57 was noted to be position self on the edge of the bed, resident began falling OOB (out of bed) and staff member assisted resident to floor to limit impact. No c/o (complaints of) pain, no s/s (signs/symptoms) of injury. Re-attempt body pillow. R57 was documented to not be wearing non skid footwear per care plan intervention. The new intervention of attempting the use of the body pillow was added to the care plan but the intervention of repositioning R57 away from the edge of the bed was not added to the care plan. R57's Fall Scene Investigation Report, dated 3/20/18, documents: R57 was placed in bed at 1:00PM with gripper socks on. R57 was found on the floor next to the bed on the mat. R57 was laid down and changed at 1:00 PM. R57 has a history of rolling self on to the floor. R57 has a history of severe cognitive deficits,[MEDICAL CONDITION](Hypertension) and Hx (history) of stroke. R57 noted to have some swelling to the right hand. MD (Medical Doctor) was notified. X-rays were ordered. R57 noted to have a right 5th metatarsal fx (fracture). Interventions to prevent future falls: body pillow and mattress on the floor. Surveyor noted the intervention of the use of a body pillow was put into place and added to the care plan after the fall on 2/8/18. Surveyor noted the investigation report does not question why the care planned interventions were not in place at the time of the fall. This fall was not documented in R57's medical record. On 10/18/18, at 8:04 AM, Surveyor interviewed Registered Nurse (RN)- M, who stated she was on break at the time of R57's fall on 3/20/18. The former Director of Nursing assessed R57 after the fall. When RN-M arrived to the unit R57 was assessed and back in bed. When RN-M checked on R57 she noticed her right hand was swollen and red. RN-M did receive doctors orders for hand x-rays because she believed that R57 could have fractured something as a result of the fall. When RN-M assessed R57 after the fall she did notice pillows at the edge of the bed but is unable to state if the pillows were in place prior to the fall since she did not assess R57 immediately after the fall. RN-M stated eventually a body pillow was put into place but R57 didn't like it so the facility ordered a bigger bed. On 10/18/18, at 9:22 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-N, who stated: she assisted another nursing assistant in laying R57 down in bed at 1:00 PM on 3/20/18. CNA-N stated that there was no body pillow or pillows placed in the bed when she laid down R57. After R57 fell from the bed that day the body pillow intervention was put into place and then shortly after that the facility started to use a bumper mattress for R57. CNA-N stated, after the fall R57 was assisted by hoyer lift back into bed and pillows were placed as a barrier on the bed of the bed as this intervention was approved by the nurse following the fall. On 10/18/18, at 9:47 AM, Surveyor interviewed Director of Nursing-B, who stated: she is unable to speak to R57's falls on 2/8/18 or 3/20/18 as she just started working at the facility. DON-B stated she would expect to see interventions from all fall investigations added to the care plan and implemented for each resident. Surveyor informed DON-B that CNA-N stated she did assist with putting the R57 to bed prior to the fall. CNA-N stated the R57 did not have a body pillow or pillows at the edge of the bed when she put R57 in bed on 3/20/18 prior to the fall. Surveyor informed DON-B of the concern that fall interventions were not implemented after R57's fall on 2/8/18 causing a fall and fracture on 3/20/18. 2.) On 10/17/18 at 01:39 PM, while in the Unit 4 bathing room, Surveyor observed a waist high floor cabinet. On top of the cabinet was a 1 quart spray bottle of liquid Lysol IC disinfectant which had a warning label that read, Keep out of Reach of Children .causes irreversible eye damage and skin burns, harmful if swallowed, do not get, in eyes on skin or on clothing. Wear protective eye wear. This spray bottle was almost empty but still did contain at least a half of cup full of liquid at the bottom of the bottle (enough to swallow). Surveyor noted that the door to the bathing room was unlocked and that this Lysol IC disinfectant was not stored in a locked cabinet. When Surveyor opened the door to the bathing room, no residents were in the hallway area. At 10/17/18 01:48 PM, RN L came into the bathing room and Surveyor asked about the bottle of Lysol IC disinfectant not being stored in a locked cabinet. RN L stated that would be housekeeping .I honestly don't know what is in there. On 10/17/18 01:52 PM, Housekeeper K arrived to the bathing area. Surveyor showed Housekeeper K the Lysol IC disinfectant. Housekeeper K stated, it's supposed to be stored in our closet not sure how it got in here maybe one of the aides were using it for a room. Housekeeper K then removed the Lysol IC disinfectant. On 10/17/18 03:03 PM, Surveyor discussed the unlocked chemicals was discussed with the Administrator, Director of Nursing B and RN C. On 10/18/18 11:56 AM, Surveyor re-checked the shower room on unit 4 and observed there were no unlocked chemicals. On 10/18/18 11:48 AM, Surveyor interviewed RN J who stated there are there are 17 residents who reside on unit 4. RN J stated she was not familiar with any of the residents on this unit; however of the 17 residents, R40 who is sometimes ambulatory and other times uses a wheelchair has dementia. R56 has Alzheimer's dementia and is wheelchair bound. RN J stated R56 does wheel herself around the facility by herself. Certified Nursing Assistants (CNAs) E and F who stated they were familiar with the residents on unit 4. CNAs E and F reported R56, R40 and R42 are Residents on unit 4 who are getting confused and will enter other resident rooms but they have never tried to access the shower room as the door to the shower room is too heavy. CNAs E and F stated, these 3 residents have never entered any shower room, and they don't like showers. 2. On 10/17/18 at 01:59 PM, in the unlocked bathing room of unit 5, Surveyor observed an unlocked wall cabinet that was about 4 feet off of the floor. Surveyor observed; 1 quart bottle of Air Wick Wizard Deodorizer which was labeled, Keep out of children. 1 quart bottle of Lysol IC disinfectant bottle labeled, Keep out of Reach of Children .causes irreversible eye damage and skin burns, harmful if swallowed, do not get, in eyes on skin or on clothing. Wear protective eye wear, protective clothing & protective gloves. Harmful if inhaled and was observed to be 3/4 full. 1 quart bottle of TrueKleen Enzymatic Reorder #502 Foul Odor Digester Keep out of reach of children. No know significant effects or hazards. On 10/17/18 at 02:16 PM, Surveyor stepped out of the unit 5 bathing area and observed no residents in the hallway. Surveyor informed CNA G of the unlocked chemicals in bathing room unlocked cabinet. CNA G stated, I will go lock the cabinet now. On 10/17/18 03:03 PM, Surveyor discussed the unlocked chemicals was discussed with Administrator A, Director of Nursing B and RN C. On 10/18/18 11:41 AM, Surveyor re-checked the unlocked bathing room on unit 5 unit. Surveyor again observed the 3 bottles of chemicals in the unlocked cabinet which were: 1 quart bottle of Air Wick Wizard Deodorizer which was labeled, Keep out of children. 1 quart bottle of Lysol IC disinfectant bottle labeled, Keep out of Reach of Children .causes irreversible eye damage and skin burns, harmful if swallowed, do not get, in eyes on skin or on clothing. Wear protective eye wear, protective clothing & protective gloves. Harmful if inhaled and was observed to be 3/4 full. 1 quart bottle of TrueKleen Enzymatic Reorder #502 Foul Odor Digester Keep out of reach of children. No know significant effects or hazards. Surveyor showed RN D the chemicals and asked who is responsible to lock cabinet. RN D stated housekeeping and that the chemicals should not be in there to begin with. Surveyor and RN D observed a key on a chord that is attached to the cabinet. Surveyor then observed the housekeeping cart arrived and was in the hallway outside of the bathing room. Surveyor observed no residents are in the area. On 10/18/18 11:40 AM Surveyor interviewed RN D regarding residents on the unit who may have dementia and who get around on unit 5. RN D stated there were 16 residents on unit 5. RN D stated R1 is wheelchair bound, R31 is wheelchair bound with [MEDICAL CONDITION] and ambulates with assistance and R212 is confused but not so much as dementia. RN D stated they are wheelchair bound and need help getting around the unit. RN D stated, they don't go into the shower room by themselves and would not have been able to access the chemicals from yesterday. RN D stated they go to the shower room with the CNA. On 10/18/18 12:02 PM, Surveyor notified the Director of Nursing (DON) B of the observation of chemicals not being stored in a locked area. DON B stated she would immediately check to make sure the chemicals were locked up. On 10/18/18 12:15 PM, Surveyor interviewed Maintenance Director I regarding the observations of unlocked chemicals in the bathing room. Maintenance Director I stated, they (chemicals) should not be in there .I don't know who all has access to them.

Based on observation, record review and interview, the facility did not notify the physician of changes in wound status for 1 (R6) of 15 sampled residents. R6 had surgical debridement of a right hip pressure injury prior to admission on 6/16/17. On 6/22/17, facility staff did not contact the surgeon to obtain a suitable wound treatment on the suggestion of the wound physician. Staff did not contact the physician when the wound had signs of infection on 7/13/17 and 7/17/17. Staff did not contact the physician when there was partial tendon exposure in the wound bed on 7/27/17. Staff did not contact the physician when tunneling was noted to the wound on 8/3/17 and 8/17/17. The facility's failure to consult with R6's physician created a finding of immediate jeopardy that began on 7/13/17. NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were notified of the immediate jeopardy on 8/23/17 at 3:07 pm. The immediate jeopardy was removed on 8/25/17. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: R6 is a [AGE] year old resident who was admitted from a community hospital on [DATE] after having a surgical debridement of the pressure injury down to the muscle of her right hip. Admitting [DIAGNOSES REDACTED]. On 6/15/17, the Operative Report from the hospital, prior to admission to the facility, described the debridement of the decubitus ulcer to involve the skin and subcutaneous tissue all the way to the muscle layer on the right hip. The wound measured 5 centimeters (cm) by 5 cm with a depth of about 2 cm. The wound was then packed using plain gauze packing. The Patient Discharge Instructions given to the facility when R6 was admitted state, in addition to the debrided right hip, the left hip has a Stage 1 pressure ulcer, the left heel has a suspected deep tissue injury (DTI) that is purple in color with calloused skin, and the right heel has a Stage 1 pressure ulcer. The facility Definitions for Staging of Pressure Ulcers effective July 2015 states: The following pressure ulcer staging system is consistent with the recommendations of the National Pressure Ulcer Advisory Panel (NPUAP). Pressure ulcers are staged using the system below. (Suspected) Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. . Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. . Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. . Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. . Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. . Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The admitting order for wound care to the right hip on 6/16/17 states: dressing tx (treatment) to R. (right) Trochanteric (hip). Cleanse (with) N/S (normal saline) followed by packing of saline wet-to-dry dressing cover with ABD (abdominal pad) and tape. (Change) dressing daily. On 6/22/17, R6 was seen by the facility wound physician. The physician identified two pressure injuries to the right hip: #1 right hip, #2 right superior hip. The physician progress notes [REDACTED]. Initial wound encounter measurements are 4.5 cm length x 3.2 cm width x 1.5 cm depth, . There is a moderate amount of serous drainage noted. Wound bed has a 76-100% granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Wound #2 Right, Superior Hip has a Primary Etiology of pressure ulcer and is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Open. Initial wound encounter measurements are 4.5 cm length x 2.4 cm width, . There was no drainage noted. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The physician documented he discussed with facility staff to discuss Silver Alginate dressings in place of the wet to dry dressings with the surgeon because the wound did not need mechanical debridement. The wound physician changed the wound treatment order on 6/22/17 to start ½ Dakins F/B (followed by) wet to dry dressing Cover with ABD (and) tape. (Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION].) No documentation was found in the EMR (Electronic Medical Record) that nursing staff contacted the surgeon to request a change in wound treatment per the wound physician's suggestion. In an interview with DON-B on 8/22/17 at 9:25 am, Surveyor asked DON-B about the suggestion of the wound physician to contact the surgeon to change the treatment for [REDACTED]. DON-B provided the Smith & Nephew Clinical Practice Quick Reference Guide stating this was the facility's reference for all wound care. The Reference Guide states: The use of wet-to-dry dressings may damage healthy granulated tissue and may lead to excessive bleeding and increased pain. DON-B stated the staff usually call the surgeon when the wound physician suggests a change in treatment. DON-B stated she would look to see if there was any documentation. No documentation was provided. The facility uses a form labeled Skin Grid to document and track wounds. The top left box of the form has initial identification information. Under the Initial Identification box, there is a section that describes the stages of pressure injuries. Under the Staging Descriptions section, the following columns are used for weekly documentation: Date, Stage Pressure Ulcer ONLY, length in cm, width in cm, depth, color of drainage (S, P, or O), color (P, R, Y, N, or B), odor (O, M, or F), tunneling/undermining with a circle and numbers of a clock around it, tunneling/undermining depth, and RN/LPN initials. The bottom section has the Documentation Key: Drainage: S - Serosanguineous, P - Purulent, O - none; Color: P - Pink, Y - Yellow, N - Necrotic/Slough, R - Red, B - Black (eschar); Odor: 0 - None, M - Mild, F - Foul; Tunneling: Use clock to indicate location. R6's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/23/17 was completed on 6/29/17. R6's cognition was evaluated to be severely impaired due to the inability to answer any of the assessment questions accurately. R6 is non-ambulatory and is assisted by one staff member for bed mobility, toileting/incontinent care, dressing, repositioning, and bathing. R6 is incontinent of both bowel and bladder at all times. R6 has functional limitation in range of motion of one arm and both legs. The Stage 3 pressure injury has measurements of 4.5 cm x 3.2 cm x 1.5 cm, consistent with the charting from the wound physician's rounds on 6/22/17. The Pressure Injury Care Area Assessment (CAA) states R6 was admitted with a Stage 3 pressure area to right hip with area around injury of discoloration 4.5 cm. R6 is receiving high calorie supplements and [MEDICATION NAME] (an antidepressant medication used to stimulate appetite) to assist with appetite stimulation to increase intake and assist with healing. Turning and repositioning every two hours noted to be ongoing. Pressure relieving devices are in place, but does not state what type of devices. It is denoted on the CAA that the facility will proceed to a pressure ulcer - functional status plan of care to avoid complications and minimize risks of skin breakdown. A plan of care for pressure ulcer to the right hip related to decreased mobility was initiated on 6/30/2017 with a goal that the pressure ulcer will show signs of healing and remain free from infection by/through review date with a target date of 11/12/17. Interventions include: administer medications as ordered, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly and PRN (as needed), measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvement and declines to the MD (Medical Doctor) . follow facility policies/protocols for the prevention/treatment of [REDACTED]. report loose dressing to treatment nurse, monitor/document/report to MD PRN change in skin status: appearance, color, wound healing, signs or symptoms of infection, wound size (length x width x depth), stage . notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care, obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated . treat wound as per facility protocol. On 6/30/17 at 5:33 pm, the nursing progress notes state they received an order for [REDACTED].>On 7/10/17, R6 had surgical wound debridement of the right hip as a same day surgery. The wound treatment ordered by the surgeon was a daily wet to dry dressing change with normal saline. No documentation was found in the EMR or in the hard chart that an assessment was done of the newly debrided wound upon returning to the facility. On 7/11/17, R6 was admitted to hospice. In an interview with DON-B on 8/22/17 at 9:25 am, Surveyor informed DON-B there was no documentation after R6 returned from having the wound debrided by the surgeon on 7/10/17. The first assessment of the wound was documented on 7/17/17 on the Skin Grid. The right hip Skin Grid for 7/13/17 was blank except for the date. Documentation for the right hip Skin Grid on 7/13/17 was provided by DON-B on 8/22/17 at 10:50 am. The information provided was on a worksheet used by the wound team on 7/13/17. The documentation staged the right hip wound to be a DTI (deep tissue injury) measuring 9.1 cm x 7.1 cm x 1.8 cm, red in color with green drainage and no odor or tunneling. The narrative stated, (No) c/o (complaints of) pain. Resident has (no) s/sx (signs or symptoms of) infection. Red & blanchable peri wound. There is no signature of who completed the assessment. On 8/22/17 at 1:37, Surveyor interviewed DON-B regarding the concerns of documentation of the right hip wound on 7/13/17. DON-B stated DON-B, ADON-G, and Deputy DON-H worked as a team on 7/13/17 and did the assessment together. Surveyor showed DON-B the Skin Grid for 7/13/17 with documentation of the open wound being classified as DTI, green drainage, and narrative stating there were no signs or symptoms of infection. DON-B agreed that green drainage is a symptom of infection. There was no notification to the surgeon or physician for consultation and no change in treatment obtained. DON-B did not provide any documentation that any physician had been notified or consulted with regarding the change in R6's status of her pressure injury. On 7/17/17, the right hip Skin Grid documents the wound to be a DTI of the left hip (right hip is the affected area) with measurements of 10.7 cm x 6.9 cm x 2.5 cm, red in color with green drainage, and no odor or tunneling. The narrative states the wound treatment and measurements were completed by the hospice nurse and the hospice nurse placed a phone call to the surgeon for orders. There is no documentation in the EMR progress notes or in hospice progress notes that hospice did wound care or a wound assessment on 7/17/17. There is no documentation of hospice contacting the physician for orders. In an interview on 8/22/17 at 10:50 am with DON-B regarding the right hip assessment on 7/17/17, DON-B was unable to provide any documentation that a physician had been notified of the green drainage or a request for a new treatment order. On 7/19/17, the hospice physician ordered wound care to the right hip: Cleanse area with normal saline. Use Dakins solution to wet gauze dressing and place on wound bed. Cover with ABD pad and secure with [MEDICATION NAME]. Change twice daily. On 7/20/17, the right hip Skin Grid stages the wound as a DTI with measurements of 6.9 cm x 10 cm x 1.8 cm. The narrative states the edges are reddened and rolled. The wound base has 50% granulation and 50% slough with no tunneling. A new treatment was obtained by the hospice physician. In an interview with DON-B on 8/22/17 at 1:37 pm, DON-B thought that the hospice nurse had tried to contact the surgeon on 7/17/17, but was unable to either contact the surgeon or the surgeon didn't want to change the order for the wound care. The hospice nurse then contacted the hospice physician to get a new treatment order. DON-B didn't have any documentation to show the order of events. On 7/27/17, the right hip Skin Grid documents the wound to be unstageable with measurements of 6.8 cm x 10.2 cm x 0.9 cm. The wound is red with serosanguineous drainage and a mild odor. The narrative states the lateral edge of the wound is pink and blanchable with no undermining. The wound base has 75% granulation and 25% slough and a tendon with partial exposure. There is no documentation in the Progress Notes of staff contacting a physician or hospice to report and consult with regarding the visible tendon in the wound. There is no documentation in the Hospice Progress Notes that they were notified of the change in status of the wound. In an interview with DON-B on 8/22/17 at 9:25 am, Surveyor asked about the documentation of an exposed tendon on 7/27/17 and who was notified of the change in status. DON-B stated that it was thought at the time not to be a tendon but stringy slough and just misinterpreted as a tendon. DON-B didn't think a physician was notified, but hospice might have been. DON-B would contact hospice to clarify. No documentation was provided. In an interview with Deputy DON-H on 8/22/17 at 1:37 pm, Surveyor questioned Deputy DON-H about the documentation and tendon that was exposed in the right hip wound on 7/27/17. Deputy DON-H stated that she thinks it was mislabeled; it was probably just stringy slough. Deputy DON-H stated she is not Wound Care Certified so she doesn't really know what she's looking at. Deputy DON-H did not notify a physician or consult with them regarding the change in status of the wound. On 8/3/17, the right hip Skin Grid does not stage the wound. The measurements are 9.8 cm x 6.0 cm x 0.5 cm with red wound base and serosanguineous drainage with a mild odor. The clock diagram has an arrow pointing from the center to 3 o'clock with a measurement of 0.3 cm, but the tunneling column has a line across it. The narrative states there are no signs or symptoms of infection, no complaints of pain, and there is a slight odor. There is no signature of who completed the assessment. On 8/10/17, the right hip Skin Grid does not stage the wound. The measurements are 9.4 cm x 5.5 cm x 1.8 cm with red wound base and serosanguineous drainage with a mild odor. The clock diagram has a line from the center to just above the 3 o'clock position and the tunneling column has a line across it. The narrative states there are no signs or symptoms of infection, no complaints of pain, and the wound base has 25% slough and 75% granulation. There is no signature of who completed the assessment. In an interview with DON-B on 8/22/17 at 9:25 am, DON-B stated she did the wound measurements on 8/3/17 and 8/10/17. DON-B stated on 8/3/17 there was a small dimpling on the edge of the wound, but on 8/10/17 it was no longer present. DON-B did not notify a physician when there was tunneling to the wound. DON-B stated she should not have made the line on the clock diagram on 8/10/17; she should have put a circle with a line through it to show there wasn't any tunneling. On 8/17/17 at 2:00 pm, Surveyor observed R6's wound treatment completed by DON-B, ADON-G, and Deputy DON-H. DON-B was the lead in the dressing change. DON-B removed the old dressing from the right hip and then applied Dakin's soaked gauze to the wound base. The area was wiped with normal saline soaked gauze before the area was measured. A normal saline soaked gauze was put into the wound base and then covered with an ABD pad and taped around the perimeter of the bandage. Deputy DON-H handed the supplies to DON-B as needed while ADON-G talked to R6 and held R6's hand. R6 moaned slightly during the dressing change and with repositioning and guarded the right hip with her right arm at those times. DON-B asked if R6 had received any pain medication. ADON-G stated R6 had gotten the scheduled pain medication but no PRN (as needed) pain medication and indicated R6 would get a PRN pain medication after the treatment was done. DON-B, ADON-G, and Deputy DON-H then completed the wound treatment to R6's left outer ankle. DON-B removed the old dressing and measured the area stating the skin was intact and had never been an open wound. The area was wiped with normal saline soaked gauze and dried off with gauze. ADON-G held R6's leg and Deputy DON-H put the date on the new dressing. The Allevyn Life dressing was applied to the left outer ankle by DON-B. R6 was positioned on the left side with a pillow under the left leg and between the legs. The bed mattress was set on 3 indicating 140 pounds. On 8/17/17, the right hip Skin Grid does not stage the wound. The measurements are 6.4 cm x 9.9 cm x 1.5 cm. The wound is red with a moderate amount of serosanguineous drainage with no odor. Tunneling measures 0.5 cm at 3 o'clock. The narrative states there is no odor, no complaints of pain, and no signs or symptoms of infection. The wound bed has 80% granulation and 20% slough with new skin growth. On 8/17/17 at 6:43 pm, the Progress Notes state no new treatment was ordered. There is no documentation stating who was contacted to obtain a new treatment or when they were contacted. On 8/22/17 at 2:10 pm, Surveyor discussed concerns with NHA-A regarding R6's pressure injury and no physician notification when there was a change in condition. There was no documentation of nursing staff calling the physician when there was green drainage from the wound, the partial exposure of a tendon, and new tunneling in the wound bed. NHA-A did not provide any more information. The facility's failure to notify and consult with R6's surgeon and physicians when changes were noted to R6's pressure injury including the development of green drainage and visible tendon led to further deterioration of R6's pressure injury (Cross-reference F314) and created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 8/25/17 when it implemented the following action plan: * House wide audit of E-interact and changes of conditions to ensure proper MD notification. * Staff education on EInteract and change in condition policy. Staff will also be educated on process for when MD does not answer and for verification and timely response with a fax. * Education with staff on shift to shift report including the 24 hour report board being pulled up in front of them during report. * Nurses notes to be reviewed 5 days a week to ensure changes have been communicated up to the MD and that the e-interact protocol is followed. * Weekly grand rounds will be completed utilizing company policy and tool. * Review all MD orders and appointments consults 5 days a week to ensure proper follow up and notification. * Audit shift to shift report to ensure 24 hour report board is being utilized. * AD-H(NAME) QAPI with medical director, ED, DON, DDON, ADON, educator, and DCS. * Audits will be taken to QAPI monthly for 3 months for further review and recommendations. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan.

Based on observation, record review, and interview, the facility did not ensure that 3 (R6, R11, R14) of 11 residents reviewed for risk of pressure injuries received care in accordance to current standards of practice for pressure ulcer care. * R6 was admitted to the facility with a surgically debrided pressure injury on her right hip that was debrided down to muscle (stage 4 pressure injury). The discharge summary at the time of admission also indicates R6 had various other pressure injuries to her left hip and feet. Upon admission to the facility, a comprehensive skin assessment was not completed that included stages and characteristics of R6's pressure injuries, there is no indication R6 received ordered treatments for two days following admission. Appropriate pressure relieving devises were not implemented for R6 at the time of admission. On 6/22/17 a comprehensive assessment was completed on R6's hip pressure injury which was now two pressure injuries, one being a new deep tissue injury. Weekly wound monitoring did not include comprehensive or at times accurate assessments of the pressure injuries. The physician was not notified of changes in status of the right hip pressure injury including when possible tendon was observed and/or when green drainage and foul odor was noted. On 8/23/17 R6 was observed during a head to toe skin assessment to have 2 pressure injuries to her ear caused by a hearing aide, in addition to an unstageable pressure injury to a toe and a non-blanchable area to a previous toe amputation site; none were previous The facility failed to provide necessary treatment to promote healing, prevent infection and prevent new ulcers from developing, creating a finding of immediate jeopardy that began on 6/16/17. Nursing home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on 8/23/17 at 3:07 pm. The immediate jeopardy was removed on 8/25/17. The deficient practice continues at scope/severity of D with the following examples and as the facility continues to implement their action plan. * R11 was admitted to the facility on [DATE] and had excoriation to the right buttock area. The excoriation was not assessed. On 5/14/17 R11 developed a stage 2 pressure injury to the right buttock. The facility did not complete a comprehensive assessment of the pressure injury from 5/14/17 (date discovered) through 5/28/17, which included measurements to determine if the pressure injury was progressing toward healing or deteriorating. The facility did not notify the wound care team and did not develop a plan of care for the wound from 5/14/17 through 5/28/17. On 5/14/17 an order was obtained for a foam dressing to the area. The treatment was not always documented as being completed. On 5/28/17 there was a physician's telephone order to discontinue the treatment to the right buttock pressure injury because the area was healed. The nurse who obtained the order did not document their name or the date of the order and did not document a progress note regarding the condition of the pressure injury. * R14 was admitted with a Stage 2 pressure injury and no treatment was provided for four weeks. Findings include: 1.) R6 is a [AGE] year old resident who was admitted from a community hospital on [DATE] after surgical debridement of a pressure ulcer on the right hip. This pressure injury was debrided down to muscle. Admitting [DIAGNOSES REDACTED]. On 6/15/17, the Operative Report from the hospital, prior to admission to the facility, described the debridement of the decubitus ulcer to involve the skin and subcutaneous tissue all the way to the muscle layer on the right hip. The wound measured 5 centimeters (cm) by 5 cm with a depth of about 2 cm. The wound was then packed using plain gauze packing. The Patient Discharge Instructions given to the facility when R6 was admitted state, in addition to the debrided right hip, that the left hip has a Stage 1 pressure ulcer, the left heel has a suspected deep tissue injury (DTI) that is purple in color with calloused skin, and the right heel has a Stage 1 pressure ulcer. The facility Definitions for Staging of Pressure Ulcers effective July 2015 states: The following pressure ulcer staging system is consistent with the recommendations of the National Pressure Ulcer Advisory Panel (NPUAP). Pressure ulcers are staged using the system below. (Suspected) Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The facility Policy and Procedure for Skin Assessment effective July 2015 states: 1. Complete the Skin Assessment form on all residents following: admission; re-admission; return from Leave of Absence (LOA); return from emergency room Visit; discharge. 2. Place a check mark in the appropriate box(s): No areas of skin impairment; See Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other; See Treatment Administration Record. 3. Place a letter(s) at the site of skin impairment(s) on the anatomical body using the documentation key. 4. Document the measurement next to the area of skin impairment letter. 5. File in the Assessments section of the medical record. On 6/16/17, R6 was assessed by Registered Nurse (RN)-I. RN-I used the Admission Assessment in the Electronic Medical Record (EMR) to record R6's nursing assessment. In Section C: Skin Integrity, charting denotes skin color is normal in both lower extremities and the skin temperature of the upper and lower extremities are cool, equal, and dry. In subsection 3 of Section C, RN-I denotes there is a concern with skin integrity but all focus, goal, and intervention areas of the document are blank. On 6/16/17, the Admission Skin Assessment found in the hard medical chart, was signed by Licensed Practical Nurse (LPN)-J. The document has a diagram of a body with a front and back view. The front view of the body has a small circle on the right antecubital space of the arm with a BR next to it that indicates a bruise to that area. The right lower hip has a circle with the word mole next to it. The right big toe has a line drawn across it with the word amputated next to it. There is the same notation to the diagram of the bottom of the right foot. There is a small circle on the lower right leg and two small circles on the top of the left foot with no notation as to what are on these areas. The back view of the body has a small circle on the lower back with the word scab next to it. There is a circle on the right hip with the letter P next to it that indicates pressure area. The words surgical scar is written in the coccyx area of the diagram. There is a circle on the left hip with the letter P next to it that indicates a pressure area. There are measurements of 3.5 cm, 5 cm, and 0.2 cm deep written next to the left hip circle. The comments section of the document is blank. On 8/22/17 at 9:25 am, Surveyor discussed R6's admission documentation with DON-B. Surveyor pointed out there is no documentation of wound bed color, tissue type, drainage, odor, or any other description of areas in the EMR. On the admission Skin Assessment form, the area circled for the open pressure area with measurements was on the left hip; the surgical debridement was on the right hip. DON-B stated documentation is an issue. Staff gets confused with right or left side of the body when charting. In a phone interview with RN-I on 8/22/17 at 2:55 pm, RN-I stated she was in training at the time of R6's admission so she was pretty sure she was only assisting with the skin assessment. RN-I stated she only works occasionally at the facility so she has limited interaction with R6. RN-I could only recall that the wound on the hip was deep, but couldn't recall any other distinguishing characteristics such as a bad smell or drainage. RN-I stated the wound may have been a little red around the edges. RN-I denied knowledge of R6 having any other pressure areas at that time. In an interview with LPN-J on 8/22/17 at 3:30 pm, LPN-J stated he signed the Admission Skin Assessment document. When asked what the circled areas meant on the diagram that didn't have any writing by them, he stated the writing on the document was not his handwriting so he couldn't say why the circled areas were marked. LPN-J stated two nurses do skin assessments and LPN-J did the admission skin assessment with RN-I. When looking at the document, LPN-J recalled a 0.2 cm tunneling on one edge of the hip wound, but couldn't recall what part of the wound had tunneling. LPN-J thought the base of the wound was moist and reddened. LPN-J couldn't recall any significant area around the hip wound. LPN-J stated there were no other skin areas that were open. The admitting order for wound care to the right hip on 6/16/17 states: dressing tx (treatment) to R. (right) Trochanteric (hip). Cleanse (with) N/S (normal saline) followed by packing of saline wet-to-dry dressing cover with ABD (abdominal pad) and tape. (Change) dressing daily. The Treatment Administration Record (TAR) has the treatment signed out as completed on 6/19/17 and 6/20/17. No initials were entered into the TAR for 6/17/17, 6/18/17, or 6/21/17. On 6/22/17, R6 was seen by the facility wound physician. The physician identified two pressure areas to the right hip: #1 right hip, #2 right superior hip. The physician progress notes [REDACTED]. Initial wound encounter measurements are 4.5 cm length x 3.2 cm width x 1.5 cm depth, . There is a moderate amount of serous drainage noted. Wound bed has a 76-100% granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Wound #2 Right, Superior Hip has a Primary Etiology of pressure ulcer and is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Open. Initial wound encounter measurements are 4.5 cm length x 2.4 cm width, . There was no drainage noted. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The physician documented he discussed with facility staff to discuss Silver Alginate dressings in place of the wet to dry dressings with the surgeon because the wound did not need mechanical debridement. The wound physician changed the wound treatment order on 6/22/17 to start ½ Dakins F/B (followed by) wet to dry dressing Cover with ABD (and) tape. (Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION].) The TAR has the treatment signed out as completed 6/24/17-6/27/17, 6/29/17, and 6/30/17. No initials were entered into the TAR for 6/22/17, 6/23/17, and 6/28/17. No documentation was found in the EMR that nursing staff contacted the surgeon to request a change in wound treatment per the wound physician's suggestion. In an interview with DON-B on 8/22/17 at 9:25 am, Surveyor asked DON-B about the suggestion of the wound physician to contact the surgeon to change the treatment for [REDACTED]. DON-B provided the Smith & Nephew Clinical Practice Quick Reference Guide stating this was the facility's reference for all wound care. The Reference Guide states: The use of wet-to-dry dressings may damage healthy granulated tissue and may lead to excessive bleeding and increased pain. DON-B stated staff usually call the surgeon when the wound physician suggests a change in treatment. DON-B stated she would look to see if there was any documentation. No documentation was provided. The facility uses a form labeled Skin Grid to document and track wounds. The top left box of the form has initial identification information. Under the Initial Identification box, there is a section that describes the stages of pressure injuries. Under the Staging Descriptions section, the following columns are used for weekly documentation: Date, Stage Pressure Ulcer ONLY, length in cm, width in cm, depth, color of drainage (S, P, or O), color (P, R, Y, N, or B), odor (O, M, or F), tunneling/undermining with a circle and numbers of a clock around it, tunneling/undermining depth, and RN/LPN initials. The bottom section has the Documentation Key: Drainage: S - Serosanguineous, P - Purulent, O - none; Color: P - Pink, Y - Yellow, N - Necrotic/Slough, R - Red, B - Black (eschar); Odor: 0 - None, M - Mild, F - Foul; Tunneling: Use clock to indicate location. The Initial Identification box on the Skin Grid for the right hip states the pressure wound was present on admission 6/16/17 with a length of 3.5 cm and a depth of 0.2 cm. There is no measurement for the width and no documentation of drainage, color, odor, tunneling/undermining, amount of drainage, Braden Risk Assessment score (The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.), or signature of the staff member completing the section. On 6/22/17, the right hip Skin Grid has the measurements that were provided by the wound physician, but no staging of the pressure injury was documented. The right superior hip was documented on the same form, even though it was two separate areas of injury. The Skin Grid has the area denoted as Super DTI 4.5 x 2.4. No other descriptors were used of the area. The comment section below the columns for 6/22/17 state the change in wound treatment to include the ½ Dakin's and documentation that R6 had pain with the dressing change. There was no documentation in the nursing progress note on 6/22/17. R6 received scheduled [MEDICATION NAME] 200 mg every evening for pain. Tylenol 650 mg was administered at 1:30 am 6/22/17. No other pain medications were given during 6/2017. (Cross-reference F309). On 6/28/17, R6 went to the scheduled appointment with the surgeon for a follow-up after hospitalization . The surgeon's note of that visit states the right hip has more skin necrosis which will require surgical debridement again. R6 is starting to have other areas of pressure: the left hip, the left medial hip and the left lateral ankle. The surgeon ordered [MEDICATION NAME] dressing to each area to prevent skin breakdown in those areas due to pressure. No measurements or descriptors were documented in the physician note for any of the pressure areas. In an interview with DON-B on 8/22/17 at 9:25 am, Surveyor informed DON-B there was no documentation on the Skin Grid for 6/29/17 for the right hip pressure injury. DON-B stated she believed the DTI on the right hip merged with the Stage 3 wound on the right hip to become one large area. Documentation for the Skin Grid on 6/29/17 was provided by DON-B on 8/22/17 at 10:50 am. The information provided was on a worksheet used by the wound team on 6/29/17. The new information on the Skin Grid for the right hip pressure injury states the staging of the wound to be DTI, 9 cm x 3.4 cm x 1.7 cm with 100% granulation tissue. The definition of a DTI is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft from pressure. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size. In an interview with Assistant Director of Nursing (ADON)-G on 8/22/17 at 1:37 pm, Surveyor questioned ADON-G about the documentation on the Skin Grid on 6/29/17 and the discrepancy comparing it to the description of the right hip wound the surgeon documented on 6/28/17. The surgeon wrote the wound was necrotic to the point that it needed surgical debridement and ADON-G had documented the wound had 100% granulation tissue. ADON-G stated she was not Wound Care Certified and she may not have known what kind of tissue was in the wound base. ADON-G stated the wound team works together measuring and documenting all the wounds in the facility. The team consists of ADON-G, DON-B, and Deputy DON-H, but none of them are Wound Care Certified. The team does rounds with the wound physician to all the residents in the facility that have wounds unless the resident is on hospice or the area of concern is excoriation. Those residents are monitored by facility staff and the wound team only. On 6/29/17, [MEDICATION NAME] dressing to left hip, left medial foot, and left lateral ankle were signed on the TAR as being administered. There was no documentation of dressings applied to areas at any other time. No Skin Grid sheets were started for any of the pressure areas of concern. No documentation of monitoring was found. R6's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/23/17 was completed on 6/29/17. R6's cognition was evaluated to be severely impaired due to the inability to answer any of the assessment questions accurately. R6 is non-ambulatory and is assisted by one staff member for bed mobility, toileting/incontinent care, dressing, repositioning, and bathing. R6 is incontinent of both bowel and bladder at all times. R6 has functional limitation in range of motion of one arm and both legs. The Stage 3 pressure ulcer has measurements of 4.5 cm x 3.2 cm x 1.5 cm, consistent with the charting from the wound physician's rounds on 6/22/17. The Pressure Injury Care Area Assessment (CAA) states R6 was admitted with a Stage 3 pressure area to right hip with area around ulcer of discoloration 4.5 cm. R6 is receiving high calorie supplements and [MEDICATION NAME] (an antidepressant medication used to stimulate appetite) to assist with appetite stimulation to increase intake and assist with healing. Turning and repositioning every two hours noted to be ongoing. Pressure relieving devices are in place, but does not state what type of devices. It is denoted on the CAA that the facility will proceed to a pressure ulcer - functional status plan of care to avoid complications and minimize risks of skin breakdown. A plan of care for pressure injury to the right hip related to decreased mobility was initiated on 6/30/17 with a goal that the pressure ulcer will show signs of healing and remain free from infection by/through review date with a target date of 11/12/17. Interventions include: administer medications as ordered, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly and PRN (as needed), measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvement and declines to the MD (Medical Doctor), avoid dry skin, complete Braden Scale weekly times four weeks on admission, quarterly, and with change of condition, do not massage over bony prominences, do not use Do-Nut type devices, follow facility policies/protocols for the prevention/treatment of [REDACTED]., needs pressure relieving mattress to protect the skin while in bed, notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care, obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated, provide assistance to turn/reposition at least every two hours, and as needed or requested, treat wound as per facility protocol. On 7/4/17, an intervention was added regarding managing nutrition. In an interview on 8/22/17 at 9:25 am, Surveyor asked DON-B if there was a plan of care in place when R6 was admitted since the initial plan of care wasn't initiated until 6/30/17. DON-B stated there is no interim plan of care when a resident is first admitted . Every resident has a CNA (Certified Nursing Assistant) Care Card that informs staff of the care the resident is to receive. After admission, the Unit Manager will do a chart audit and then create a plan of care for the resident. The current CNA Care Card states R6 requires assist of two for transfer with a mechanical lift using a navy sling. For skin interventions it states: Yellow dot No pressure to right hip. Surveyor asked if there was a CNA Care Card for the time of admission until the plan of care was initiated on 6/30/17. DON-B provided CNA Care Cards, but there were no dates on them to signify when they were in use. Surveyor asked DON-B about the Yellow dot notation on the CNA Care Card. DON-B stated nurses check and track the CNA's for positioning those residents on the Yellow Dot program. The TAR has the Yellow Dot program initiated on 6/19/17 and goes to present. DON-B provided the facility Policy and Procedure for the Turning and Repositioning Program, which she referred to as the Yellow Dot policy, dated 7/2015. It states: The center will follow Skin Care Protocols regarding the turning and positioning of residents that may include, but is not limited to a person with: Sensory impairment; Braden Risk Assessment that scores low in mobility and/or sensory perception. 1. Place a yellow dot on the nameplate of the resident's door and/or wheelchair/gerichair whenever a resident is: unable to turn self; unable to reposition self. 2. Turn and reposition residents every 1-2 hours when; in bed; in any type of chair 3. Offer reminders to turn and reposition residents with sensory impairment whenever a resident is: able to turn self; able to reposition self. 4. Turn and reposition between 15 minutes before and 15 minutes after the pre-determined times. 5. Place a black line thru the Yellow Dot for residents who: cannot tolerate lying on their left, right or back; require more frequent turning and repositioning; personal preference. 6. Communicate the individualized turning and repositioning schedule using: Skin Integrity Assessment: Prevention and treatment Care Plan; Care Delivery Guide/Nursing Assistant Assignment Sheet. 7. Document repositioning using CareTracker. On 6/30/17, nursing staff received an order from the physician for an air mattress related to a Stage 3 pressure injury to be obtained for R6. On 6/30/17 at 5:33 pm, the nursing progress notes state they received an order for [REDACTED].>The TAR for 7/2017 had a space with the order for shift signatures regarding the air mattress related to the Stage 3 pressure wound - check settings every shift 2. Initials were in all the shift boxes for 7/1/17-7/4/17 indicating mattress was checked for the appropriate setting. On 7/5/17 at 10:17 am, the nursing progress notes state the air mattress was ordered with a confirmation number listed. In an interview on 8/22/17 at 10:50 am, DON-B verified that the air mattress for R6 was delivered on 7/5/17. Surveyor informed DON-B that staff had signed that the mattress was in place on 7/1/17 through 7/4/17. DON-B stated she wasn't sure what mattress was in place on the dates in question. DON-B thought there might have been an air mattress in the facility that was put in place until the ordered mattress arrived. No other information was provided. On 7/6/17 at 11:14 am in the progress notes, the Nutrition Services Director has a comprehensive note with recommendations to increase wound healing. This is the first documentation of dietary involvement with R6. In an interview on 8/22/17 at 9:25 am, Surveyor asked DON-B about the timing of alerting the dietician of a new admission with pressure injuries. DON-B stated she did not know how that information is communicated. The interdisciplinary team meets daily during the work week and they review any incident report that is filed by nursing of any new pressure injury, but DON-B was unsure of how an existing pressure injury on a new admitting resident is handled. On 7/6/17, R6 was seen by the wound physician on wound rounds. The progress note states wound #1 right hip is a Stage 3 pressure injury and measures 8 cm length x 3.3 cm width x 1.6 cm depth. Undermining has been noted at 12:00 and ends at 3:00 with a maximum distance of 0.9 cm. There is a small amount of serous drainage. Wound bed is 100% necrotic slough/eschar with low moisture. Wound #2 right superior hip has converted and merged with wound #1. Wound #3 left lateral ankle is a DTI with measurements of 0.7 cm length x 0.5 cm width. This is the initial encounter with this wound. The wound physician ordered the right hip wound to be irrigated twice a day with [MEDICATION NAME] and covered with a secure dressing. The left ankle was to be treated Monday, Wednesday, and Friday: cleanse with saline, apply skin prep to the periwound, and cover the area with a bordered foam dressing with silicone. On 7/6/17, the right hip Skin Grid stated DTI (left) hip Allevyn life with no descriptive documentation for that area such as measurements or color. The right hip wound documentation was the same as the wound physician's progress note, but did not contain a statement of the merging of the two separate wounds into one or have any staging of the wound. No Skin Grid was initiated for the left hip pressure area. On 7/6/17, a Skin Grid for the left ankle was initiated with the measurements obtained from the wound physician during wound rounds. It is staged a DTI. On 7/6/17 at 10:28 am, the progress notes state R6 was seen by the wound physician on weekly rounds. The measurements and wound description are consistent with other documentation of the right hip wound and there are complaints of pain when touched. There is a DTI to the left lateral ankle and new treatment orders have been received. The left hip is red but blanchable, and a new preventative treatment has been ordered for the left hip. The 7/2017 TAR has an order hand written stating: to (left) ankle & (left) hip - cleanse (with) NS (normal saline) F/B (followed by) Allevyn life, (Change) M/W/F (Monday/Wednesday/Friday) & PRN. The TAR has signatures on 7/8/17 and 7/19/17 indicating treatment was done to the left ankle and left hip. All other Monday, Wednesday, and Friday dates in 7/2017 are blank. On 7/7/17 at 1:28 pm in the progress notes, there is a clarification from R6's Power of Attorney (POA) regarding which doctor is responsible for R6's care. The POA stated R6 will continue to see the Primary Care Physician, but all wound care issues are to be addressed by the surgeon. On 7/10/17, R6 had surgical wound debridement of the right hip as a same day surgery. The wound treatment ordered by the surgeon was a daily wet to dry dressing change with normal saline. No documentation was found in the EMR or in the hard chart that an assessment was done of the newly debrided wound upon returning to the facility. On 7/11/17, R6 was admitted to hospice. In an interview with DON-B on 8/22/17 at 9:25 am, Surveyor informed DON-B there was no documentation after R6 returned from having the wound debrided by the surgeon on 7/10/17. The first assessment of the wound was documented on 7/17/17 on the Skin Grid. The right hip Skin Grid for 7/13/17 was blank except for the date. Documentation for the right hip Skin Grid on 7/13/17 was provided by DON-B on 8/22/17 at 10:50 am. The information provided was on a worksheet used by the wound team on 7/13/17. The documentation staged the right hip wound to be a DTI measuring 9.1 cm x 7.1 cm x 1.8 cm, red in color with green drainage and no odor or tunneling. The narrative stated, (No) c/o (complaints of) pain. Resident has (no) s/sx (signs or symptoms of) infection. Red & blanchable peri wound. There is no signature of who completed the assessment. On 8/22/17 at 1:37, Surveyor interviewed DON-B regarding the concerns of documentation of the right hip wound on 7/13/17. DON-B stated DON-B, Deputy DON-G, and ADON-H worked as a team on 7/13/17 and did the assessment together. Surveyor showed DON-B the Skin Grid for 7/13/17 with documentation of the open wound being classified as DTI, green drainage, and narrative stating there were no signs or symptoms of infection. DON-B agreed that green drainage is a symptom of infection. There was no notification to the surgeon or physician and no change in treatment obtained. DON-B did not provide any documentation that any physician had been notified of the change in status. (Cross-reference F157). On 7/17/17, the right hip Skin Grid documents the wound to be a DTI of the left hip (right hip is affected hip) with measurements of 10.7 cm x 6.9 cm x 2.5 cm, red in color with green drainage, and no odor or tunneling. The narrative states the wound treatment and measurements were completed by the hospice nurse and the hospice nurse placed a phone call to the surgeon for orders. There is no documentation in the EMR progress notes or in hospice progress notes that hospice did wound care or a wound assessment on 7/17/17. There is no documentation of hospice contacting the physician for orders. In an interview on 8/22/17 at 10:50 am with DON-B regarding the right hip assessment on 7/17/17, DON-B was unable to provide any documentation that a physician had been notified of the green drainage or a request for a new treatment order. On 7/19/17, the hospice physician ordered wound care to the right hip: Cleanse area with normal saline. Use Dakins solution to wet gauze dressing and place on wound bed. Cover with ABD pad and secure with [MEDICATION NAME]. Change twice daily. On 7/20/17, the right hip Skin Grid stages the wound as a DTI with measurements of 6.9 cm x 10 cm x 1.8 cm. The narrative states the edges are reddened and rolled. The wound base has 50% granulation and 50% slough with no tunneling. A new treatment was obtained by the hospice physician. In an interview with DON-B on 8/22/17 at 1:37 pm, DON-B thought that the hospice nurse had tried to contact the surgeon on 7/17/17, but was unable to either contact the surgeon or the surgeon didn't want to change the order for the wound care. The hospice nurse then contacted the hospice physician to get a new treatment order. DON-B didn't have any documentation to show the order of events. On 7/20/17, the left ankle Skin Grid stages the wound as a DTI with measurements of 1.0 cm x 0.5 cm with no depth and 100% granulation. The narrative states: (R6) has no complaints of

Based on record reviews and observations, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs for 7 of 9 residents (#3, #40, #39, #41, #38, #12, & #2) on living units 1, 4 & 5, receiving [MEDICATION NAME] (an anticoagulant). An unnecessary drug is any drug used without adequate monitoring or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. * Resident #3 was receiving [MEDICATION NAME] related to a history of [MEDICAL CONDITION] embolism. On 10/23/12, the physician ordered a PT/INR ([MEDICATION NAME]/International Normalization Ratio, a blood test for measuring the blood's clotting ability) for 11/20/12. In the meantime, Resident #3 was started on Bactrim DS twice daily on 11/1/12. Bactrim is a drug that has a probable reaction of increasing anticoagulation effects of [MEDICATION NAME]. The facility did not notify an MD to report the potential drug interaction and did not monitor for increased signs and symptoms of bleeding. On 11/6/12, Resident #3 had dark urine and active oral bleeding. A PT/INR drawn by the lab in error on 11/6/12 (because the facility had failed to notify the lab that the order was no longer valid) revealed the PT was over 110, and the INR was over 11. Normal PT is 9.6-12.6 and normal INR is 2.0-3.0. Resident #3 was admitted to the hospital with [REDACTED]. Resident #3 was hospitalized from [DATE] through 11/10/12. A review of Resident #3's record on 3/7/13 revealed there was no [MEDICATION NAME] monitoring log in the Medication Administration Record (MAR) and the next scheduled PT/INR had not been brought forward onto the March 2013 MAR. On 3/7/13, a total of 14 residents are receiving [MEDICATION NAME], 7 of 9 residents residing on Wings 1, 4 & 5, (including #3) who are receiving [MEDICATION NAME] have missing components of their [MEDICATION NAME] monitoring. The Director of Nursing and Administrator informed Surveyor # on 3/6/13, that the facility does not have a [MEDICATION NAME] monitoring policy/procedure. Facility laboratory procedures direct nurses to add the ordered labwork to the Laboratory/Diagnostic Test Tracking Sheet and to the Treatment Administration Record (TAR). Additionally, nurses are to initiate a [MEDICATION NAME] (PT/INR) Log, to be kept in the Medication Administration Record (MAR). The Director of Nursing states nursing staff are to write upcoming PT/INR's on the MAR. * Resident #40, who was receiving [MEDICATION NAME] and [MEDICATION NAME] for a recent [MEDICAL CONDITION] embolism, had a PT/INR drawn on 3/4/13, which was high at 49.9 and 4.7 respectively. Nursing staff notified the physician of the PT/INR results and orders were received to hold the [MEDICATION NAME] on 3/4 & 3/5/13, recheck the PT/INR on 3/6/13, and call the MD with the results. Orders were also received to discontinue the [MEDICATION NAME]. On 3/7/13, Surveyor # noted that there were no PT/INR results for 3/6/13. Surveyor # asked Licensed Practical Nurse (LPN)-K about the results of the PT/INR ordered for 3/6/13. LPN-K called the laboratory and discovered the PT/INR request for 3/6/13, had never been sent to the laboratory. The physician was notified and a STAT (immediate) PT/INR was ordered and drawn on 3/7/13. The 3/7/13, PT/INR was 14.0 and 1.3 respectively. [MEDICATION NAME] 8mg daily was ordered and the [MEDICATION NAME] was restarted. * Resident #39 had an order for [REDACTED]. The PT/INR ordered for 3/18/13, was not written on the MAR, nor was it written on the Lab/Diagnostic Test Tracking Sheet. * Resident #41 was receiving [MEDICATION NAME] with dosages varying according to PT/INR results. Resident #41 had PT/INR's ordered for every Monday and Thursday. Upon review of the [MEDICATION NAME] monitoring for Resident #41 on 3/7/13, there was no [MEDICATION NAME] (PT/INR) Log in the MAR. * Resident #38 was receiving [MEDICATION NAME] related to a [DIAGNOSES REDACTED].#38 on 3/7/13, revealed there was no [MEDICATION NAME] (PT/INR) Log in the MAR. * Resident #12 was receiving [MEDICATION NAME] related to a [DIAGNOSES REDACTED]. An order was received to hold [MEDICATION NAME] 9/14-9/16 and recheck on 09/17. The 9/17/12, PT/INR was completed and the physician notified. [MEDICATION NAME] was continued at 2mg daily with another PT/INR ordered for 9/20/12. The 9/20/12, PT/INR was not drawn. This was noted by nursing on 9/29/12. The MD ordered a STAT PT/INR and instructed nursing staff to complete an incident report. Review of the results of the STAT PT/INR were slightly abnormal and Resident #12 suffered no ill effects from the missed PT/INR on 09/20/12. On 3/7/13, Resident #12's current [MEDICATION NAME] monitoring was reviewed. There was no [MEDICATION NAME] (PT/INR) Log in the March 2013, MAR. There was a physician's orders [REDACTED]. The PT/INR ordered for 3/13/13 was not written on the March 2013 MAR. * Resident #2 was receiving [MEDICATION NAME] related to a [DIAGNOSES REDACTED]. The facility's failure to have a system to adequately monitor [MEDICATION NAME] usage, by not ensuring labwork was completed as ordered, that subsequent labs were scheduled when PT/INR results were returned, and by failing to increase monitoring when changes in residents' medication regimes suggested enhanced monitoring was needed, created a finding of Immediate Jeopardy, which began on 11/1/12. The facility was informed of the Immediate Jeopardy on 3/7/13 at 1:45p.m. The Immediate Jeopardy was removed on 3/8/13, but continues at a scope/severity level of E (Potential for Harm that is not Immediate Jeopardy/Pattern) until all inservices are completed and the revised system is completely implemented. Findings include: Anticoagulation medications are high-risk drugs. There is a very small window for therapeutic dosing: too much of a drug can cause bleeding, and too little may lead to clotting. Division of Quality Assurance Memo 08-002, March 4, 2008 indicates a standard of practice for [MEDICATION NAME] monitoring. The standard of practice includes the following: A test call International Normalization Ratio (INR) is the lab test that is routinely performed to monitor [MEDICATION NAME] levels. For most individuals a stable, safe INR level will be between 2 and 3.5., depending on the reason for the medication. When a [MEDICATION NAME] regimen is started, a baseline INR is typically obtained. This initial INR should be performed within two to three days. After the initial INR, the follow-up INR's may be done every three to five days. INR's are then continued every three to five days until two consecutive stable therapeutic INR readings are established, usually a level between 2 and 3.5. After two consecutive INR readings are obtained that are between 2 and 3.5, guidelines support INR's to be drawn weekly for four weeks. When a resident is stable after the weekly INR's, an INR will be performed every four weeks as long as the [MEDICATION NAME] is being used... Oftentimes, a resident may be stable while on [MEDICATION NAME]; other factors may cause the [MEDICATION NAME] to become toxic or is some cases ineffective. Facility staff needs to be aware of those circumstances that may compromise [MEDICATION NAME]'s effect so that they can inform the resident, the resident's family, physician, or pharmacist. Monitoring and additional interventions can then be taken in order to avoid clotting or bleeding. Facility staff needs to include the following in their [MEDICATION NAME] monitoring procedures: DRUG INTERACTIONS- There are many medications that interact with [MEDICATION NAME]. Some medications increase the effect of [MEDICATION NAME], while other medication decrease its effect. In most cases, if a medication is added that interacts with [MEDICATION NAME], an INR should be checked within one week. Subsequent INR readings will be dependent on those initial readings and the length of time that the medication interacting with [MEDICATION NAME] will be used. Generally, INR readings will be done as often as every two to four days while a resident is on the offending medication and continued until there is evidence that the medication interaction is stable. If; however, a medication that interacts with [MEDICATION NAME] is used short term, and if the INR is within normal range, or even slightly elevated at the first check, then it is likely that the effects of the [MEDICATION NAME] will not be altered... MONITORING- Besides monitoring for INR, facility staff can monitor for signs and symptoms of bleeding. Those symptoms include bruising, bleeding form the gums during teeth brushing, blood in the stool, sudden onset confusion that may indicate bleeding in the brain, or recent changes in breathing patterns or sounds that may indicate bleeding in the lungs. These symptoms need to be reported to the physician and addressed quickly as they may be an indication that [MEDICATION NAME] has become toxic. On 3/6/13 at 1:50p.m., the Administrator and Director of Nurses told Surveyor # that the facility does not have a specific policy/procedure related to [MEDICATION NAME]/[MEDICATION NAME] monitoring. Rather, the facility has a general policy for all ordered labwork, and utilizes a [MEDICATION NAME] (PT/INR) Log in the MAR to assist the nurses in monitoring [MEDICATION NAME]. Nurses are to write upcoming PT/INR's on the MAR, and bring that information forward when reconciling MAR's each month. On 3/7/13, Surveyor # reviewed the procedure for Laboratory/Diagnostic Test Values-Monitoring, (revised July 2011). The facility is required to use a Test Tracking binder (three-ring binder) and a tracking tool called a Laboratory/Diagnostic Test Tracking Sheet. The Test Tracking Sheet is kept in the front of the Test Tracking binder. Each nurse, when transcribing a lab/test order, will add the lab/test ordered to the Laboratory/Diagnostic Test Tracking Sheet and the Treatment Administration Record (TAR). (Although the policy directs nurses to add the lab/test to the TAR, nurses at the facility instead add the information to the MAR. This was confirmed through interview with RN-L, Nurse Educator on 3/7/13 at 10:25a.m.) On 3/7/13, Surveyor # received a copy of a [MEDICATION NAME] (PT/INR) Log dated 11/11. The following information is to be included on the [MEDICATION NAME] (PT/INR) Log: Date/Time, MD ordered PT/INR Range, PT/INR, Current [MEDICATION NAME] Dose, Reviewed Previous PT/INR, MD Notified, Dose Change, Next Date PT/INR and Signature. On the bottom of the form there is a section that lists common drugs which increase INR (Bactrim is listed as one of the antibiotics which increases INR.), common drugs which decrease INR, and common drugs which may increase or decrease INR. The [MEDICATION NAME] (PT/INR) Log is the only tool utilized by the facility that contains all the information needed to ensure that [MEDICATION NAME] is being adequately monitored. The [MEDICATION NAME] (PT/INR) Log must be completed in its entirety in order for nursing staff to know that [MEDICATION NAME] is being safely administered. 1.) Surveyor # reviewed Resident #3's record as part of a complaint investigation on 2/28-3/14/13. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. [MEDICATION NAME] was prescribed related to the history of [MEDICAL CONDITION] emboli. On 10/2/12, there is a physician's orders [REDACTED]. The October 2012 and November 2012 Mars reveal Resident #3 received [MEDICATION NAME] 2mg daily from 10/2/12 through 11/5/12. A PT/INR was drawn on 10/21/12 (results 26.2 and 2.8), and a repeat PT/INR was ordered for 11/20/12. These PT/INR's were noted on the October and November 2012 MAR's. Resident #3 was sent to the emergency roiagnom on [DATE], diagnosed with [REDACTED]. On 11/1/13, a physician's orders [REDACTED]. Antibiotics such as Bactrim can increase the effecs of [MEDICATION NAME]. On 3/6/13, Surveyor # reviewed the nurses' notes for documentation related to [MEDICATION NAME], PT/INR's and any change in monitoring of signs or symptoms of bleeding after the start of Bactrim on 11/1/12. There was no documentation that the physician was consulted related to potential interactions of Bactrim and [MEDICATION NAME] or that staff increased its monitoring for signs/symptoms of [MEDICATION NAME] overdose. On 11/6/12 at 8:30a.m., nursing documents the physician was notified of critical PT/INR and amber urine. An SBAR (Situation, Background, Assessment, Request) Communication and Progress Note dated 11/6/12, states the PT is 114.3 and the INR is 11.2. Normal PT is 9.6-12.6 and normal INR is 2.0-3.0. Urine was described as dark amber and the resident had active oral bleeding. Nursing documentation on 11/6/12 at 2:00p.m. indicates the resident was admitted to the hospital with [REDACTED]. The hospital history and physical dated 11/7/12 indicates Resident #3 was brought to the hospital due to complaints of coughing up blood clots as well as dark urine. The INR in the emergency room was 5.93. The resident was found to have anticoagulant induced hematuria and hemoptysis. Resident #3 was hospitalized until 11/10/12. On 3/6/13 at 10:30a.m., Surveyor # spoke with RN-I who stated she had been on duty 11/6/12, and had seen the blood clots that Resident #3 was coughing up. An Infection Plan of Care was initiated on 11/1/12, related to the antibiotic for a UTI. The only intervention listed was to encourage oral fluids. There was no mention of the need to monitor for potential interaction the prescribed antibiotic (Bactrim) and [MEDICATION NAME]. There was an Anticoagulant Therapy Plan of Care dated 12/12. In the section of "[MEDICATION NAME]/[MEDICATION NAME] Therapy", the box next to the intervention "Monitor for signs and symptoms of bleeding when the (PT/INR) level is too high..." was not checked. A review of Resident #3's physician's orders [REDACTED]. Surveyor # asked RN-M on 3/6/13 at 11:00a.m. if the facility had identified the need for increased monitoring and asked for a PT/INR. RN-M stated she would try to find out what had happened. On 3/6/13 at 6:15p.m., RN-M told Surveyor # that she had determined that the labwork done on 11/6/12, including the PT/INR, was done because of a previous physician's orders [REDACTED]. On 3/7/13, Surveyor # reviewed the current orders for [MEDICATION NAME], as well as the monitoring currently in place for the use of [MEDICATION NAME]. Resident #3's current physician's orders [REDACTED]. The next PT/INR was ordered for 3/21/13. A review of the March 2013 MAR revealed Resident #3 had no [MEDICATION NAME] (PT/INR) Log in the MAR, nor had the PT/INR ordered for 3/21/13 been added to the March 2013 MAR. 2.) Surveyor # reviewed Resident #40's record on 3/7 - 3/14/13. Resident #40 was readmitted to the facility on [DATE], after being hospitalized from [DATE] - 3/1/13 for a [MEDICAL CONDITION] embolism. A progress note from the hospitalization , dated 2/28/13, indicates Resident #40 is being anticoagulated with [MEDICATION NAME] and [MEDICATION NAME]. Her INR is still not at 2.0. She is currently on Levoquin for a Urinary Tract Infection [MEDICAL CONDITION]. Admission physician orders [REDACTED]. A PT/INR was ordered for 3/4/13. Nursing documentation on 3/1/13 pm shift indicates no signs or symptoms of bleeding. Documentation on 3/2/13 does not indicate whether any assessment of evidence of bleeding was completed. On 3/3/13, nursing documentation states Resident #40 is complaining of a sore left arm. Resident #40 was found to have a bruise from the blood draw tourniquet. "Is hard lump. Will update physician in a.m. regarding arm." There is no nursing documentation on 3/4/13. It is unknown whether the physician was notified. Resident #40 had a PT/INR drawn on 3/4/13. The PT was 49.9 and INR was 4.7. Normal PT is 9.6-12.6 and normal INR is 2.0-3.0. Written on the lab result form on 3/4/13, is NOR (new order received). Hold [MEDICATION NAME] 3/4 & 3/5/13, recheck (PT/INR) 3/6/13, call MD with results. Discontinue [MEDICATION NAME]. On the night shift of 3/5/13, nursing documents the bruise on the left arm from the blood draw, and that the [MEDICATION NAME] is on hold with a PT/INR to be done 3/6/13. Surveyor # reviewed Resident #40's March 2013 MAR. Resident #40 did not have a [MEDICATION NAME] (PT/INR) Log in the MAR. The March 2013 MAR indicated a PT/INR was to be done on 3/6/13. There was no indication on the MAR that the PT/INR had been completed. The surveyor pointed this out and LPN-K called the laboratory while Surveyor # was at the nurses' station. On 3/7/13 at 9:28a.m., LPN-K told Surveyor # that the PT/INR was not drawn because the laboratory never received a request to draw the PT/INR. LPN-K called Resident #40's physician and obtained an order for [REDACTED]. Resident #40's PT/INR results on 3/7/13 were subtherapuetic at 14.0 and 1.3 respectively. Physician orders [REDACTED]. The 3/11/13 PT/INR was drawn as ordered. Results were 20.1 and 1.9. The [MEDICATION NAME] was discontinued and [MEDICATION NAME] continued at 8mg daily. 3.) Surveyor # reviewed Resident #39's record on 3/7 - 3/14/13. Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #39 received [MEDICATION NAME] therapy related to the [DIAGNOSES REDACTED]. Resident #39 has a physician's orders [REDACTED]. The order of 3/1/13 states the office will call back on 3/4/13, with next PT/INR order. On 3/4/13, there is a physician's orders [REDACTED]. A review of the March 2013 MAR reveals Resident #39 has a [MEDICATION NAME] (PT/INR) Log in place. There was no information on the [MEDICATION NAME] (PT/INR) Log regarding the PT/INR ordered for 3/18/13. The March 2013 MAR does indicate the next PT/INR ordered for 3/18/13. A review of the Lab/Diagnostic Test Tracking Sheet at the front of the Test Tracking binder reveals no information regarding the PT/INR ordered for 3/18/13. A copy of the requisition sent to the laboratory is contained within the binder, behind the "18th" tab. 4.) Surveyor# reviewed Resident #41's record on 3/11-3/18/13. Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #41 has a physician's orders [REDACTED].< 2, [MEDICATION NAME] 1mg daily if INR 2-3. Hold [MEDICATION NAME] if >3. Continue PT/INR draws every Monday and Thursday. On 3/7/13 at 9:25a.m., Surveyor # reviewed the [MEDICATION NAME] monitoring system for Resident #41. The PT/INR's are programmed on the March MAR, but Resident #41 has no [MEDICATION NAME] (PT/INR) Log. [MEDICATION NAME] has been administered as ordered. PT/INR's have been completed as ordered. On 3/7/13 at 9:30a.m., LPN-K told Surveyor # that she did not know why the [MEDICATION NAME] (PT/INR) Logs were not in the March 2013 MAR. 5.) Surveyor # reviewed Resident #38's record on 3/11 - 3/18/13. Resident #38 was admitted to the facility 1/14/13 with a [DIAGNOSES REDACTED]. Resident #38 receives [MEDICATION NAME] therapy related to this diagnosis. Resident #38 has weekly PT/INR's ordered for Mondays. The weekly PT/INR's are programmed on the March 2013 MAR. The PT/INR was drawn as ordered on March 4, 2013. On 3/7/13, Surveyor # reviewed the [MEDICATION NAME] monitoring system for Resident #38. There was no [MEDICATION NAME] (PT/INR) Log in the March 2013 MAR. On 3/7/13 at 9:30a.m., LPN-K told Surveyor she did not know why there was no [MEDICATION NAME] (PT/INR) Log in the March 2013 MAR. 6.) Surveyor # reviewed Resident #12's medical record on 03/05/13-03/18/13. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #12's Physician's Telephone Orders revealed an order dated 09/06/12 for [MEDICATION NAME] 4mg daily and recheck PT/INR 09/14/12. Review of Nurses' Progress Note documentation revealed an entry dated 09/14/12 Days, indicating, "MD called to report critical PT/INR of 57.5 and 5.4. Order received to hold [MEDICATION NAME] 9/14-9/16 and recheck on 09/17." A Nurses' Progress Note dated 09/17/12 at 12:15p.m., indicated, "Call received from MD's office states they received lab results. Give [MEDICATION NAME] 2mg daily and recheck PT/INR on 09/20/12." A Nurses' Progress Note dated 09/29/12 at 5:00p.m., indicated, "Noticed PT/INR was not drawn on 09/20/12. MD was paged..." A Progress Note dated 09/29/12 at 6:00p.m. indicated Resident #12's physician called back at ordered a STAT (immediate) PT/INR, and to complete an incident report. Review of the incident report related to the missed PT/INR revealed no new information. Review of the results of the STAT PT/INR were slightly abnormal and Resident #12 suffered to ill effects from the missed PT/INR on 09/20/12. On 03/07/13 at 9:45a.m., Surveyor # reviewed Resident #12's March 2013 Medication Administration Record (MAR). Review of the MAR revealed Resident #12's MAR did not contain a [MEDICATION NAME] (PT/INR) Log and Resident #12's ordered PT/INR to be drawn on 03/13/13 had not been recorded on the MAR. The above information was shared with facility administrative staff at the daily meeting on 03/07/13, at approximately 3:00p.m. The facility did not provide any further information as to why Resident #12's PT/INR scheduled to be done on 09/20/12, had not been completed, why Resident #12's MAR did not contain a [MEDICATION NAME] (PT/INR) Log, or why Resident #12's scheduled PT/INR draw due 03/13/13 had not been recorded on the MAR 7.) Surveyor # reviewed Resident #2's medical record on 03/06/13-03/18/13. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's physician's orders [REDACTED]. On 03/07/13, Surveyor # reviewed Resident #2's Medication Administration Record (MAR) for March 2013. Review of Resident #2's MAR revealed she did not have a [MEDICATION NAME] (PT/INR) Log included in the MAR. The above information was shared with facility administrative staff at the daily meeting on 03/07/13 at approximately 3:00p.m. The facility did not provide any further information as to why Resident #2's [MEDICATION NAME] (PT/INR) Log was not included in her MAR. The facility's failure to have a system that adequately monitors [MEDICATION NAME] usage led to the determination of Immediate Jeopardy, which began on 11/1/12. The facility removed the Immediate Jeopardy on 3/8/13, when the facility initiated the following: Inservice initiated immediately for all licensed nurses on 3/7/13 on [MEDICATION NAME] monitoring. Inservice training will continue until all nurses have been inserviced prior to their shift. Inservices will include the following: Re-education on policies/procedures for monitoring laboratory values (including use of PT/INR Log and Lab/Diagnostic Test Tracking Sheet), the SBAR process as it related to [MEDICATION NAME] therapy, the centers anitcoagulation therapy plan of care, antibiotics/anti-infectives that interact with [MEDICATION NAME], and the [MEDICATION NAME] One Stop Resource ( includes interventions to monitor for signs/symptoms of bleeding, completion of laboratory tests per physician order, and monitoring for new medications which will increase/decrease PT/INR). All residents on [MEDICATION NAME] therapy will have laboratory monitoring tests performed per physician order. Licensed staff and certified nursing assistants will use SBAR process and Early Warning Tool to monitor for adverse reactions to [MEDICATION NAME] therapy and detect subtle changes in resident condition that may requires more frequent PT/INR monitoring. Licensed staff will monitor for completion of laboratory tests following the Laboratory/Diagnostic test Values-Monitoring policy and the Episodic Documentation policy (this includes use of the Lab/Diagnostic Test Tracking Sheet and the [MEDICATION NAME] (PT/INR) Log. The center will implement an Anticoagulant Therapy Plan of Care for all residents on [MEDICATION NAME] therapy. Residents receiving [MEDICATION NAME] will be assessed by a licensed nurse for adverse effects to [MEDICATION NAME] therapy. The DON or designee will review residents receiving antibiotic therapy together with [MEDICATION NAME] therapy. Physicians will be contacted to determine if more frequent monitoring of PT/INR is warranted. Labs to be drawn per MD order. Center's DON or designee will monitor for completion of ordered laboratory tests in the clinical meeting process. Center's DON or designee will review all telephone orders/admission orders [REDACTED]. All residents with a change of condition that may affect [MEDICATION NAME] therapy will be reviewed by the center's IDT in the daily clinical review meeting. The center's DON or designee will audit 5 residents on [MEDICATION NAME]/week for the next 12 weeks to ensure PT/INR's were drawn per physician order, that appropriate physician follow-up is complete and that [MEDICATION NAME] is administered per physician order. The results of the audit will be reviewed at the center's monthly quality assurance meeting.

Based on record review and interviews, the facility did not ensure that 6 of 6 residents (#17, #3, #14, #2, #38 & #5), who did not have a bowel movement for 9 or more shifts (3 days), received the necessary care and services to attain or maintain the highest practicable physical well-being regarding routine bowel management. Resident #17 was hosptalized on [DATE], with urosepsis. A secondary [DIAGNOSES REDACTED].#17 usually had daily bowel movements, but had the last bowel movement prior to hospitalization , on 11/7/12. There was no evidence that Resident #17 had her bowel status assessed until 11:00p.m., on 11/10/12 (11 shifts). She was then found to have a hard, distended abdomen and hypoactive bowel sounds. The physician was notified and Resident #17 was sent to the hospital, where on 11/11/12, a [MEDICATION NAME] diagnosed Resident #17 with a fecal impaction. Resident #3 had a bowel movement during the dayshift on 3/1/13. The next recorded bowel movement is on 3/5/13, during the dayshift (11 shifts). There was no evidence of nursing assessment or administration of Milk of Magnesia. According to facility protocol, Milk of Magnesia is to be administered after 9 shifts with no bowel movement. Resident #3 was recorded to have a bowel movement on 3/5/13, with no problems noted. Resident #14 had a bowel movement during the dayshift on 2/27/13. The next recorded bowel movement is on the dayshift of 3/5/13, 6 days later (17 shifts). Resident #14 should have been assessed for interventions on the evening of 3/2/13. Resident #14 did not receive Milk of Magnesia until the evening of 3/4/13 (on the 16th shift with no BM). There was no evidence that a bowel assessment was completed. Resident #14 was recorded to have a bowel movement on 3/5/13, with no problems noted. Resident #2's bowel monitoring record showed no bowel movement from the 1st shift on 3/6/13, through the 3rd shift of 3/8/13, totaling 9 consecutive shifts with no bowel movement. Resident #2 was not assessed, nor did she receive Milk of Magnesia on the 1st shift of 3/9/13. Resident #38 had no recorded bowel movement from 2/1/13 to 2/6/13 (16 shifts), 2/14/13 to 2/18/13 (15 shifts) and 2/24/13 to 2/27/13 (11 shifts). Resident #38 was recorded to have bowel movements after each of these periods with no problems noted. According to facility protocol, Milk of Magnesia should be given on the third day with no bowel movement. There was no evidence of nursing assessment or administration of Milk of Magnesia, despite the length of time between bowel movements. Resident #5 had no recorded bowel movement from 3/1/13 to 3/5/13 (11 shifts). Resident #5 was recorded to have a bowel movement on 3/5/13, with no problems noted. There was no evidence that nursing staff assessed Resident #5 or administered Milk of Magnesia after 9 consecutive shifts. Findings include: On 3/11/13 at 10:20a.m., Surveyor # received a facility procedure (revision date January 2009) related to constipation. The procedure states, standard bowel care to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following: Milk of Magnesia 30cc PO (orally) every third day without BM (bowel movement) [MEDICATION NAME] Suppository if no results from the Milk of Magnesia Fleets enema rectally if no results from the [MEDICATION NAME] Suppository. On 3/13/13 at noon, Surveyor # received a facility procedure (revision date July 2012) regarding the Management of Constipation. The procedure states elimination results are documented using CareTracker. On 3/13/13, the Administrator shared with Surveyor # a Quality Performance Improvement Plan dated 2/22/13, related to bowel management. The concern was Bowel Regime: CareTracker reporting and follow through on residents with small or no BM listed. The root cause was nurses not following up on residents on the list for small or no BM, given to nurses every day. Actions to be taken to correct the concern included: If resident has had a small or no BM in 3 days, nurse to give Milk of Magnesia; After each Follow-up meeting Unit Manager to give resident list of no BM's to nurse; If no BM after 3 days obtain order for suppository; If no BM after suppository, give fleet enema, contact physician, KUB (abdominal x-ray) if indicated; Nurses and CNA's (Certified Nursing Assistants) to be educated on bowel protocol. On 3/11/13 at 8:30a.m., Surveyor # interviewed LPN-H regarding facility procedures for BM monitoring. LPN-H stated CNA's document BM's in CareTracker, including the amount of BM. If no BM after 2-3 days, "gets flagged for nurses". On 3/11/13 at 9:20a.m., Surveyor # interviewed Registered Nurse Nurse Manager (RN/NM)-D regarding the facility procedure for bowel management. RN/NM-D stated the Director of Nursing reviews the data from CareTracker. CareTracker indicates residents who have had no BM in 3 days. This information is brought to the daily clinical meeting and placed on the Follow-up Tool, which is then shared with the nurse working on the unit. The RN/NM will follow up later in the day to see if problem has been resolved. RN/NM-D stated it is difficult for floor nurses to access information in CareTracker. On 3/13/13 at 12:10p.m., Director of Operations-C informed Surveyor # that a quality improvement plan had been initiated on 3/12/13, regarding the BM protocol. The protocol will be initiated on the 10th shift. Staff training is occurring. 1.) Surveyor # reviewed Resident #17's record on 2/28/13 - 3/14/13. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent full Minimum Data Set (MDS), completed 12/17/12, indicates Resident #17 requires extensive assistance with most activities of daily living, including toileting, and is always incontinent of bowel. The Bowel Data Collection and assessment dated [DATE], indicates Resident #17 is always incontinent of bowel and should be checked and changed every 2 hours and as necessary. An alteration in bowel elimination care plan initiated 6/10, and last updated in 1/13, has a goal that Resident #17 will have a BM every 3 days. One of the listed interventions is to review CareTracker BM reports and monitor bowel elimination using CareTracker. A nutrition risk plan of care dated 12/12, indicates Resident #17 will have a normal BM every 2-3 days. A review of the CareTracker bowel incontinence monitoring reveals that Resident #17 had BM's daily from 10/28 through 11/7/12. No further BM's are documented for the next 10 shifts. A review of nurses' note documentation reveals Resident #17 was being monitored for signs and symptoms of [MEDICAL CONDITION] exacerbation, since at least 10/29/12. Nurses were documenting at least daily regarding her respiratory status. On 11/7/12, Resident #17 had a small emesis after eating only a few bites of supper. On 11/8/12, the dayshift documents the resident states she feels "lousy", daughter states she had been fatigued for the last few days. She had no emesis. The physician was notified and ordered a straight cath urinalysis with culture and sensitivity. On 11/9/12,[MEDICATION NAME] ordered for a positive UA result. Resident #17's temperature was 99.5 and she is described as lethargic, with a poor appetite. Nursing documentation on 11/10/12 at 11:40a.m., notes an elevated blood sugar of 495, which was called to the physician. At 1:15p.m., Resident #17's blood sugar is 442, and the resident is resting in bed. On 11/10/12 during the dayshift, an SBAR (Situation, Background, Assessment, Request) communication form was sent to the physician. Although the from has a section to note any gastrointestinal or [MEDICAL CONDITION] changes, this section was blank, indicating no abdominal assessment was completed. (11/10 is day 3 with no BM, with dayshift being the 9th shift with no BM). A decrease in intake is noted. The purpose of the SBAR was to notify the physician of the elevated blood sugar. Resident #17 is described as lethargic. During the second shift of 11/10/12, the nurse documents the resident's temperature, that there were no adverse reactions from the antibiotic, and the blood glucose is 346. There was no documentation of a physical assessment, or mention of no BM since 11/7/12. On 11/11/12 at Midnight, nursing documents; "Writer went into resident's room at 11:00p.m. to check BS (blood sugar) 222. Noticed resident had distended abdomen, hypoactive bowel sounds and abdomen was hard. Writer called the MD to send the resident to ER for eval. She was admitted for urosepsis..." The hospital admission history and physical, dated 11/11/12, indicates the chief complaint is abdominal distention and altered mental status. The abdominal x-ray preliminary report showed possible ileus. The Assessment and Plan section of the History and Physical indicates Resident #17 had a severe urinary tract infection [MEDICAL CONDITION], altered mental status likely due to the UTI, dementia, diabetes mellitus, ileus probably due to UTI and [MEDICAL CONDITION]. On 11/11/12, a Gastrointestinal (GI) consult was completed. The consult [DIAGNOSES REDACTED]. A CT scan shows a large fecal impaction. Review of systems reveals abdomen is distended, few bowel sounds. Rectal exam reveals huge fecal impaction, large amount of stool removed with finger. Assessment: Large fecal impaction. Plan/recommendations: Repeat digital disimpactions. Enemas if needed. The facility submitted additional information on 3/21/13, indicating the facility charts by exception, and that the resident was assessed every day for a week leading up to the hospital admission. Despite the additional information regarding assessments, no information was provided that nurses were aware that Resident #17, who normally has daily BM's had not had a BM for 3 days, or that during the afternoon shift of 11/10/12, which was the 10th shift with no BM, an abdominal assessment or intervention for constipation had been initiated. When interviewed by Surveyor # on 3/12/13 at 9:40p.m., the Director of Nursing stated per protocol nursing staff would have started Milk of Magnesia on the afternoon shift of 11/11/12. That would have been the 13th shift with no BM. When interviewed by Surveyor # on 3/12/13 at 1:55p.m., Registered Nurse (RN)-I stated the facility protocol is to initiate Milk of Magnesia on the 3rd day with no BM (9 shifts). The initial physical assessment with [DIAGNOSES REDACTED]. The GI review of symptoms indicated there was no history of abdominal pain, nausea or vomiting. There was positive abdominal distention. The definition of ileus, taken from Melloni's Illustrated Medical Dictionary, 2nd Edition is; "obstruction of the intestines accompanied by severe colicky pain, vomiting, and sometimes fever." The subsequent GI consultation completed on 11/11/12, referenced a CT scan of the abdomen and pelvis, showing a large fecal impaction. The GI consult [DIAGNOSES REDACTED]. 2.) Surveyor # reviewed Resident #3's record on 2/28 - 3/14/13. Resident #3 was admitted to the facility 3/10/09, with [DIAGNOSES REDACTED]. A review of Resident #3's quarterly Minimum (MDS) data set [DATE], indicated Resident #3 was independent for toileting, and was continent of BM. On 3/11/13, Surveyor # reviewed Resident #3's bowel records which indicated Resident #3 had no bowel movement from 3/1/13 to 3/5/13 (11 shifts). Resident #3 was recorded to have a bowel movement on 3/5/13 with no problems noted. Resident #3 has a care plan care plan for bowel elimination dated 2/13 which read: Constipation, will have bowel movement every 3 days, monitor bowel elimination, provide medication as ordered to aid in elimination. On 3/12/13 Surveyor # reviewed Resident #3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of nurses' notes documentation between 3/1 - 3/5/13, revealed no mention of the Resident #3's bowel status. On 3/13/13 at 12:10p.m. Surveyor # interviewed Director of Operations-C who stated that on the 10th shift of no bowel movement the Resident should get Milk of Magnesia. 3.) Surveyor # reviewed Resident #14's record on 2/28 - 3/14/13. Resident #14 was admitted to the facility 6/2/10, with [DIAGNOSES REDACTED]. A review of Resident #14's quarterly Minimum (MDS) data set [DATE], indicated Resident #14 required extensive assistance with toileting and was occasionally incontinent of stool. On 3/11/13, Surveyor # reviewed Resident #14's bowel records which indicated Resident #14 had a bowel movement during the dayshift on 2/27/13. The next recorded bowel movement is on the dayshift of 3/5/13, 6 days later (17 shifts). According to the facility bowel protocol, Resident #14 should have been assessed for interventions on the evening of 3/2/13 (9 shifts with no BM). There is no documentation in the nurse's notes regarding any abdominal assessment or administration of Milk of Magnesia. According to the March 2013, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no evidence in the nurses' notes that a bowel assessment was completed. On 3/12/13 at 1:45p.m., Surveyor # spoke with RN/NM-J, who stated that Resident #14 usually has BM's regularly, and can use the toilet independently, so sometimes staff are unaware of BM's. The Director of Nurses arrived during the surveyor's interview with RN/NM-J and stated she would check the monitoring sheet used to communicate with nurses to see when nurses had been alerted to no BM. On 3/14/13, Surveyor # received a copy of a Clinical Meeting Follow-Up Tool dated 3/5/13, which indicated Resident #14 was on the list of residents to be checked for BM status. Resident #14 was recorded to have a bowel movement on 3/5/13, with no problems noted. 4.) Surveyor # reviewed Resident #2's medical record on 02/28-03/18/13. Resident #2 was admitted to the facility 09/25/12, with [DIAGNOSES REDACTED]. On 3/13/13, Surveyor # reviewed Resident #2's bowel records which indicated Resident #2 had had no bowel movement from 1st shift on 03/06/13, through 3rd shift on 03/08/13, totaling 9 nine consecutive shifts without a bowel movement. Per the facility bowel protocol, Resident #2 should have received Milk of Magnesia (MOM), on the 1st shift of 03/09/13. Review of Resident #2's Nurses' Progress Note documentation and PRN (as needed) Medication Administration Records revealed no evidence Resident #2 had received MOM on the 1st shift on 03/09/13. The above information was shared with facility administrative staff at the daily meeting on 03/12/13. On 03/13/13 at 1:15p.m. the Director of Nursing informed Surveyor # that Resident #2 did not receive MOM on the 1st shift of 03/09/13. Resident #2 did not suffer any ill effects from not receiving the MOM on 03/09/13. 5.) Resident #38 was admitted to the facility 1/14/13 with [DIAGNOSES REDACTED]. On 3/12/13 Surveyor # reviewed Resident #38's Initial Minimum Data Set dated 2/5/13 which indicated Resident #38 needed extensive assistance for toileting. On 3/13/13 Surveyor # reviewed Resident #38's bowel records which indicated Resident #38 had no bowel movement from 2/1/13 to 2/6/13 (16 shifts), 2/14/13 to 2/18/13 (15 shifts), and 2/24/13 to 2/27/13 (11 shifts). Resident #38 was recorded to have bowel movements after each of these periods with no problems noted. On 3/13/13 Surveyor # reviewed Resident #38's care plan for bowel elimination dated 1/28/13 which read: Incontinent, will have bowel movement every 3 days, monitor bowel elimination, provide medication as ordered to aid in elimination. On 3/13/13 Surveyor # reviewed Resident #38's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 3/13/13 at 12:00p.m. Surveyor # interviewed Director of Operations-C who stated that on the 10th shift of no bowel movement the Resident should get milk of magnesia. On 3/13/13 Surveyor # reviewed the Procedure titled Management of Constipation provided by the facility last dated 7/12 which read if no bowel movement on the third day give milk of magnesia. The above findings were shared with the Administrator on 3/14/13. Additional information was requested if available. None was provided. 6.) Resident #5 was admitted to the facility 4/29/11 with [DIAGNOSES REDACTED]. On 3/11/13 Surveyor # reviewed Resident #5's quarterly Minimum (MDS) data set [DATE] which indicated Resident #5 needed extensive assistance for toileting. On 3/12/13 Surveyor # reviewed Resident #5's bowel records which indicated Resident #5 had no bowel movement from 3/1/13 to 3/5/13 (11 shifts). Resident #5 was recorded to have a bowel movement on 3/5/13 with no problems noted. On 3/12/13 Surveyor # reviewed Resident #5's care plan for bowel elimination dated 2/13 which read: Incontinent / Constipation, will have bowel movement every 3 days, monitor bowel elimination, provide medication as ordered to aid in elimination. On 3/13/13 Surveyor # reviewed Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 3/13/13 at 12:00p.m. Surveyor # interviewed Director of Operations-C who stated that on the 10th shift of no bowel movement the Resident should get milk of magnesia. On 3/13/13 Surveyor # reviewed the Procedure titled Management of Constipation provided by the facility last dated 7/12 which read if no bowel movement on the third day give milk of magnesia. The above findings were shared with the Administrator on 3/14/13. Additional information was requested if available. None was provided.

Based on record review, review of facility investigations, observations and interviews, the facility did not ensure that the resident environment remained free of accident hazards as is possible, and that each resident received adequate supervision and assistance devices to prevent accidents for 4 of 25 residents reviewed (Residents #1, #5, #9 & #21). * On 5/20/11, while Certified Nursing Assistant (CNA)-N was moving Resident #1's wheelchair, the rear right wheel came off. CNA-N was able to steady the wheelchair, while Licensed Practical Nurse (LPN)-O put the wheel back on the wheelchair. According to the facility's policy, any broken or malfunctioning equipment is to be removed from the resident's room, and not used again until examined by someone from the maintenance department. Resident #1 was taken out of the wheelchair and assisted into a different wheelchair by CNA-N. Neither CNA-N, nor LPN-O notified the maintenance department that the wheel for Resident #1's wheelchair had come off. On 5/23/11 at 6:30p.m., CNA-P was turning the wheelchair when the wheel came off again, this time causing the wheelchair to tip over. Resident #1 fell out of the wheelchair striking her head on the floor. 911 was called, and Resident #1 was transferred to the hospital where she was diagnosed with [REDACTED]. Subsequent to the head injury, Resident #1 had a decline in mental alertness, and now requires a feeding tube for all nutrition. The facility's failure to remove the wheelchair after the wheel fell off and to have the wheelchair inspected and repaired before using created an immediate jeopardy situation that began 5/20/11. The Administrator was informed of this finding on 8/4/11, at 11:45a.m. The facility removed the immediate jeopardy on 5/23/11, and the deficient practice continues at a scope/severity level of an E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following: *Resident #1 who was at risk for falls, had a fall intervention to place a mat beside her bed. Resident #1 was observed in bed at 7:55a.m., on 8/4 & 8/8/11, with no mat on the floor beside her bed. *Resident #5 had been identified by the facility as being at risk for falls and had fallen 6 times from 03/21-06/17/11, including 4 falls from her bed. A 2/18/11 care plan intervention to minimize Resident #5's fall risk included every 1 hour checks by staff. On the night shift of 06/16-06/17/11, the Certified Nursing Assistant (CNA), assigned to Resident #5 admitted not completing 3 hourly checks, at 11:30p.m., 12:30a.m. and 1:30a.m. At the hourly check at 2:30a.m., Resident #5 was found on the floor of her room after having fallen. *Resident #9 was admitted to the facility on [DATE] and was assessed to not be at risk for elopement. On 7/21/11, Resident #9 attempted to go outside the facility without assistance. The facility reassessed Resident #9 and determined the resident to be at risk for elopement. The facility updated/revised the plan of care to include a Wanderguard. On 7/29/11, staff observed Resident #9 outside without supervision. The Wanderguard was observed to be in place. The facility investigated the incident and concluded that Dietary Staff-L deactivated an alarm system in the Wing 5 dining room and let Resident #9 go outside without supervision. *Resident #21 is at risk for falls. Interventions on his plan of care include assistance of 1 staff for transfers and ambulation. On 8/05/11, Resident #21 became noncompliant with requesting assistance. The facility did not reassess, develop interventions, and/or revise the plan of care to reduce the risk of falling when Resident #21 became noncompliant with requesting assistance. Findings include: 1. Surveyor # reviewed Resident #1's record on 8/2 - 8/4/11. The facility has a procedure dated March 2007, related to wheelchair safety checks. The policy states: "When clinical or non-clinical staff notices loose hardware or other possible safety issues with the operation of a wheelchair, the resident should be removed from the potentially unsafe wheelchair, the wheelchair taken out of operation, and repair personnel should be contacted. The appropriate repair person will be notified. Regular preventative maintenance checks on wheelchairs will be performed monthly by the Maintenance Department. The procedure states: 1. Remove or have the resident removed from the potentially unsafe wheelchair and place in bed. 2. Remove the wheelchair from operation if the repair issue makes the chair unsafe for operation. (Provide an acceptable alternative if available.) 3. Complete a Maintenance Request upon discovery of any safety issues with a wheelchair operation, including but not limited to: loose hardware/bolts, loose upholstery or cushions, welded joints intact, loose rail guides, improper wheel operation including swivels, loose brakes. 4. Await repair of the wheelchair. 5. Return wheelchair to resident after repair. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a physician's progress note dated 2/3/11, Resident #1 had experienced some weight loss and now has to be fed. Resident #1 has chronic deep vein thrombosis of the right leg and is anticoagulated with Coumadin. A physician progress notes [REDACTED]. Resident #1 had a physician's orders [REDACTED]. Due to changes in ability to maintain position in her wheelchair, she was seen in therapy and was issued an Invacare tilt and recline high backed wheelchair in early March of 2011. This was the only Invacare tilt and recline wheelchair in the facility. A review of the manufacturer's description of the Invacare tilt and recline positioning chair, indicated the chair had 5 inch locking castors, three swivel and one directional. According to statements that were submitted 5/24/11 during the facility's investigation of an accident that had occurred on 5/23/11, the wheel on Resident #1's wheelchair had come off on 5/20/11. CNA-N's statement indicated that during the afternoon on 5/20/11 she was in the room with Resident #1. While moving the chair, the right rear caster bumped the fall mat and dislodged. The chair was prevented from tipping, the caster was replaced. CNA-N informed the nurse. On 8/8/11 at 1:15p.m., Surveyor # spoke with CNA-N regarding the incident on 5/20/11. CNA-N stated she had gone to Resident #1's room to assist LPN-O. LPN-O had then assisted CNA-N transfer Resident #1 into her chair. After the transfer, the chair caught the mat (next to her bed). The wheel came off. CNA-N described how she pushed the chair against the bed to hold the chair up. She called for assistance. LPN-O, who was in the resident's bathroom washing her hands, responded, and put the wheel back on, as CNA-N continued to steady the chair against the bed. CNA-N stated that she then asked CNA-E to assist her in transferring Resident #1 into a different wheelchair. CNA-N stated she placed the chair that the caster had come off of out of the resident's room (in the hallway). CNA-N stated that normally she would take something broken to maintenance, but was busy that day, and thought LPN-O would tell maintenance since she was aware of the problem. CNA-N stated she had not had any problems with Resident #1's chair prior to 5/20/11. LPN-O submitted a statement that during the afternoon of 5/20/11, CNA-N was in the room with Resident #1. When she moved the chair it must have hit the fall mat. The caster on the right rear fell out of the chair. LPN-O replaced it. In her statement LPN-O indicated she "did not think that it was faulty," she thought is was just made that way. The chair moved fine after that. She was unaware there was an issue. On 8/4/11 at 3:10p.m., Surveyor # spoke with LPN-O regarding the incident of 5/20/11. LPN-O stated the she and CNA-N were in the room. LPN-O was in the bathroom washing her hands when CNA-N said the wheel came off and she needed help. LPN-O helped put the wheel back on. LPN-O stated she thought Resident #1's weight would keep the wheel on, and did not say anything to maintenance about the incident. LPN-O stated she thought the chair was stable. Contrary to facility policy, no one informed maintenance of the problem. Staff continued using the Invacare wheelchair. According to an Accident/Incident Report dated 5/23/11 at 6:30p.m., Resident #1's CNA was turning her chair around to take her to her room. As the CNA turned the chair, it tipped to the right side and Resident #1 fell out of the chair. The right rear wheel fell off as the chair tipped over. Resident #1 hit the right side of her forehead sustaining a 3cm x 5 cm skin tear. LPN-Q documented the following in the nurses' notes dated 5/23/11: "CNA was starting to move resident chair, it tipped to the right and the right rear wheel flew across opening to wing 4 hallway. As the chair tipped, resident fell sideways out of the chair and hit floor with the right side of her forehead. Chair fell against floor behind her." 911 was called, and Resident #1 was transferred to a local hospital where a CT scan showed an intracerebral hemorrhage. Resident #1 was then sent flight for life to a Milwaukee hospital, where it was determined that she had a right subdural hematoma. According to a Summary Report from the hospital dated 6/1/11, the family decided to surgically intervene and Resident #1 had a craniotomy with evacuation of the hematoma. During this hospitalization , Resident #1 was found to be unable to eat by speech therapy, and on 6/1/11, she had a PEG tube placed for enteral feedings. Her discharge [DIAGNOSES REDACTED]. A review of nursing documentation since readmission on 6/2/11, indicated that initially, Resident #1 was unresponsive, but in the last few weeks has had a few occasions when she has opened her eyes and said a few words. During observations of Resident #1 throughout the survey (8/2, 8/3, 8/4 & 8/8/11), Resident #1 did not open her eyes or attempt to interact in any way with caregivers. Resident #1 continues to receive all nutrition via the PEG tube. On 5/23/11, the facility removed the chair from service and initiated an investigation. An undated summary of the investigation, written by the Director of Nursing (DON), indicated that the chair was assessed and the front casters lock in place, but there was no locking mechanism for the rear castors. There was no evidence of wear to the right rear castor. The castor does not snap in place. Maintenance does not have a log to indicate any repairs or maintenance needed. The investigation summary indicated that on 5/24/11, a family member told the facility staff that "the back right wheel was always wobbly". (On 8/3/11, the Administrator informed Surveyor # that the family had never reported any concerns related to the chair.) The investigation summary indicated that on 5/24/11, the Director of Nursing (DON) was informed by a CNA that on 5/20/11, the right rear wheel (caster) came off while doing a transfer in the room. The staff replaced the wheel but did not report it as they thought this was the way the chair was designed as the caster did not click in. On 8/2/11 at 3:10p.m., Surveyor # spoke with the Director of Maintenance -R, who described the process of submitting work orders. The Director of Maintenance-R stated there were no work orders for Resident #1's chair prior to 5/23/11. The Director of Maintenance-R stated someone from the maintenance department is on call 24 hours per day, 7 days per week. The Director of Maintenance-R stated that all wheelchairs were inspected for safety the evening of 5/23/11. On 8/2/11 at 1:30p.m., Surveyor # spoke with the Administrator who stated the chair was locked in the facility garage. Resident #1 had been using the only Invacare tilt and recline chair in the facility. There had been no reports prior to 5/23/11 of any problems with the chair. On 8/4/11 at 10:00a.m., Surveyor # observed the Invacare tilt and recline chair which was being stored in the facility garage. The chair has 4 small wheels that insert into the frame of the chair. Not removing Resident #1's chair on 5/20/11 when the wheel first came off, not notifying maintenance so the chair could be checked, and continuing to use the Invacare wheelchair resulted in a finding of immediate jeopardy for Resident #1. The facility removed the immediate jeopardy on 5/23/11, when: 1. The chair was removed from the facility; 2. Maintenance staff completed a safety inspection on all facility wheelchairs; 3. By 5/25/11, all nursing staff have been inserviced on the facility procedure regarding faulty/broken equipment. LPN-O stated on 8/4/11 at 3:10 p.m. that after Resident #1 fell out of the chair on 5/23/11, staff have been inserviced on the need to keep residents safe by removing faulty equipment and notifying maintenance. The deficient practice continues at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) based on the following: 2. Surveyor # reviewed Resident #1's record on 8/2 - 8/4/11. Resident #1 had a Fall/Injury Assessment:Prevention and Management Plan of Care with a rewrite date of 3/2/11. The care plan indicated Resident #1 was at Fall/Injury risk related to pain, poor weight bearing, unsteadiness, and osteoporosis. Cognitive impairment factors included dementia and mental status changes of 6/2/11. One of the interventions listed on the care plan was the use of a floor mat. Resident #1's bed was to be placed next to the wall with a mat to the floor on the other side of the bed. On 8/4/11 at 7:55a.m., Surveyor # observed Resident #1 in bed on her left side. There was no mat in place beside the bed. On 8/8/11 at 7:55a.m., Surveyor # observed Resident #1 in bed with no mat in place beside her bed. The mat was observed in place beside the bed at 8:55a.m. On 8/8/11 at 9:30a.m., Surveyor # asked the Administrator why Resident #1's mat had not been in place on 8/4 & 8/8/11. At 12:10p.m., the Administrator informed Surveyor # that Resident #1's mat had been lifted in anticipation of the surveyor observing cares on 8/4/11, and on 8/8/11, had been moved to complete Resident #1's tube feeding. The Administrator further stated that the need for the mat was going to be assessed as the resident is less mobile. 3. Surveyor # reviewed Resident #5's medical record on 08/02-08/08/11, as part of a recertification and facility self-report survey. Resident #5 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set assessment dated [DATE], indicated under Functional Status/Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair and standing position), that Resident #5 requires an extensive assist with a 2+ persons physical assist. Review of Resident #5's Fall/Injury Assessment: Prevention And Management Plan Of Care, rewritten 02/18/11, indicated Resident #5 is at risk for falls and injury related to pain, DJD, poor weight bearing and exhaustion/weakness. An intervention to minimize Resident #5's risk for falls included "continue 1 hour checks." Review of Resident #5's nurses' note documentation revealed she has had 6 falls from 03/21-06/17/11, including 4 falls from her bed. Surveyor # reviewed a facility self-report investigation regarding Resident #5 being found on the floor of her room next to her bed on 06/17/11. A summary statement of the investigation indicated, "Certified Nursing Assistant (CNA)-I, was assigned to Resident #5 on the night shift of 06/16-06/17/11. Rounds were completed at 10:30p.m. by CNA-I and Resident #5 was sleeping in her bed at the time. At 2:30a.m. CNA-I reported to Licensed Practical Nurse (LPN)-K, Unit Supervisor, that Resident #5 was on the floor in her room sleeping and that she had fallen...Upon further investigation into the fall without injury, it was documented that CNA-I had failed to do the 1 hour rounding (at 11:30p.m., 12:30a.m. and 1:30a.m.), on Resident #5 per her individualized care plan. CNA-I stated that she had not checked on Resident #5 since 10:30p.m. CNA-I gave no reason for not checking on Resident #5." An undated statement obtained from Registered Nurse (RN)-J, indicated that LPN-K had called her to assess Resident #5 after she was found on the floor. RN-K's statement indicated Resident #5 did not appear uncomfortable and had obviously been there (on the floor) for a period of time. On 08/03/11 at approximately 8:00a.m., Surveyor # asked the Director Of Nursing (DON), if she could obtain a statement from RN-K when RN-K came on duty the night shift of 08/03-08/04/11. Surveyor # wanted RN-K questioned as to how she had determined Resident #5 had been on the floor for a "period of time." On 08/03/11 at approximately 8:45a.m., the DON indicated she had called RN-K and obtained another statement. Review of RN-K's statement dated 08/03/11, indicated Resident #5 appeared to have been there quite some time based on her physical assessment. "Resident #5's cheek and arm were cold from the tile floor, then when we did get her up she had an indentation on her cheek and arm." 4. On 8/03/11, Surveyor # reviewed Resident #9's medical record. The record indicates Resident #9 is [AGE] years old and was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated [DATE], indicates Resident #9 has a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact), has not exhibited wandering behavior, requires extensive assistance of staff for transfers and locomotion on and off the unit, and uses a wheelchair for mobility. The Elopement Plan of Care: Assessment, Prevention and Management, dated 7/13/11, indicates Resident #9 has risk factor for elopement including confusion and impaired vision. The plan of care indicates Resident #9 is not at risk for elopement and has not exhibited exit seeking behaviors. The Accident/Incident Report, dated 7/21/11 at 9:15 a.m., indicates Resident #9 was found in the facility's front parking lot. The report indicates a Wanderguard was placed on Resident #9 as an immediate action to prevent further incidents. The Elopement Plan of Care: Assessment, Prevention and Management, revised 7/21/11, indicates Resident #9 is at risk for elopement at this time. Interventions include a " Wander Alert System." The Accident/Incident Report, dated 7/29/11 at 1:20 p.m., indicates Resident #9 went outside of the building through the Wing 5 dining room doors. The report indicates a dietary staff may have turned the Wing 5 dining room door alarm off. The report does not indicate the location of the incident. On 8/03/11 at 8:30 a.m., Surveyor # observed the Wing 5 dining room exit doors. The door opens into a fenced patio. To exit the door into the patio area an alarm will sound unless it is deactivated by pushing a button on the wall next to the door. The door is not alarmed with the Wanderguard system. The fenced in area of the patio has a door that opens into the parking lot. The door has an unlocked latch that keeps the door shut. On 8/03/11 at 10:10 a.m., Surveyor # spoke with the Administrator regarding Resident #9's elopement on 7/21/11 and 7/29/11. The Administrator indicated Resident #9 was assessed on 7/13/11 and identified to not be at risk for elopement. The Administrator indicated that after Resident #9 left the faciity on [DATE], the facility reassess the resident, identified the resident was at risk of elopement, and revised the plan of care to include the intervention of a Wanderguard. The Administrator indicated that after Resident #9 left the building on 7/29/11, an investigation was completed. The Administrator indicated the facility concluded, after the investigation, that dietary staff-L deactivated the Wing 5 dining room door, let Resident #9 outside without supervision, and Resident #9 was found outside in the front of the building. The Administrator indicated the investigation revealed Resident #9 was outside without supervision for less than 5 minutes. The Administrator indicated dietary staff are not to deactivate the alarm and assist residents outside onto the patio. The Administrator indicated all Wing 5 dietary staff attended an in-service on 7/29/11, directing them not to assist residents outside without nursing staff permission. On 8/04/11, Surveyor # reviewed the Elopement Prevention and Management Program, dated 10/08/11. The program indicates elopement occurs when a resident who needs supervision leaves a safe area without supervision. The program includes procedures that are used to help mitigate the risk of a resident leaving a safe area without staff supervision. The program procedures include the completion of a comprehensive elopement assessment, development of a plan of care with individualized interventions, communication of risk and interventions to the caregiving team, and proving staff training as needed. 5. On 8/08/11, Surveyor # reviewed Resident #21's medical record. The record indicates Resident #21 is [AGE] years old and was admitted to the facility on [DATE]. The Fall/Injury Plan of Care: Assessment, Prevention and Management, dated 7/11/11, indicates Resident #21 is at risk for falls. The plan of care indicates Resident #21 requires assist of 1 staff for ambulation and transfers. The plan of care does not indicate interventions for noncompliance with requesting assistance with transferring and ambulating. The Care Area Assessment (CAA) for falls and Activities for Daily Living (ADL), dated 8/01/11, indicates Resident #21 has had no recent falls, requires extensive assist of staff for transfers and uses a wheelchair for mobility. The admission Minimum Data Set (MDS), dated [DATE], indicates Resident #21 has a Brief Interview for Mental Status (BIMS) score of 5 (severely impaired cognition), requires extensive assistance of staff for transfers and requires extensive assistance from staff for walking in the room. On 8/8/11 at 10:40 a.m., Surveyor # observed Resident #21 in his room. Resident #21 was observed to stand up from his wheelchair and walk to his bed (approximately 4 feet). There were no staff members in the room. On 8/08/11 at 10:43 a.m., Surveyor # spoke with Registered Nurse (RN) -M who indicated Resident #21 is at risk for falls. RN-M indicated, to prevent falls, Resident #21 should have assistance of 1 staff for transfers and ambulation. RN-M indicated Resident #21 has been noncompliant with requesting assistance with transfers and ambulation. RN-M indicated that on 8/05/11, Resident #21 started to self transfer and ambulate without requesting staff assistance. On 8/08/11 at 1:30 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON verified the facility did not assess, develop interventions, and/or revise the plan of care for Resident #21, to include approaches based on the resident's noncompliance with requesting transfer and ambulation assistance. The plan of care was updated on 8/08/11, after the surveyor inquired about Resident #21's ability to safely self transfer and ambulate.