Every finding on record at Bayshore Nursing & Rehab

Based on interviews, record review, and policy review, the facility failed to ensure two (Resident (R) 1 and R9) of four residents reviewed for physical abuse out of the sample of 11 residents were free from physical abuse. Specifically, in a resident-to-resident altercation, R2 hit R1 and R8 hit R9. These failure had the potential to cause harm for residents throughout the facility. Findings include: 1.Review of R1's admission Record located in the Profile tab of the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] and was discharged on 02/02/26 Review of R1's discharge assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/26 a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating R1 was cognitively intact. R1 required a wheelchair for ambulation and was independent with most activities of daily living (ADL). Review of R2's admission Record located in the Profile tab of the EMR indicated R2 was admitted to the facility on [DATE] with diagnoses of paraplegia and chronic pain. R2 required a wheelchair for ambulation. Review of R2's quarterly MDS with an ARD of 03/27/26 revealed that R2 has a BIMS score of 15 of 15, indicating R2 was cognitively intact. The MDS indicated that R2 required the use of a wheelchair for ambulation. Review of the Alleged nursing home resident mistreatment, neglect, and abuse report, dated 11/24/25 revealed that [R2] approached [R1] and grabbed [R1] by the shirt flipping him backward out his chair. During an interview on 04/28/26 at 1:07 PM, R2 stated he did have an altercation with R1. He stated, I was tired of the way he was talking to everyone. R2 stated he had not gotten into any other altercations before this one. During an interview on 04/30/26 at 12:10 PM, Licensed Practical Nurse (LPN) 1 stated she was sitting at the nurses' station when she heard the commotion. She saw R2 put his hand in front of R1's face and then R1 was on the floor. She stated she reported to the Administrator and Social Services Director (SSD), and they started the risk management form. LPN1 stated no other residents witnessed the event. During an interview on 04/30/26 at 12:34 PM, the Administrator stated he and the SSD are both the abuse coordinators in the facility. He confirmed the incident between R2 and R1 did occur. The Administrator stated when the event occurred there were no resident witnesses, just staff. He stated that staff separated the residents and provided supervision. 2. Review of R9's quarterly MDS with an ARD of 03/27/26 and located under the MDS tab of the EMR revealed R9 was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction, anxiety and depression. The MDS BIMS score of two out of 15 which indicated R9's cognition was severely impaired. Review of R9's Care Plan located under the Care Plan tab of the EMR, revealed a focus area of experienced physical assault placing resident at risk for emotional trauma, fear, behavioral change, initiated on 02/11/26, with a goal to verbalize feeling safe in the facility and not demonstrate trauma related symptoms, and interventions including ensure separation from aggressor, avoid seating placement near triggering individuals and provide staff presence during group activities. Review of R9's Interact Change of Condition Evaluation Guide assessment dated [DATE] and located under the Assess tab of the EMR revealed in the summary observations and evaluation dated 02/11/26, Resident was struck with closed fist on right side of face/head by a resident. Swelling redness noted to right head above, and in front of temple area, and under right eye Review of the facility Incident Report dated 02/11/26 and provided by the SSD indicated, [R8] became acutely agitated while participating in a supervised group activity with other residents.Staff immediately observed [R8] escalating and positioned themselves between [R8] and R9. A third staff member simultaneously went to remove R8 from the activity to reduce risk of exposure. Despite the staff efforts, [R8] was able to forcefully maneuver past staff and struck R9 once before fully separated. Immediately after the incident R8 was placed on 1:1 supervision, and his psychiatric provider recommended increasing his antipsychotic medication. R8's care plan was revised to include interventions. Review of LPN5's witness statement dated 02/11/26 at 9:35 AM revealed, [R9] was sitting at a dining table. [R8] started threatening [R9] with violence. Staff attempted to intervene. [R8] reached up and punched [R9] in the face several times. Review of CNA3's witness statement dated 02/11/26 revealed, on 02/11/26 at 9:35 AM, [R9] was sitting across the table from [R8] .[R8] went off on [R9] came around the table where [R9] was and started hitting [R9] in the face [two to three] times. Review of Housekeeper (Staff B)'s witness statement revealed, on 2/11/26 at 9:35 AM, [R8] flipped out cursing at [R9] trying to get to [R9] to hit [R8] . [R8] just [kept] on cursing and [hitting] [R9] in the face. Review of R8's Care Plan located in the Care Plan tab in the EMR indicated: Becomes easily irritated and frustrated when peers joke and make comments toward me, initiated 09/15/25, with a goal to remain free from verbal altercations with peers and interventions including monitor R8's social interactions, provided education on coping strategies and reinforce positive behaviors. Exhibits impulse-driven behaviors including taking food from peers and when they resist R8 becomes physically aggressive, initiated 11/21/25, with goal to demonstrate improved impulse control and interventions including increased observation during mealtimes, seat resident in a location that minimizes opportunity for taking others, and provide clear, consistent boundaries. Repeated involvement with Resident-to-Resident altercations placing self and other at risk for physical injury, initiated 01/15/26, with a goal to remain free from res-to-res altercations and interventions including monitoring R8's behavior, provide seating that minimizes conflict with peers, and redirect R8 away from peers at early signs of agitation. During an interview on 04/30/26 at 1:45 PM, with Administrator and SSD, the Administrator indicated there was an incident on 2/11/26 between R9 and R8 in which R8 hit R9 in the face. The SSD stated that since the resident-to-resident altercation on 02/11/26 with R9, R8 had been on 1:1 supervision. R8 was discharged on 04/17/26. Review of the facility's undated policy titled Abuse/Neglect/Exploitation provided by the facility 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.

Based on record review and interviews, the facility failed to ensure care plans reflected the changing needs of residents to include a plan to maintain communication with family and a plan to be able to volunteer at a soup kitchen for two of 11 sampled residents (Resident (R) 6 and R7) reviewed for care plan revisions. This failure had the potential to cause unmet care needs, distress and a decline in psychosocial well-being. Findings include: 1. Review of R7's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/26 and located in the MDS tab of the electronic medical record (EMR), revealed R7 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS indicated that R7 did not have behaviors. Review of Progress Notes located under the Prog Note tab revealed the following: On 10/08/25 at 3:40 PM, Social Service Director (SSD) met with R7 to ensure no negative psychosocial impacts following the incident where R7's family member (FM) A was escorted from the facility by the local police due to suspicion of drug use while in the facility. R7 was calm and verbalized understanding of the situation. SSD encouraged R7 to contact FM A through alternative ways to maintain communication with family. Review of the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, provided by the facility and the state agency, revealed on 10/08/25, the facility was notified by the state agency that FM A called the state agency to make a report against the DON stemming from an incident the prior day. FM A made physical threats of harm against the DON, as a result the state agency dispatched local police to the building to file formal report. Review of R7's Care Plan initiated 08/26/21, last revised 04/25/26, located under the Care Plan tab in the EMR, did not address how R7 was going to maintain communication with FMA, who could not come into the facility. During an interview on 04/28/26 at 1:07 PM, R7 said he does have family visit from time to time. R7 said he had no concerns about family visits. When asked about FM A, R7 did not respond. During an interview on 04/29/26 at 11:31 AM, the Administrator confirmed that the incidents with FM A and how R7 would communicate with family was not in R7's care plan. During an interview on 04/29/26 at 12:12 PM, SSD confirmed that she reviewed R7's care plan and confirmed the care plan did not address how R7 could have communication with FM A During an interview on 04/30/26 at 12:50 PM, the Assistant Director of Nursing (ADON) indicated there was an issue with lack of care planning for R7 and how R7 would maintain communication with his family. 2. Review of R6's quarterly MDS with an ARD of 02/21/26 and located under the MDS tab of the EMR revealed R6 was admitted to the facility on [DATE] with diagnoses including bipolar disorder and a traumatic brain injury. The MDS revealed a BIMS score of 15 out of 15 which indicated R6's cognition was intact. Review of the Elopement Off Premises Report dated 12/12/25 and provided by the Administrator, revealed R6 called a taxicab to take her to a soup kitchen without the guardian's consent. Review of R6's Care Plan located under the Care Plan tab of the EMR revealed R6 had a Court Ordered Guardian initiated 07/09/25 and last revised 04/18/26 indicated resident was not permitted to leave the facility independently. R6 was at risk for elopement due to impaired judgment and unsafe decision-making, with the goal of not having any incidents of elopement Since the elopement incident dated 12/12/25, R6's Care Plan did not address that R6's guardian approved for R6's to have planned outings to the soup kitchen and the intervention of the facility escort going with R6 and remaining with R6 while at the soup kitchen. During an interview on 04/28/26 at 1:29 PM, R6 indicated the Administrator has made arrangements for her to go to the soup kitchen three times a week. During an interview on 04/29/26 at 2:41 PM, SSD said she was not able to find anything in R6's care plan for R6 to go to the soup kitchen and the facility escort to remain with her while on the outing. During an interview on 04/30/26 at 12:47 PM, when asked about care planning for R6 and going to the soup kitchen, the ADON confirmed that R6's care plan does not address R6 going on outings to the soup kitchen three times a week with a facility escort.

Based on record review, interviews, and policy review, the facility failed to perform medication administration by following accepted standards of identifying the resident prior to administering the medications for one of one resident (Resident (R) 5) reviewed for medication administration in the sample of 11 residents. This failure had the potential to cause decreased quality of life, medication adverse side effects, and exacerbation of health condition. Findings include: Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/26 and located in the MDS tab of the electronic medical record (EMR), revealed R5 was admitted on [DATE] with diagnosis of systemic lupus erythematosus (an active chronic autoimmune connective tissue disease. The MD indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS indicated R5 received scheduled and as needed pain medication for occasional moderate pain. Review of R5's Care Plan initiated 11/14/22 and located under the Care Plan tab of the EMR, addressed pain management with a goal to maintain adequate levels of comfort and with interventions including to administer pain medications as ordered. Review of the Incidents Log provided by the Administrator indicated a medication error occurred on 02/03/26 for R5. Review of the Incident Audit Report dated 02/03/26 and provided by the Administrator, revealed the resident usually received scheduled Oxycodone (narcotic pain medication) 5 milligram (mg) three times daily. The resident was scheduled to receive the Oxycodone at 3:00 AM, however, Licensed Practical Nurse (LPN) 2 (night shift nurse) gave R5 Hydrocodone/APAP (acetaminophen) (Norco, a pain medication combining a narcotic Hydrocodone with a non-narcotic acetaminophen, 5/325 mg) instead. Resident was unaware until notified by the floor nurse. Review of the Incident Report revealed it included a statement from LPN2 that indicated on 02/03/26 at 3:00 AM a medication administration error occurred in which R5 was given Norco 5/325 mg instead of Oxycodone 5 mg. The resident was assessed often with no adverse effects observed. Resident does not have an allergy to Norco. Vitals were monitored and were within normal limits. Provider was notified and new orders were for vitals to be taken every shift for 72 hours with continued monitoring for adverse effects. Resident voiced an understanding when notified. The incident report did not reveal the resident had experienced an upset stomach, nausea, and extreme drowsiness for several hours. Review of a grievance dated 02/03/26 and provided by the Social Service Director (SSD) that had been filed by R5 indicated, I was given wrong medication on 02/03/26 . Date of occurrence was 02/03/26. During an interview on 04/28/26 at 1:14 PM, R5 said on 02/03/26 at 5:13 AM, she received another resident's medication, and stated she usually got medication at that time of day. During an interview on 04/29/26 at 5:31 PM, with the Administrator and SSD, the Administrator said they did a complete investigation into the medication error. The Administrator indicated the medication administration six rights had not been followed. Review of the facility's policy titled, Medication Administration dated 2025 and provided by the Administrator documented under the heading Policy Explanation and Compliance Guidelines: 3. Identify resident by photo in the MAR (medication administration record). 10. Ensure that the six rights of medication administration are followed: a. Right resident. Review of the facility's policy titled, Medication Errors dated 2025 and provided by the Administrator documented, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. The policy defined Medication error as the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order. or accepted professional standards and principles which apply to professional providing services. Under the heading Policy Explanation and Compliance Guidelines indicated, 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders, c. In accordance with accepted standards and principles which apply to professionals providing services. 7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information:.Right resident.

Based on record review, interviews, and policy review, the facility failed to implement interventions to prevent elopement of a resident who eloped from the facility without the guardian's approval for one of three sampled residents (Resident (R) 6) reviewed for accident hazards and supervision in the sample of 11 residents. This failure had the potential for impaired judgments and/or unsafe decision making to cause serious harm to the resident. Findings include:Based on record review, interviews, and policy review, the facility failed to implement interventions to prevent elopement of a resident who eloped from the facility without the guardian's approval for one of three sampled residents (Resident (R) 6) reviewed for accident hazards and supervision in the sample of 11 residents. This failure had the potential for impaired judgments and/or unsafe decision making to cause serious harm to the resident. Findings include: Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25 and located in the MDS tab of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with diagnoses including bipolar disorder and a traumatic brain injury. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6's cognition was intact. Review of the Elopement Off Premises Report dated 12/12/25 and provided by the Administrator revealed R6 called a taxicab to take her to a soup kitchen without her guardian's consent. R6 said she was going to the store. The taxicab company was called for the location of where R6 was dropped off. Facility staff went to the location to bring R6 back to the facility. Review of R6's Care Plan located under the Care Plan tab of the EMR revealed R6 had a Court Ordered Guardian and was not permitted to leave the facility independently, initiated 07/09/25. R6 was at risk for elopement due to impaired judgment and unsafe decision- The goal indicated that the resident would not have any incidents of elopement. Interventions included hourly checks, initiated 08/15/25; all exits of the building required a staff escort and prior guardian approval, initiated 12/12/25. Review of Progress Notes located under the Progress Note tab of the EMR revealed the following: On 08/30/24 at 9:42 PM (date of admission), R6 had a history of elopement while at home. On 12/12/25 at 9:39 AM, Social Service Director (SSD) notified that R6 had left the facility without supervision and without the permission of the court appointed guardian. Facility conducted thorough search of building, but the resident was not located. SSD notified the guardian. Staff were dispersed throughout the surrounding neighborhood and nearby stores. Local police were also notified. During the investigation, it was identified that the resident had been observed leaving the facility via Yellow Cab taxi. Yellow Cab was contacted and drop-off location was obtained. Local police escorted SSD to the identified address. R6 was located at the address volunteering. R6 was appropriately dressed for the weather and situation. R6 said she was safe and had already coordinated transportation back to the facility. The psychiatric physician was notified of the elopement. R6 returned to the facility safely. Ongoing monitoring, care plan review, and interdisciplinary follow-up to address elopement risk would continue. Review of Progress Notes in the EMR under Progress Notes tab revealed that on 12/12/25 at 11:01 AM, Licensed Practical Nurse (LPN) 3 made a late entry: Writer arrived to work at 7:25 AM. R6 was standing in the entrance way and doorway of the building. When writer entered building, asked R6 where she was going. Appointment this early? R6 said, I'm going to the store and asked if I had any change. Writer said no, but needed to clock in because of being late, and would come back. Writer also asked Administrator and Director of Nursing (DON) for change. DON asked writer where R6 was going, and the writer said to the store. The DON said by herself, and the writer said yes, R6 said she is coming right back. Writer asked DON if R6 had signed out. They both looked in the book, and said no. Writer asked if she should chart or sign R6 out, and the DON said tell the SSD about it. It was not until the writer was approached by one of the social workers that was informed that R6 eloped because no one knew where R6 was. Writer told the social worker about the morning activities and was informed to speak to SSD. On 12/15/25 at 9:14 AM, noted on 12/15/25, R6 was observed manic and exhibiting increased agitation, exit seeking behaviors and combative behaviors both verbally and physically. R6 became upset regarding the desire to have breakfast with a friend. R6 said she had contacted the guardian 72 hours in advance, per guardian request, to obtain permission for an outing, but the guardian had not responded. On 12/15/25 at 2:00 PM, revealed nursing staff brought R6 to SSD due to exit-seeking behaviors and attempted to leave the facility unsupervised. SSD met with R6 who was observed to be anxious and expressing a desire to leave the facility. SSD provided redirection and R6 was able to engage in appropriate conversation. SSD reviewed the process for requesting outings and assisted R6 with submitting a request. R6 remained in the building, and no further exit seeking was observed at the conclusion of the encounter. During an interview on 04/28/26 at 1:29 PM, R6 indicated the Administrator had made arrangements for her to go to the soup kitchen three times a week. During an interview on 04/29/26 at 2:41 PM, SSD said after R6 went under guardianship she indicated she would act out because of the guardianship. SSD said she was not able to find anything in the care plan specifically for going to the soup kitchen and the circumstances when she does have permission to go out. During an interview on 04/30/26 at 12:47 PM, when asked about care planning for R6 and going to the soup kitchen, Assistant Director of Nursing (ADON) indicated it was not written in the care plan. During an interview on 04/30/26 at 4:48 PM, with the Administrator and SSD, SSD said R6 was first on 1:1s after the elopement on 12/12/25, then on 15-minutes checks and then at the time of the 12/12/25 elopement was on hourly checks. The facility became aware that she was gone and getting into a cab because of the hourly checks. At 4:57 PM, the Administrator showed a video of R6 standing in the doorway and leaving the building. During an interview on 04/30/26 at 6:30 PM, LPN3 said she had training on elopements and wander guards upon hire and after R6 eloped. During an interview on 04/30/26 at 6:35 PM, the Administrator said staff had elopement training in July and then after R6's elopement in December 2025. The Administrator said after the guardian agreed R6 could go to the soup kitchen three times a week, the facility agreed to provide the transportation and supervision while the resident was at the soup kitchen. During an interview on 04/30/26 at 6:50 PM, Staff A said he went to the food pantry on Monday, Wednesday and Friday and was R6's escort. He stated that he stayed with her while she was there and returned with her to the facility. Review of the facility's undated policy titled, Elopement provided by the Administrator indicated, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Review of the facility's undated policy titled, Policy Explanation and Compliance Guidelines the policy indicated .3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision.6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions and document accordingly. 7. Procedure for Locating Missing Resident: a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code). b. The designated facility staff will look for the resident.8. Procedure Post-Elopement: d. The resident and family/authorized representative will be included in the plan of care.

Based on observation, interview, and record review, the facility was not administered in a manner that enabled it to use its resources effectively to ensure residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to affect all 85 residents residing in the facility at the time of the survey.*The facility did not provide skin care treatments based upon accepted standards of practice and assessments. Residents sustained avoidable deterioration in wounds as a result of not being thoroughly assessed, care planned for interventions to prevent decline, and ongoing monitoring with revisions to the care plan. Wounds became infected and necrotic. Hospitalizations were required. One resident required a left above knee amputation and a right below knee amputation as a result of the wounds not being provided care and treatment according to acceptable standards of practice, assessments and individualized needs. Cross-reference F684.*The facility did not prevent residents from developing avoidable pressure injuries. The facility did not ensure assessments and treatments were provided based on current standards of practice and individual resident needs. The facility did not ensure each resident had their clinical condition evaluated, defined interventions were implemented based upon individual needs and standards of practice, and the interventions were monitored and revised as indicated to prevent decline in the pressure injures. Residents developed multiple, avoidable pressure injuries that became infected and required hospitalizations and antibiotic treatment. Cross-reference F686.*The facility failed to ensure the medical director was coordinating the care of the residents in the facility. During the survey, regulatory care concerns were identified with pressure and non-pressure wounds not being care for according to professional standards of practice. The facility medical director deferred any wound concerns to the wound physician, did not know who the wound physician was, and was unaware the facility did not have systems in place to ensure ongoing assessment, care and treatment for individuals with wounds and those at risk for the development of wounds. Residents sustained serious injury and impairment as a result of the medial director's failure to coordinate care in the facility. One resident lost both lower extremities to amputation as a result of wound care not provided in accordance with acceptable standards of practice. A second individual sustained multiple surgeries and infections as a result of the facility not having coordinated medical care. Medical Director-QQ did not coordinate the overall medical services within the facility to ensure residents reached their highest practicable level of well-being.*The facility's leadership were aware of procedural changes that were implemented by Operator-FFF were not based on clinical standards of practice. The facility leadership did not implement procedures to ensure the care and treatment of the residents met clinical standards of practice and resident needs. During the time the procedural changes were implemented the facility did not maintain a full time Director of Nursing. Cross-reference F727. Systemic failures occurred at the facility during this time in the areas of clinical care and management of resident care, quality of life, and resident choices. *The facility's Governing Body/Administration did not ensure they maintained an effective Quality Assurance and Performance Improvement Program as it did not identify systemic concerns in the facility related to pressure and non-pressure skin concerns due to clinical procedural changes being implemented that were not based on standards of practice, a lack of coordination of care from the medical director, and lack of clinical oversight of a full time Director of Nursing. Cross-reference F867.A total of 39 deficiencies have been cited as a result of the recertification and complaint survey investigations including the concerns identified at F835 - Administration.The facility's failure to ensure the building was administered in a manner that enabled it to use its resources effectively and efficiently to allow residents to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being created a finding of immediate jeopardy that began on 4/1/25. On 9/17/25, at 1:30 PM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the immediate jeopardy. The immediate jeopardy was not removed prior to exit from the survey when the facility failed to implement the immediate jeopardy removal plans they submitted prior to exit from the survey.Findings include:The Facility Assessment Tool updated 5/2025 and reviewed at QAPI 5/2025, documents, Part I: Our Resident Profile: (Name of Facility) typically accepts residents or continues to provide care for residents that may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that requires complex medical care and management. Each resident is assessed and reviewed on an individual basis. Potential admissions with atypical diseases and/or conditions are reviewed and considered individually, as is set forth below.Integumentary System: Skin Ulcers, Injuries Musculoskeletal Systems: Fractures, Osteoarthritis, other forms of ArthritisInfectious Diseases: Skin and Soft tissue Infections, . Urinary Tract Infections, Infections with [NAME]-Drug-Resistant-Organisms, Septicemia, .Part 2: Services and Care We Offer Based on our Residents' Needs:Skin Integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds).Infection Prevention and Control: Identification and containment of infection, prevention of infections. Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: Administration (e.g., Administrator, . QAPI, .)Nursing Services (e.g., DON .) .Medical/Physician Services (i.e., Medical Director, Attending Physician, Physician Assistant, Nurse Practitioner, .) .On 9/16/25, at 1:05 PM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B informed Surveyor previous DON-DDD resigned their position on July 30, 2025. NHA-A stated previous DON-DDD had been on leave from the facility from 4/1/25-5/12/25. NHA-A stated they had asked Operator-FFF to provide clinical support for the facility during this time, but none was provided until 5/8/25 when a mock survey was conducted. NHA-A stated it was a terrible time without clinical support, and he was asking for the help. NHA-A stated he would call Operator-FFF for clinical decision making but no one was present in the building. NHA-A informed Surveyor Operator-FFF changed the entire wound care program, requiring far less of what was previously required. DON-B stated Operator-FFF minimized the process for wound care. DON-B stated responsibilities were taken away from the wound care nurse that were previously required and she felt there would be issues that would occur. Surveyor asked why Operator-FFF would be minimizing or changing wound care practices at the facility. DON-B stated Operator-FFF wanted to decrease the workload during the receivership because they were losing the facility. DON-B stated weekly wound logs that contained measurements and documented progress of pressure and non-pressure wounds were eliminated as well as fall investigation packets. DON-B stated she had worked at the facility previously but had resigned as the DON on 12/31/24 following a survey that identified deficient practice and concerns that did not align with her values. DON-B stated prior to her resignation they (the facility) had systems and checks and balances in place and then Operator-FFF dismantled so many practices. DON-B stated she was working on reestablishing procedures and putting out fires and trying to make things better. On 9/16/25, at 2:55 PM, Medical Director (MD)-QQ informed Surveyor he was not aware of systemic issues with the facility's wound treatment program and deferred all wound treatment to the wound physician. MD-QQ informed Surveyor he was not sure who the facility's wound physician was and was not made aware the facility did not have an RN (Registered Nurse) overseeing the facility's wound program for many weeks, treatments were not being completed, and concerns with wounds were not discussed with him or at the facility QAPI meetings. During the recertification survey conducted 9/9/25-9/17/25, it was determined 39 deficiencies existed. The deficiencies identified systemic issues that were not identified and addressed by administration through established processes. The facility's governing body did not identify the systemic issues within the facility as evidenced by an ineffective Quality Assurance and Performance Improvement (QAPI) program. (Cross Reference F867) The facility did not identify and address system failures of care and management practices including clinical care, quality of life, resident choices, nursing services, and administration. Two of the 39 deficiencies have been identified as substandard quality of care. Of these two deficiencies, two are at a severity level of immediate jeopardy, to include F684 Quality of Care and F686 Treatment/Services to Prevent/Heal Pressure Ulcers. F841 Responsibilities of Medical Director and F835 Administration have also been identified to be immediate jeopardies.One of the 39 deficiencies has been identified at a severity level of actual harm that is not immediate, F689 Free of Accident Hazards/Supervision/Devices. At the time of the recertification survey, facility administration was aware of current noncompliance regarding F689 at the facility was not in compliance for F689 from previous survey event IDs: HBE511 and HBE5-H2.Example 1: F684, Quality of Care, Immediate Jeopardy:R97 developed an infection in a left leg surgical wound and developed other non-pressure wounds that were not comprehensively assessed by a Registered Nurse (RN) or treated despite physician orders. R97's surgical wound was not evaluated in the orthopedic office on 1/9/2025 as ordered on the hospital discharge summary. When R97 was seen in the clinic on 1/30/2025 R97's surgical wounds had deteriorated significantly requiring debridement, twice a day treatments with packing, and an order for 14 days of antibiotics. On 3/19/2025 at 8:00 AM in the progress notes, wound LPN-I documented R97 went to the outpatient wound clinic for the left lateral knee wound, the left heel, the left dorsal foot, and the left lateral foot. Wound care was not completed by LPN-I that shift. At 11:12 AM in the progress notes, nursing documented R97 was being admitted from the wound clinic to the hospital for possible left lower extremity wound infection, osteomyelitis, etc. with wounds probing down to bone and/or left lower extremity hardware. The hospital admission note on 3/19/2025 documented R97 presented to the emergency room with a worsening presentation of the wound in the left lower extremity. R97 was at a scheduled wound care visit with clinician note citing that R97's chronic wound probes to the hardware and bone in several locations, had malodor, and had increased depth and necrosis. R97 also had increased malaise. There was also a note of a right foot wound with increased pain, edema and necrosis. R97 was started on antibiotics due to the concern of osteomyelitis. The physical exam documented an open wound on the left anterior knee, tender, non-draining without any pus or blood noted, the right foot has a wound on the heel with eschar present and the left foot has wounds on the medial and lateral sides with eschar, along with a large wound on the left heel with an overlying eschar. All wounds were painful to palpation. R97 was readmitted to the facility on [DATE]. R97 had orders for intravenous antibiotics for the wound infection after surgical removal of hardware to the left knee. R97 was hospitalized from [DATE] to 4/22/2025 for a left surgical above the knee amputationExample 2: F684, Quality of Care, Immediate Jeopardy:R98 was admitted to the facility with a history of excoriation to the perineum area, diabetic ulcer to the right 2nd toe, and incision and drainage of a scrotal abscess. On 7/3/2025, nursing documented R98 was not able to get wound treatment or measurements completed but does not indicate what wounds required treatment or measurement. On 7/13/2025, nursing documented R98 has left inner thigh concerns and scrotal abscess. On 7/16/2025, R98 is assessed by the wound physician and found to have trauma/excoriation to the left medial thigh. On 7/22/2025, R98 expressed concerns with left finger getting caught in the wheelchair and no monitoring being completed. On 8/2/2025, R98 was sent to the emergency room for concerns of infection and admission diagnoses included: Fournier's Gangrene in male, severe sepsis, cellulitis of finger on the left hand, and scrotal erythema requiring surgical intervention and IV antibiotics.Example 3: F686, Treatment/Services to Prevent/Heal Pressure Ulcers, Immediate Jeopardy:R97 did not have comprehensive skin assessments upon readmission to the facility on [DATE], 4/9/2025, 4/22/2025, 7/9/2025, and 7/12/2025. R97 developed a Deep Tissue Injury to the left heel on 1/2/2025 that became Unstageable, an Unstageable pressure injury to the left lateral heel/foot on 2/17/2025, a blister to the left lateral foot on 3/4/2025 with no etiology of the wound or staging, and a Stage 2 pressure injury to the coccyx on 5/20/2025. Ordered wound treatments were not implemented timely; the treatment to the left lateral foot ordered on 2/18/2025 was not implemented until 2/24/2025 and the treatment orders for the sacral wound ordered on 7/9/2025 were not implemented until 7/20/2025. Treatments were ordered for wounds that were not assessed or documented. R97 had an order for a treatment to the sacrum on 4/9/2025 with no documentation of a wound present and an order for a treatment to the left gluteal wound on 7/26/2025 with no documentation of a wound present. Wounds were not comprehensively assessed weekly by an RN in the facility after 2/13/2025 when R97 stopped being seen by the wound physician. R97 was hospitalized from [DATE] to 4/22/2025 for a left surgical above the knee amputation.On 7/30/2025, at 1:26 PM in the progress notes, wound Licensed Practical Nurse (LPN)-I documented R97 was seen by Wound Physician (WP)-O for the right foot, right ankle, and the right thigh wound. WP-O noted gangrene and dusky color to the right great toe and noted maggots in the ankle wound. R97 was sent to the hospital for further evaluation and treatment. On 7/30/2025, R97 was admitted to the hospital. The hospital physician documented R97 had wounds on bilateral buttocks in addition to the wounds on the right lower extremities. R97 had chronic appearing wounds on the right lower extremity extending up to the thigh. On 8/7/2025, R97 had a right above the knee amputation. R97 did not return to the facility.Example 4: F686, Treatment/Services to Prevent/Heal Pressure Ulcers, Immediate Jeopardy:R98 was admitted to the facility with a history of a stage 2 pressure injury to the right buttock. On 7/3/2025, nursing documented R98 was not able to get wound treatment or measurements completed but does not indicate what wounds required treatment or measurement. On 7/13/2025, nursing documented R98 has a pressure injury to the right lateral coccyx. On 7/16/2025, R98 is assessed by the wound physician and found to have unstageable pressure injuries to the right ischium and sacrum/right buttock.On 7/23/2025, a deep tissue injury to the right heel and an unstageable pressure injury to the left heel are identified. On 8/2/2025, R98 was sent to the emergency room for concerns of infection and R98's admission diagnoses included: Two necrotic decubitus ulcers on the left and right buttocks, draining yellow discharge and very foul odor, severe sepsis, Fournier's gangrene in male, stage 4 pressure injury to the left buttock, stage 4 to the right buttock, deep tissue injury to the right heel, and unstageable pressure injury to the left heel. On 8/2/2025, R98 underwent surgical debridement and findings included: Two necrotic decubitus ulcers on the left and right buttocks, draining yellow discharge and very foul odor and necrotic tissue to the bilateral buttocks with significant fat and muscle necrosis. R98's left buttock wound tracked down to the bone, and right buttock wound tracked down to subcutaneous fat. Example 5: F727, No Full Time Director of NursingOn 09/16/2025, at 1:05 PM, Surveyor interviewed NHA-A and DON-B regarding previous DON-DDD ending employment at the facility and was told they walked out on July 30, 2025. NHA-A also stated previous DON-DDD was gone from 4/1/25 through 5/12/25 on a leave of absence. NHA-A stated Operator-FFF told NHA-A that they would provide clinical support but did not. NHA-A stated being able to call for clinical decision making but no one was present in the building. DON-B signed the offer letter on 8/4/25 and then had to fulfill notice of other job at (name of hospital) for 2 to 3 days a week for 2 to 3 weeks at 24 hours a week. DON-B worked around this schedule and put in full time work at this facility. Now DON-B is at the facility full time hours Monday through Friday, full days. The first day of the survey 9/9/25, DON-B had a planned day off which explains why they were not there.Surveyor noted that the facility was without full time DON coverage from 4/1/25 to 5/12/25 and again 7/31/25 until at least 8/4/25.Example 6: F841, Responsibilities of Medical Director, Immediate Jeopardy:On 9/16/25 at 2:55 p.m. Medical Director (MD)-QQ informed Surveyor he is not typically involved with wound care, especially complex wound treatment. MD-QQ stated he typically defers all wounds to the facility wound team and the Wound MD. MD-QQ wasn't certain who the Wound MD was. MD-QQ was not aware residents were not receiving wound assessments with RN oversight for many weeks and treatments were not being completed as ordered. MD-QQ informed Surveyor wound concerns were not discussed with him or in QAPI meetings. Example 7: F865 QAPI Program/PlanThe facility's Quality Assurance Committee did not meet to discuss crucial quality of care practices being eliminated or decreases in overall monitoring practices being implemented at the facility nor meet to discuss the lack of clinical oversight by a Director of Nursing present in facility 4/1/25 to 5/12/25 and 7/31/25 to 9/9/25.On 9/16/25 at 1:05 PM Surveyor asked NHA-A if NHA-A was apprised of the serious clinical concerns occurring at the facility, particularly related to quality of care and overall care concerns. NHA-A stated, previous Director of Nursing-DDD was in charge of the clinical aspects of the building and NHA-A should have been apprised of all clinical concerns but was not. NHA-A stated he did not realize the clinical issues were this bad, particularly with two residents, R97 and R98 with wounds. NHA-A stated the Department Heads met every morning and afternoon to discuss clinical issues, or any other areas of concern and no issues were brought up to the level of harm, especially issues with lack of wound care and practices. NHA-A stated NHA-A trusted clinical leaderships' report during morning and afternoon meetings as accurate and NHA-A stated there were always minor concerns brought to his attention but never the kind of issues brought forth with this survey.On 09/17/2025, at 8:03 AM, Surveyor interviewed NHA-A and DON-B. Surveyor asked NHA-A and DON-B how the facility identifies systemic issues. DON-B stated, through the QAPI process and Interdisciplinary Team (IDT) meetings and then discuss as team. Then facility determines which department is affected, creates root cause analysis to develop solutions and monitors with frequency and duration for effectiveness.Surveyor notes, NHA-A produced QAPI meeting templates with minutes indicating there was a monthly QAPI meeting in January, February, March, and April of 2025 and an ad hoc QAPI meeting in July 2025 following a State survey. NHA-A confirms there was no QAPI meeting during prior DON-DDD's leave of absence, leaving no DON in facility from 4/1/25 -5/12/25 nor following prior DON-DDD's return from leave of absence on 5/13/25 until 7/1/25 after receiving an immediate jeopardy citation. The facility cannot illustrate the required QAPI attendees were present as there are no sign in sheets for the QAPI meetings held in January, February, March, and April of 2025. None of the QAPI meeting minutes address the dismantling of the entire wound care program nor falls investigation practice following DON-B's original departure on 12/31/24. The facility was unable to provide Surveyor with a PIP (Performance Improvement Plan) for 2025 that has been implemented and/or corrected for wounds, pressure injuries, fall investigations, or Medical Director concerns/coordination of care, only PIPS in initial development.The failure of administration to ensure the building was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility submitted a removal plan to address the immediate jeopardy alleging the implementation of the following plan by 9/24/2025:* Facility leadership conducted a comprehensive review of policies, procedures, and oversight practices.* Any deficiencies in administrative oversight or documentation were immediately addressed and corrected.* Staff were educated on expectations for reporting, accountability, and adherence to facility policies. * A full review of current administrative and clinical practices was completed to identify areas where oversight was insufficient.* Corrective measures were implemented to ensure timely identification and resolution of all resident care concerns.* The governing body and administration have implemented a structured oversight plan including daily review of critical logs and resident care reports by the administrator and DON. Monthly review of compliance and quality assurance measures with the governing body. Clear assignment of accountability for all areas of regulatory compliance.* Policies were updated to clarify expectations for administration and governing body involvement in resident care and regulatory compliance.* A system for audits, monitoring and involvement of QAPI has been established until substantial compliance is achieved.The immediate jeopardy for F835 was not removed prior to the exit of the survey on 9/30/25 as surveyors could not verify implementation of this plan prior to survey exit.

Based on interview and record review, the facility did not ensure the medical director followed through on his responsibilities regarding the coordination of care and treatment the residents received in the facility. This has the likelihood to cause serious harm, injury, or impairment to all 85 residents currently residing in the facility.Medical Director (MD)-QQ was not aware of and did not ensure facility residents with wounds had care and treatment necessary to prevent and heal pressure and non-pressure injury wounds. Medical Director-QQ deferred all wound care and treatment to the facility's wound team and Wound MD (Medical Doctor). Following Medical Director-QQ's decision to defer all wound care to the contracted wound MD, Medical Director-QQ did not ensure the resident care policies were implemented and that there was ongoing coordination of the medical care in the facility in accordance with policies and procedures and accepted standards of practice for medical care. Cross-reference F684 and F686.Medical Director (MD)-QQ was not aware the facility had implemented wound care procedural changes that were not based on clinical standards of practice. During the implementation of the procedural changes the facility did not maintain a full time Director of Nursing to oversee the clinical care and treatment of the residents. Medical Director (MD)-QQ was not aware the facility did not maintain a full time Director of Nursing to oversee the clinical care and treatment of the residents. Cross-reference F727 and F867.Medical Director-QQ did not fulfill his role on the facility quality assessment and assurance (QAA) committee by failing to assist with administrative decisions including recommending, developing, and approving facility policies and procedures related to resident care, coordination of medical care and implementation of policies and procedures. Cross-reference F867.Medical Director-QQ did not work with the facility's clinical team to provide surveillance and develop policies and procedures to prevent the potential infection of residents as deficient practice was identified with the facility's overall surveillance program for tracking and trending the prevalence of infections in the facility, antibiotic stewardship, and vaccinations. Cross-reference F880.The facility's failure to ensure Medical Director-QQ fulfilled their responsibility for the implementation of resident care policies and the coordination of medical care in the facility created a situation of immediate jeopardy starting 9/9/2025. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 9/16/2025 at 2:00 PM. The immediate jeopardy was not removed prior to exit from the survey as the facility failed to implement their immediate jeopardy removal plan they established prior to exit on 9/30/2025.Findings include:The Medical Director Agreement signed by Medical Director-QQ on 1/1/24 documents: Responsibilities and Functions of Medical Director.A. Supervise and coordinate provisions of medical services and resident care in the Facility.B. Assist Facility in arranging for and/or providing as needed continuous physician coverage for medical emergencies and in development of emergency treatment procedures for residents/patients as needed.C. Review and sign all incident reports, identify hazards to health and safety, and provide recommendations to the Facility's Administrator to promote a safe and sanitary environment for residents, guest and personnel.E. Assist the facility in its review and response to any surveys, complaints, or inspections or any medical care or treatment issues or concerns.F. Conduct periodic formal meetings with the Facility's department heads and chairpersons of the Facility's committees. G. Participate in identifying the need for, developing, amending, recommending, approving, implementing and monitoring written policies governing resident care including policies related to admissions, transfers, and discharges; infection control; use of restraints; physician privileges and practices; and responsibilities of non-physician health care workers (e.g. nursing, rehabilitation therapies, and dietary services in resident care, emergency care and resident assessment and care planning). Medical Director shall also assist with policies related to accidents and incidents; ancillary services such as laboratory, radiology, and pharmacy; use of medications; use and release of clinical information; and overall quality of care.H. Advise the Facility's Administrator as to the adequacy of the Facility's resident care services and medical equipment.K. Serve as a member of QAPI committee, no less than monthly, and other committees as reasonable requested by Facility.L. Participate in any Facility accreditation or certification process.M. Make routine visits to the Facility to meet with the Facility's Administrator and Director of Nursing, or their designee (s), to discuss various issues and problems including, but not limited to administrative, dietary, and housekeeping issues, specific resident care problems, and professional staff needs for education or consultants. Medical Director QAPI and Facility Wound Program Concerns:On 9/16/25, at 2:55 p.m., Surveyor interviewed Medical Director-QQ. Surveyor asked Medical Director-QQ how often he visits the facility. Medical Director-QQ stated he visits the facility every other week but his NP (nurse practitioner) visits two to three times a week. Surveyor asked if Medical Director-QQ participates in facility QAPI meetings, and he stated yes, he participates in QAPI. Medical Director-QQ stated recently the facility has gone through transitions with ownership and he has let Nursing Home Administrator (NHA)-A deal with all the changes that have occurred. Surveyor asked Medical Director-QQ, when a resident develops a pressure or non-pressure wound, what is his role. Medical Director-QQ stated he typically is not involved with wounds, especially complex wounds. Medical Director-QQ stated he defers all wounds to the facility wound team and the Wound MD (Medical Doctor). Medical Director-QQ stated he is only involved if there is an emergent situation where they can't reach the Wound MD and the resident needs orders to be sent to the hospital. Medical Director-QQ stated he wasn't sure who the facility Wound MD was. Medical Director-QQ then mentioned the name of a wound MD Surveyor noted the facility no longer works with. Surveyor explained to Medical Director-QQ the concerns regarding wound care in the facility. Specifically, R97 and R98 had developed pressure and non-pressure wounds that developed into serious concerns needing hospitalization and having significant impact on the resident's quality of life including systemic infections and/or amputation. Surveyor explained R97 and R98 were not receiving wound assessments in accordance with standards of care and there wasn't RN oversight for wound management for many weeks. Surveyor explained treatments were not being completed. Medical Director-QQ stated he was not aware of any issues regarding wound management. Medical Director-QQ reiterated he defers to the wound team. Medical Director-QQ stated wound concerns were not discussed with him or in QAPI meetings. Cross-reference F867, F684, and F686.Medical Director QAPI and Infection Prevention and Control Concerns:On 09/10/2025, at 8:36 AM, Surveyor spoke with Infection Preventionist (IP)-I, regarding the requested Infection Prevention surveillance and program documentation. Per IP-I the Director of Nursing (DON)-B is on the phone with the (name of the electronic medical record) company, there are a couple things they are still trying to get that was requested.On 09/10/2025, at 9:51 AM, Surveyor interviewed DON-B and was told that the IPC (Infection Prevention and Control software) within (name of the electronic medical record) is disabled. To be able to add orders or update cases need to enable IPC. When DON-B goes to reports and tries to historically print records, just gets a blank screen. DON-B put date range in to report and nothing shows. DON-B had been employed previously at facility until the end of December. Documentation in binders up through December is available. DON-B looked, and the previous owners disabled IPC on 8/7/25. The new management company involved is trying to get legend or access so information can be provided. Per DON-B IPC is a module that you buy extra from (name of the electronic medical record) and it has been disabled.On 9/15/25, at 9:00 AM, Surveyor interviewed DON-B and IP-I, over the weekend they used the Physician Order Report for residents with an antibiotic to create surveillance logs. The new ownership company needs to sign a contract with (name of the electronic medical record) for the IPC add on and even then there is no promise the previous data will be available. On 9/15/25, at 9:00 AM, Surveyor continued the interview asking Director of Nursing (DON)-B and Infection Preventionist (IP)-I regarding the antibiotic stewardship program and was told they follow the McGeer's criteria (The McGeer criteria are a set of clinical guidelines used for infection surveillance in long-term care facilities, focusing on identifying potential infections and guiding antibiotic stewardship.)Surveyor reviewed the monthly surveillance for January through present of 2025. Surveyor noted no antibiotic use documentation or McGeer criteria assessments in the medical record or surveillance log.On 9/16/25, at 2:24 PM, Surveyor interviewed IP-I and confirmed McGeer's is the criteria used to assess antibiotic use. Surveyor asked how they check a resident on an antibiotic meets the criteria to be on it. Per IP-I the previous DON would type it in the sheets when we talked about residents on antibiotics at the 24-hour meeting. Surveyor noted these sheets did not become part of the resident's permanent medical record. During the survey Surveyors requested the vaccination record for 4 sampled residents regarding review of the facility's practice in administering the pneumococcal vaccination to residents who were eligible to receive such vaccination. R6, [AGE] years old, has no documentation of Pneumococcal vaccine being offered. R33, [AGE] years old, has no documentation of Pneumococcal vaccine being offered. R65, [AGE] years old, has no documentation of Pneumococcal vaccine being offered. R75, [AGE] years old, has no documentation of Pneumococcal vaccine being offered. On 09/16/2025, at 9:00 AM, Surveyor interviewed Director of Nursing (DON)-B who stated she was working on immunization information that was requested, would also look in Wisconsin Immunization Record (WIR). On 9/16/2025, at 11:00 AM, Surveyor followed up with DON-B and no Pneumococcal vaccination information was located, still wants to look one more place.Additionally during the survey Surveyors requested the vaccination records for 5 sampled residents and 1 staff person to review the facility's practices in ensuring administration of the COVID-19 vaccination. R6's medical record does not contain any documentation as to whether R6 was offered, received, or declined the COVID-19 immunization. R33's medical record does not contain any documentation as to whether R33 was offered, received, or declined the COVID-19 immunization. R40's medical record does not contain any documentation as to whether R40 was offered, received, or declined the COVID-19 immunization. R65's medical record does not contain any documentation as to whether R65 was offered, received, or declined the COVID-19 immunization. R75's medical record does not contain any documentation as to whether R75 was offered, received, or declined the COVID-19 immunization. Staff member (CNA-JJ) reviewed had no documentation of COVID-19 vaccination being offered, received or declined.Surveyor noted there is no indication through the QAPI process or facility practice the facility's infection prevention and control program and policies and procedures were based upon or implemented in accordance with current standards of practice and that Medical Director-QQ had directed and reviewed the facility's infection control program as the Medical Director of the facility. This included establishing a system to track, trend and provide overall surveillance of infections within the facility, ensuring the facility had an effective antibiotic stewardship program to prevent unnecessary use of antibiotics and ensuring the facility had an active immunization program in the facility. Cross-reference F880, F881, F883, and F887.On 09/16/2025 at 1:05 PM Surveyor asked NHA-A what the role of the Medical Director in the facility is. NHA-A stated the role of Medical Director- QQ is to participate in the QAPI meetings and provide feedback. NHA-A stated Medical Director- QQ oversees the Nurse Practitioners (NP's) seeing residents at the facility. Medical Director- QQ is the support for when there are issues or concerns with other physicians.Surveyor asked what the responsibility of Medical Director-QQ regarding the overall wellness and clinical care for the residents is; specifically, how were the NP's or Medical Director- QQ not aware of the severity of R97 and R98's wounds and other clinical concerns and systemic issues regarding care. DON-B stated, the NP's and Medical Director- QQ need to have the facility apprise them of any resident wounds as the NP's and/or Medical Director- QQ is not doing a full physical comprehensive assessment when visiting the residents unless they are aware of a particular situation. DON-B stated NP's and/or Medical Director- QQ is relying on the facility wound team to address wounds. Surveyor noted it is the role of the Medical Director to establish and coordinate the overall clinical program in the facility based upon current standards of practice. Surveyor also noted Medical Director-QQ is also the attending physician for many of the facility residents.On 9/17/2025, at 8:03 AM, Surveyor interviewed NHA-A who stated the facility held QAPI meetings in January, February, March, and April of 2025, and an ad hoc QAPI meeting in July following a State survey. NHA-A confirms there was no QAPI meeting held during prior DON-DDD's leave of absence. NHA-A was unable to provide attendance sign in sheets for the meetings held in January, February, March and April of 2025. The QAPI agendas provided do not address the procedural changes implemented in wound care, the facility's plans for clinical coverage without a fulltime DON, nor a discussion with the Medical Director related to these areas of concern and how they would impact resident care and treatment at the facility. The facility's failure to ensure the medical director followed through on his responsibilities regarding the coordination of care and treatment the residents received in the facility led to a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy. The facility submitted an immediate jeopardy removal plan alleging removal of the immediate jeopardy as of 09/24/2025 with the implementation of the following plan. * Any unresolved nursing concerns were immediately escalated to the attending physicians and addressed.* Documentation was updated to reflect interventions, physician responses, and outcomes.* A comprehensive review of all current residents' charts was completed to ensure no nursing concerns requiring physician follow up were missed.* Any identified issues were immediately addressed and documented.* A new Medical Director s identified and oriented to facility policy and CMS requirements for physician oversight.* Nursing staff were re-educated on the chain of command for escalating medical concerns and expectations for timely physician responses.* Administrator and DON will review communication logs and physician notifications daily to ensure all nursing concerns are addressed promptly. * All facility policies and procedures will be reviewed with new Medical Director on 9/24/25 and the medical director will be involved in the plan of correction for the noncompliance.* The facility established a pan for audits and reporting to QAPI until substantial compliance is achieved. The implementation of this plan was not able to be verified upon exit from the survey leaving the immediate jeopardy at F841 to be ongoing at the time of survey exit on 9/30/2025.

Based on observation, interview, and record review, the facility did not ensure residents received treatment and care, based on a comprehensive assessment, in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for non-pressure injuries, changes of condition, neurological checks after unwitnessed falls, or physician follow up visits for 3 (R97, R98, and R73) of 20 sampled residents. R97 developed an infection in a surgical wound and developed other non-pressure wounds that were not comprehensively assessed by a Registered Nurse (RN) or treated despite physician orders. Due to the severity of the wounds and infections that developed, R97 required both left and right above the knee amputations. R98 developed non-pressure wounds (as well as pressure wounds) that were not comprehensively assessed or monitored and did not have ordered treatments applied consistently. R98 was admitted to the hospital with Fournier's Gangrene, severe sepsis, cellulitis of finger, and scrotal erythema requiring surgical intervention and IV antibiotics. The facility's failure to comprehensively assess non-pressure wounds, implement interventions based on the clinical condition and risk factors, and provide care consistent with professional standards of practice created a finding of immediate jeopardy that began on 1/09/2025. Surveyor notified Nursing Home Administrator/NHA-A and Director of Nursing (DON)-B of the immediate jeopardy on 9/16/2025 at 11:49 AM. The Immediate Jeopardy was not removed at the time of exit from the survey. Additional deficient practice was identified regarding R73. *R73 had unwitnessed falls on 6/25/2025, 7/1/2025, and 7/3/2025. Neurological checks were not completed. R73 was evaluated in the hospital after the fall on 7/1/2025 and had an order to be followed up in one week by the primary care physician. R73 did not see the Nurse Practitioner until 7/30/2025 and the documentation from the visit did not refer to a follow-up/evaluation of R73's falls. Findings include: The facility policy and procedure titled Wound Management documents: Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations. 4. Dressing will be applied in accordance with manufacturer recommendations. 5. Treatment decisions will be based on: a. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxis). b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size – including shape, depth, and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of the peri-wound skin. c. Location of the wound. d. Goals and preferences of the resident/representative. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above). c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. 1.) R97 was admitted to the facility on [DATE] with diagnoses of diabetes, lupus, agranulocytosis (low white blood cells to help fight infection), heart failure, acute kidney failure, anxiety, and depression. R97's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R97 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and had impairment to both arms and legs. No skin concerns were documented on the MDS assessment. R97 had a Guardian. R97's Activities of Daily Living Care Plan was initiated on 11/29/2019 and had interventions in place on 12/24/2024 of transferring with a full mechanical lift with total assistance of two people, bed mobility, dressing, bathing, hygiene, grooming, showers, etc. with extensive assistance of one person, and toileting check and change with total assistance of two people. R97's Skin Integrity Care Plan was initiated on 12/9/2019 with the interventions to float heels, have a cushion in the wheelchair, a pressure reducing mattress, and turn and reposition every two hours and as needed. R97 had the following treatments in place:-Skin prep to the left heel every shift for protection initiated 1/16/2020.-Zinc oxide paste to the buttocks every shift related to pressure injury of the sacral region Stage 4 initiated 6/26/2020.-Skin prep to the right posterior thigh daily initiated 9/30/2024. On 12/24/2024 at 12:28 PM in the progress notes, nursing indicated R97 had a fall while being assisted out of bed by staff. R97 complained a knee pain and was transferred to the hospital. R97 was in the hospital from [DATE] to 12/31/2024. The hospital documented R97 sustained a fracture to the left tibia and fibula from the fall which was surgically repaired. The discharge instructions on the After Visit Summary included to follow up at the orthopedic clinic on 1/9/2025 at 11:00 AM and to keep the dressing on the surgical incision until the follow up visit. On 12/31/2024 at 2:07 PM in the progress notes, wound Licensed Practical Nurse (LPN)-I documented a late entry on 2/18/2025 documenting R97's skin check was completed and R97 had an immobilizer to the left leg. R97 had a skin issue to the right rear thigh in the form of a blister that was not evaluated, and an Aquacel dressing that was intact and was not to be removed until the follow up orthopedic appointment. LPN-I documented R97 refused to have the right rear thigh blister examined. Surveyor noted a Registered Nurse (RN) did not assess R97's skin upon readmission to the facility. On 12/31/2024 at 3:28 PM in the progress notes, LPN-I documented a late entry clarification on 6/30/2025 documenting the Aquacel dressing to the left above the knee amputation was not to be removed until the follow up orthopedic appointment. Surveyor noted R97 did not have an amputation at that time. R97's treatment orders of skin prep to the left heel and right posterior thigh and the zinc oxide paste to the buttocks continued from pre-hospitalization. On 1/2/2025, R97 was seen by the Wound Physician. The Wound Physician documented R97 had a pressure injury to the left heel. No other wounds were documented. On 1/2/2025 on the Skin Check form, LPN-I documented R97 had wounds to the left heel, the left lateral foot, the left medial ankle, and left dorsal foot with blisters that were inhouse acquired, as well as a surgical wound to the left lateral knee. The wounds were not assessed by an RN or the Wound Physician. LPN-I documented the Wound Physician saw R97 to evaluate and treat the left heel pressure injury and the other wounds needed to be assessed or evaluated. There was no further documentation regarding the non-pressure wounds. On 1/3/2025 at 9:13 AM in the progress notes, the dietician documented R97 had a significant weight loss and had a pressure injury to the left heel. No other wounds were documented by the dietician for the dietary assessment to create a complete picture of the dietary needs of R97. No documentation was found of R97 going to the orthopedic clinic on 1/9/2025 for the follow up appointment. No documentation was found of an assessment of R97's surgical wound or left foot wounds after The skin check form dated 1/2/2025. LPN-I started a weekly wound log on 1/26/2025 that had measurements of the left lateral surgical wound. This wound log was not part of R97's medical record and was not verified or assessed by an RN. No wound descriptors were written on the log. The log was weekly until 6/7/2025. On 1/30/2025, R97 went to the orthopedic clinic. The orthopedic clinic documented on the Report of Consultation R97 was one month status post the left tibia fracture surgical repair on 12/27/2024. R97 had significant wound breakdown for not being seen on 1/9/2025 in the office. Wound debridement was done in the office and the wound required twice daily packing with 4 x 4 gauze and betadine. The orthopedic clinic ordered R97 to be followed at the wound care clinic immediately and an antibiotic, Keflex 500 mg, to be given four times a day for 14 days. Surveyor noted no assessments had been done by the facility of the surgical wound to the left outer knee. Orders were to leave the dressing in place until the first follow up appointment which R97 did not attend (on 01/09/25.) This resulted in R97 developing a wound requiring debridement and antibiotics for infection. Surveyor noted R97's record does not include any documentation to explain why R97 was not seen in the wound clinic on 1/9/2025 or if there was consultation with the clinic on that date if R97 was not able to keep their appointment. On 1/30/2025 at 10:58 AM in the progress notes, wound LPN-I documented R97 returned from the orthopedic appointment for the left tibia fracture follow up visit and has a wound to the left extremity. Sutures were removed at the office and R97 has a new order for wound care and antibiotics for the wound. At 1:57 PM in the progress notes, LPN-I documented the wound to the left lateral knee was irregular in shape measuring 14.5 cm x 2 cm x 1.5 cm with a pink and moist wound bed. The wound was not assessed by an RN. On 1/31/2025 at 7:25 AM in the progress notes, wound LPN-I documented the left lateral knee wound treatment was completed by LPN-I and the wound bed is 80% pink granulation and 20% slough. The peri wound was pink at the proximal end and brown discoloration to the distal wound. The immobilizer to the left leg was in place and the skin was checked for breakdown. Prevalon boots were in place for off-loading. On 2/3/2025 at 10:15 AM in the progress notes, wound LPN-I documented R97 was noted to have a fluid filled blister to the left dorsal foot measuring 8 cm x 2 cm x 0.1 cm. The Nurse Practitioner (NP) was notified and a treatment of skin prep to the left dorsal foot blister daily was obtained. The wound was not assessed by an RN. On 2/6/2025, R97 was seen by the in-house wound physician. The wound physician assessed the left dorsal foot blister documenting the etiology as lymphedema. The blister measured 2.5 cm x 8.1 cm x 0 cm. The wound physician did not assess the left lateral knee surgical wound. On 2/6/2025, R97 was seen in the orthopedic clinic where the left lateral surgical wound was debrided and the treatment of packing the wound with betadine gauze continued. On 2/13/2025, R97 was seen by the in-house wound physician. The lymphedema wound of the left dorsal foot measured 2.5 cm x 7.5 cm x 0.1 cm with 20% necrotic tissue, 50% slough, and 30% granulation tissue. This was the first documentation the blister was no longer intact. The treatment was changed by the wound physician. On 2/18/2025 at 12:13 PM in the progress notes, wound LPN-I documented R97 was seen in the wound clinic with a new order to start a wound vac to the left lateral knee surgical wound. The wound clinic ordered treatment of betadine to the left medial ankle and heel eschar daily. Surveyor unable to determine if the left medial ankle wound and the left dorsal foot wound were the same and labeled differently by the wound clinic. On 2/19/2025 at 7:21 AM in the progress notes, wound LPN-I documented the wound vac was applied to the left lateral knee surgical wound. The wound measured 13 cm x 3 cm x 1.5 cm with 10% granulation and 90% adipose tissue with no tunneling or undermining. The wound was surgically debrided at the wound clinic. R97 was also seen at the clinic for the left lateral ankle blister and left dorsal foot. A new treatment was obtained by the wound clinic and initiated. Surveyor noted no documentation was available in R97's medical record from the wound clinic with assessments of the wounds and the wounds were not assessed in the facility by an RN. LPN-I opened weekly wound assessment documents, but those assessments were never verified or signed by an RN. On 2/20/2025, the in-house wound physician discharged R97 from services due to R97 being followed for wounds at the wound clinic. On 2/26/2025 at 11:05 AM in the progress notes, wound LPN-I documented R97 had wounds to the left lateral knee, the left lateral foot, and the left dorsal foot. LPN-I documented the wound base tissue types but no measurements. The wounds were not assessed by an RN. On 2/26/2025 at 10:57 PM in the progress notes, nursing documented a conversation was had with the NP related to R97 needing to be assessed by psych services. R97 was noted to be crying on occasion about the left foot and the fear that the wounds will not heal and need to be amputated. Nursing documented R97's crying was related to pain. Psych services were obtained. On 3/4/2025 at 8:00 AM in the progress notes, wound LPN-I documented R97 went to the wound clinic for wounds to the left lateral knee, left heel, left lateral foot, left dorsal foot, and left medial ankle. At 10:50 AM in the progress notes, LPN-I documented the blister to the left lateral foot was newly discovered during wound care and measured 4.5 cm x 2.5 cm x 0.1 cm. LPN-I notified the NP, the Director of Nursing (DON), and R97's Guardian. The wound documentation was not verified or signed by an RN. On 3/6/2025 at 9:16 PM in the progress notes, nursing documented R97 had a new order for amitriptyline 50 mg every evening for neuropathy pain. R97 complained of bilateral feet feeling like they are on fire. On 3/13/2025 at 10:12 PM in the progress notes, nursing documented R97 was yelling out earlier in the shift related to pain to the left foot. Pain medication was administered at 1:15 PM and not effective. The NP was contacted and ordered to increase the biofreeze gel from three times daily to every six hours. The psych NP was in house and at bedside to assess R97 with no new orders for psychotropic medications. The physician was notified and received a new order to add an additional dose of amitriptyline 25 mg for neuropathy pain in the morning and to give ibuprofen 800 mg with acetaminophen 1000 mg twice daily for 14 days. On 3/15/2025 at 10:17 PM in the progress notes, nursing documented R97 continued calling out when R97 has pain from left heel open areas. R97 was encouraged to keep heel floated to relieve pressure and promote comfort. Scheduled medications and creams were helpful for pain. The treatment to the left leg and left heel/foot was completed. On 3/19/2025 at 8:00 AM in the progress notes, wound LPN-I documented R97 went to the outpatient wound clinic for the left lateral knee wound, the left heel, the left dorsal foot, and the left lateral foot. Wound care was not completed by LPN-I that shift. At 11:12 AM in the progress notes, nursing documented R97 was being admitted from the wound clinic to the hospital for possible left lower extremity wound infection, osteomyelitis, etc. with wounds probing down to bone and/or left lower extremity hardware. The hospital admission note on 3/19/2025 documented R97 presented to the emergency room with a worsening presentation of the wound in the left lower extremity. R97 was at a scheduled wound care visit with clinician note citing that R97's chronic wound probes to the hardware and bone in several locations, had malodor, and had increased depth and necrosis. R97 also had increased malaise. There was also a note of a right foot wound with increased pain, edema and necrosis. R97 was started on antibiotics due to the concern of osteomyelitis. The physical exam documented an open wound on the left anterior knee, tender, non-draining without any pus or blood noted, the right foot has a wound on the heel with eschar present and the left foot has wounds on the medial and lateral sides with eschar, along with a large wound on the left heel with an overlying eschar. All wounds were painful to palpation. Surveyor noted pictures of the listed wounds but no wound picture of the right heel. No documentation was found of R97 having a wound to the right heel prior to the hospital admission. R97 was readmitted to the facility on [DATE]. R97 had orders for intravenous antibiotics for the wound infection after surgical removal of hardware to the left knee. On 4/9/2025 at 1:00 PM in the progress notes, wound LPN-I documented R97 returned to the facility with wounds. The left lateral knee surgical wound measured 13 cm x 4 cm x 3 cm with exposed bones, ligaments, tendon, and granulation and adipose tissue. The distal end of the wound was open and superficial, and 11 sutures were intact and approximate. The wound vac was applied per order. The left lateral foot wound measured 5 cm x 6 cm x 0.1 cm with 90% eschar and 10% granulation with scant serous drainage. The right dorsal foot skin was dry with 100% eschar that measured 4 cm x 2 cm x 0.1 cm. Surveyor noted LPN-I may have documented on the left dorsal foot rather than the right dorsal foot. The left posterior calf had an open area that measured 1 cm x 1 cm x 0.1 cm with no drainage. R97's skin was not assessed by an RN. Treatments were obtained for the left lateral knee wound and the left dorsal foot wound. No treatment was obtained for the left lateral foot. On 4/11/2025, an Infection of MRSA (Methicillin-resistant Staphylococcus aureus) to the Left Thigh Wound Care Plan was initiated. On 4/16/2025 at 2:00 PM in the progress notes, wound LPN-I documented R97 complained of pain to the right inner thigh. R97 thought it was a boil. LPN-I observed and noted the right inner thigh has an abrasion from the brief being too small and too tight. The wound was irregular in shape and superficial measuring 6 cm x 4 cm x 0.1 cm with a pink moist wound bed. The NP was notified, and a treatment was obtained. The wound was not assessed by an RN. LPN-I educated staff to use larger briefs when caring for R97. On 4/18/2025 at 9:03 AM in the progress notes, wound LPN-I documented during wound care to the left lateral knee surgical wound, the wound bed had 15% bone exposed with sutures present. LPN-I notified the NP to come and assess the wound. At 9:15 AM in the progress notes, LPN-I documented the NP arrived to assess R97's left lateral knee surgical wound with partial bone exposed and sticking outward. The NP ordered R97 to be evaluated in the emergency room. On 4/18/2025 in the NP notes, the NP documented R97 was seen for a follow up on the left lateral knee surgical wound with delayed healing. The NP received a phone call that morning about a complication to the wound with a bone sticking outward per the wound nurse and that had not been the case before. There had been bone, but it was not exposed like that and definitely not sticking out. Now it looks like the bone got fractured and the rough end of the bone was sticking out and the other end of the bone was not visible. R97 was recently at the hospital and the plan was to try to heal the wound with a wound vac and the next step would be an amputation above the knee. R97 agreed to the amputation and requested to be sent out to the hospital. R97 reported a lot of pain to the left leg. R97 denied any trauma or any fall in the past few days. R97 was hospitalized from [DATE] to 4/22/2025 for a left surgical above the knee amputation. R97 was readmitted to the facility on [DATE]. On 4/22/2025 on the Clinical admission form in the Skin section, the form prefilled with previous wounds, such as the left medial ankle, the left heel, the left lateral foot and the left dorsal foot with blisters as well as the front left knee surgical wound and the right medial thigh abrasion. Those wounds were present prior to R97's hospitalizations but were not present after readmission due to the left above the knee amputation. No RN assessed R97's skin. On 4/22/2025 at 10:50 AM in the progress notes, wound LPN-I documented R97's readmission skin check had a left above the knee amputation with a wound vac to the area that was not to be removed until follow up on 4/30/2025 at the orthopedic clinic. No other skin concerns were documented. On 4/30/2025 at 2:21 PM in the progress notes, wound LPN-I documented R97 returned from the orthopedic clinic appointment with the wound vac still in place to the left above the knee amputation surgical site with a new order to discontinue the wound vac on 5/4/2025 and replace with a dressing to be left in place until the following appointment on 5/9/2025. At 4:07 PM in the progress notes, nursing documented R97 had a new order for the antibiotic Cephalexin 500 mg four times daily for 14 days for an infection to R97's wounds. On 5/29/2025 at 8:27 AM in the progress notes, wound LPN-I documented R97 had an abrasion to the left upper arm that measured 2.5 cm x 1 cm x 0.1 cm with a pink wound bed. A treatment order was obtained. The wound was not assessed by an RN. No weekly wound assessments of the left above the knee amputation surgical wound or the left upper arm abrasion were documented. On 6/18/2025, R97 was sent to the hospital and admitted for acute renal failure. On 7/9/2025 on the hospital discharge summary, the physician documented R97 had wounds to the sacrum, the right anterior and posterior thigh, right hip, left posterior thigh, the right lower leg and the right ankle/foot. Discharge wound treatment orders for the right anterior and posterior thigh ulcers, the right hip ulcer and the left posterior thigh ulcer were to be washed with soap and water, dried well, skin prep to the crusted anterior thigh wounds, and Melgisorb AG with dry cover dressing to draining wounds on the posterior and lateral aspects daily and as needed. On 7/9/2025 on the Clinical admission form in the Skin section, the form prefilled with previous wounds, such as the left medial ankle, the left heel, the left lateral foot and the left dorsal foot with blisters, the front left lateral knee surgical wound, the right medial thigh abrasion, the left upper arm abrasion and the right lateral top of the foot abrasion. Those wounds were present prior to R97's hospitalizations but the left leg wounds were not present after readmission due to the left above the knee amputation. No RN assessed R97's skin. On 7/9/2025 at 4:04 PM in the progress notes, nursing documented R97 was readmitted with wounds to the coccyx, the right buttock, the right leg, and the right foot. No assessment was completed. The treatment of zinc to the left arm continued from pre-hospitalization. No treatments were initiated from the hospital discharge orders. On 7/10/2025 at 8:38 AM in the progress notes, nursing documented R97 was sent to the hospital for evaluation of rectal bleeding. R97 was admitted to the hospital at that time. On 7/12/2025 at 8:20 PM in the progress notes, nursing documented R97 was readmitted to the facility. No skin assessment was completed or documented. No treatments were initiated to the wounds that were documented from the hospital on 7/9/2025. On 7/21/2025, treatment orders were started for the right anterior and posterior ulcers and the left posterior ulcer to wash with soap and water, skin prep to the crusted anterior thigh wounds, and multisorb AG with dry cover dressing daily. This was the order from the discharge summary on 7/9/2025, 13 days after R97 discharged from the hospital. The order did not denote where the ulcers were located and misspelled the treatment. The wounds were never assessed or documented. On 7/22/2025 at 12:16 PM in the progress notes, nursing documented during wound care, the nurse observed increased drainage that was green in color and R97 verbalized pain. The NP was contacted and on order was obtained for the antibiotic doxycycline 100 mg twice daily for 10 days and to get a wound culture. Surveyor noted the documentation did not specify which wound had the green drainage. On 7/23/2025, R97 was seen by the in-house Wound Physician (WP)-O. This was the first assessment of any wounds since 2/13/2025 when R97 was last seen by the in-house wound physician. This is not the same wound physician that had cared for R97 on 2/13/2025. WP-O documented R97 had a non-pressure wound to the right shin/foot that measured 11.19 cm x 8.78 cm x 0.2 cm with 1-25% slough and 51-75% eschar and a non-pressure wound to the right thigh that measured 11.68 cm x 15.08 cm x 0.2 cm with 1-25% granulation and 51-75% eschar. No documentation was found of green exudate by the wound physician. On 7/23/2025, R97 had a treatment order for the right lower leg/ankle to paint with betadine daily. On 7/24/2025, R97 had treatment orders for the right lower leg/ankle to paint with betadine, once dry, apply ABD pad and kerlix daily, and the right medial/anterior thigh to paint with betadine daily. On 7/26/2025, R97 had a treatment to pain the left gluteal wound with betadine and leave open to air daily. Surveyor noted R97 did not have any documentation of a wound to the left gluteus. On 7/30/2025 at 1:26 PM in the progress notes, wound LPN-I documented R97 was seen by WP-O for the right foot, right ankle, and the right thigh wound. WP-O noted gangrene and dusky color to the right great toe and noted maggots in the ankle wound. R97 was sent to the hospital for further evaluation and treatment. On 7/30/2025 on the wound physician assessment note, WP-O documented ulcers were noted on the anterior aspect of the right thigh with 100% slough, moderate purulent exudate that was malodorous, the right distal leg/foot was a large wound extending into the ankles from the lower half of the leg from the front and back, and the distal foot and all toes were noted to be cyanotic (blue) with maggots noted in the wound bed. WP-O was unable to clean the maggots at the time of the evaluation and increased malodor was also noted. R97 was presenting with grossly necrotic wounds on the right lower extremity. The decision was made to send R97 to the emergency room for further evaluation and treatment, which might include an amputation of the right lower extremity. Imaging documentation was deferred as the wounds were extensive, much larger than they were at the last visit, grossly necrotic and due to the fact that we were not able to clean the wounds of maggots at the bedside. On 7/30/2025, R97 was admitted to the hospital. The hospital physician documented R97 had chronic appearing wounds on the right lower extremity extending up to the thigh. The wounds were scabbed and oozing with no surrounding redness. The right foot was foul smelling with green drainage, maggots, and deep wounds with muscle exposure. On 8/7/2025, R97 had a right above the knee amputation. R97 did not return to the facility. In an interview on 9/10/2025 at 3:34 PM, Surveyor asked DON-B and wound LPN-I why there were no weekly assessments of wounds. DON-B stated in May 2025; LPN-I was given the guidance by the management team that LPN-I did not have to do weekly wound assessments. DON-B stated if Surveyor reviews R97's medical record, the weekly assessments were done from January to May 2025. LPN-I stated no one was signing the assessments so they are still open. Surveyor asked LPN-I if an RN looked at any of the wounds when LPN-I was either doing treatments or measuring the wounds. LPN-I stated no. DON-B stated the in-house wound physician, and the wound log LPN-I made have the assessments. Surveyor shared the concern R97 went to the wound clinic and none of those assessments are in R97's record and the wound log is not part of R97's record. DON-B agreed. In an interview on 9/15/2025 at 8:05 AM, Surveyor asked wound LPN-I what the process was for the facility to assess resident wounds. LPN-I stated the wound team, consisting of the wound physician, the NP, LPN-I, an RN from the wound agency, and the unit managers, look at all the wounds weekly. LPN-I stated after DON-B left employment on 12/31/2024, LPN-I informed the new DON that the DON needed to sign LPN-I's wound assessments until LPN-I was certified. LPN-I stated the DON never followed through with signing anything; that is why all the assessments in R97's record are still open. LPN-I stated R97 was not seen by the wound team because R97 had a surgical wound so the wound clinic preferred R97 go there for care. Surveyor asked LPN-I how often R97 went to the wound clinic. LPN-I stated some months it was every other week and then it depended on how the wound was progressing. LPN-I stated WP-O saw R97 on 7/30/2025 for a second encounter, first seeing R97 the week before, and WP-O determined the right thigh wound was caused by R97's lupus. LPN-I stated LPN-I was on vacation from 7/18/2025-7/23/2025 so had not seen R97's wound for 9 days and did not know who was covering for LPN-I when LPN-I was gone. LPN-I stated the DON knew LPN-I was on vacation that week but did not know if anything was done with wounds. Surveyor asked LPN-I if LPN-I observed maggots in R97's wound on 7/30/2025. LPN-I stated LPN-I was with WP-O and they both observed maggots in the ankle wound. In an interview on 9/15/2025 at 1:41 PM, Surveyor asked LPN-Z if LPN-Z recalled R97. LPN-Z stated LPN-Z took care of R97 after the left leg was amputated. Surveyor asked LPN-Z what wounds LPN-Z could recall that R97 had at that time. LPN-Z stated R97 had a wound on the right thigh on the front but could not recall if there was a treatment to the area. LPN-Z recalled a treatment to the right foot, but stated the wound care nurse did the treatment during the week. Surveyor asked LPN-Z what the fac

Based on observation, interview, and record review, the facility did not ensure residents with pressure injuries or at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 5 of 5 residents (R98, R97, R10, R4, and R2) reviewed for pressure injuries. *R98 was admitted to the facility with a history of a stage 2 pressure injury to the right buttock. On 7/3/2025, nursing documented R98 was not able to get wound treatment or measurements completed but does not indicate what wounds required treatment or measurement. On 7/13/2025, nursing documented R98 has a pressure injury to the right lateral coccyx. On 7/16/2025, R98 was assessed by the wound physician and found to have unstageable pressure injuries to the right ischium and sacrum/right buttock. On 7/23/2025, R98 now also has a deep tissue injury to the right heel, and an unstageable pressure injury to the left heel. On 8/2/2025, R98 was sent to the emergency room for concerns of infection and R98's admission diagnoses included: Two necrotic decubitus ulcers on the left and right buttocks, draining yellow discharge and very foul odor, severe sepsis, Fournier's gangrene in male (a rare, life threatening infection that rapidly destroys soft tissues in the genital, perineal and perianal areas), stage 4 pressure injury to the left buttock, stage 4 to the right buttock, deep tissue injury to the right heel, and unstageable pressure injury to the left heel. On 8/2/2025, R98 underwent surgical debridement and findings included: Two necrotic decubitus ulcers on the left and right buttocks, draining yellow discharge and very foul odor and necrotic tissue to the bilateral buttocks with significant fat and muscle necrosis. R98's left buttock wound tracked down to the bone, and right buttock wound tracked down to subcutaneous fat. *R97 did not have comprehensive skin assessments upon readmission to the facility on [DATE], 4/9/2025, 4/22/2025, 7/9/2025, and 7/12/2025. R97 developed a Deep Tissue Injury to the left heel on 1/2/2025 that became Unstageable, an Unstageable pressure injury to the left lateral heel/foot on 2/17/2025, a blister to the left lateral foot on 3/4/2025 with no etiology of the wound or staging, and a Stage 2 pressure injury to the coccyx on 5/20/2025 that had previously been a Stage 4 pressure injury that healed in 2020. Ordered wound treatments were not implemented timely; the treatment to the left lateral foot ordered on 2/18/2025 was not implemented until 2/24/2025 and the treatment orders for the sacral wound ordered on 7/9/2025 were not implemented until 7/20/2025. Treatments were ordered for wounds that were not assessed or documented; R97 had an order for a treatment to the sacrum on 4/9/2025 with no documentation of a wound present and an order for a treatment to the left gluteal wound on 7/26/2025 with no documentation of a wound present. Wounds were not comprehensively assessed weekly by an RN in the facility after 2/13/2025 when R97 stopped being seen by the wound physician. During the survey, systemic failures were identified in the wound care and preventative interventions the facility was providing. The facility did not have established policies and procedures for wound care that were reviewed and approved by the medical director to ensure they were based upon current standards of practice. The facility did not have a system to ensure risk factors were appropriately assessed and addressed. The facility did not have an established system to monitor and assess wounds based upon standards of practice. Surveyors notified nursing home administrator (NHA)-A, director of nursing (DON)-B, wound licensed practical nurse (LPN)- I, and regional nurse consultant (RNC)-L on 9/16/2025, at 11:50 AM. The immediate jeopardy was not removed prior to survey exit on 9/30/2025. Additional resident examples not at the scope and severity of immediate jeopardy include:* R4 developed a facility acquired stage three pressure injury to the sacrum.* R10 developed a facility acquired stage three pressure injury to the sacrum and was observed not wearing heel boots per care plan interventions during the survey.* R2 has a history of having a deep tissue injury to the heel. During survey R2 was observed to have R2's heel directly on the bed and not being offloaded. R2 was observed not wearing heel boots during the survey per R2's care plan intervention for prevention of pressure injury development. R2's pressure injury care plan was not revised to reflect patient specific interventions. Findings include: The facility policy titled Wound Management with a reference date of 2019 documents: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.5. Treatment decisions will be based on:a. Etiology of the wound .b. Characteristics of the wound .c. Location of the wound.6. Guidelines for dressing selection may be utilized in obtaining physician orders .c. The facility will follow specific physician orders providing wound care.7. Treatments will be documented in the treatment administration record (TAR).8. The effectiveness of the treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include:a. Lack of progression towards healing.b. Changes in the characteristics on the wound. 1.) R98 was admitted to the facility on [DATE] and has diagnoses that include end stage renal disease dependent on renal dialysis, nicotine dependence, diabetes mellitus, degenerative disk disease of lumbosacral area with worsening back pain, muscle wasting with atrophy/weakness, endocrine, nutritional, and metabolic disease. R98's admission minimum data set (MDS) dated [DATE] indicated R98 has intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R98 as requiring total assistance with 1 staff member for toileting hygiene and moderate assist with 1 staff member for repositioning. R98 was frequently incontinent of urine and always incontinent of bowel and wore an adult brief for protection. R98 used a bed pan while in bed for R98's toileting needs. R98 was non ambulatory and required a Hoyer lift with two staff assist for transfers into a wheelchair, R98 was able to self-propel while in the wheelchair. The facility assessed R98 on 6/13/2025 to be a mild risk for pressure injury development with a Braden score of 18. Surveyor reviewed R98's hospital discharge paperwork dated 6/13/2025 that documented R98 was admitted into the hospital on 6/6/2025 with worsening back pain and inability to stand. Hospital staff documented on 6/8/2025, R98 had a stage 2 pressure injury to the right buttock; no comprehensive assessments were documented in the hospital discharge paperwork. R98's care plan was initiated on 6/13/2025 for: Pressure at risk due to Assistance required in bed mobility with the following interventions:- Conduct weekly skin inspection.- Assist and encourage turning and repositioning every 2-3 hours.Interventions initiated 6/17/2025:- Diabetic foot check every evening.- Prevalon boots while in bed, may remove with care and therapy. R98's Pressure injury Care Area Assessment (CAA) dated 6/17/2025 documents:-Resident at risk for skin breakdown due to limited mobility secondary to decreased strength, balance, endurance. Resident admitted to (facility) with all skin intact. Braden score of 18. Pressure relieving device placed in chair and bed for prevention. Encouraged to keep bilateral heels elevated off mattress while in bed. Foot and heel checks done nightly by care staff. Cue and assist to toilet every 2-3 hours and as needed upon request, Cue and assist to reposition every 2-3 hours as needed. Weekly body check done by nurse. Will proceed to care plan to prevent alteration of skin integrity. Surveyor noted there was not a skin assessment completed on R98's admission to the facility on 6/13/2025. On 6/14/2025, at 700 AM, in the progress notes wound licensed practical nurse (LPN)-I documented (R98) is out to dialysis, skin check did not get done by wound nurse this morning shift. Will attempt later when (R98) gets back. On 7/3/2025, at 6:05 AM, in the progress notes wound LPN-I documented (R98) out on pass to dialysis and did not complete wound care or obtain measurements. On 7/10/2025, at 11:07 AM, in the progress notes wound LPN-I documented (R98) is out to dialysis and did not get seen by [wound care team] today. (LPN)-I will obtain measurements once (R98) returns. Surveyor noted there is no documentation on what wounds R98 needs to have assessed or treated. Surveyor noted wound measurements and treatments identified in the progress notes as needing to be completed on 7/3/2025 and 7/10/2025 were not obtained/completed . Surveyor reviewed R98's medication administration and treatment administration records (MAR/TARs) for July 2025 and noted there were no wound treatment orders. On 7/13/2025, at 11:59 AM, in the progress notes LPN-P documented a skin check assessment that documented the following skin issues: .-right coccyx, pressure ulcer/injury. Measurements not documented as part of this assessment: Wound care team to evaluate during wound rounds.Surveyor noted a comprehensive assessment was not completed for R98's right coccyx wound.Surveyor noted a skin assessment completed on 7/1/2025 documented R98 had no skin concerns. There was not a skin assessment competed after 7/1/2025 until 7/13/2025 when LPN-P documented the skin concerns for R98 on 7/13/2025. On 7/15/2025, R98's pressure injury care plan was revised with the following: .- Risk versus benefits discussed related to staying in wheelchair for extended periods of time. (R98) chooses to stay in wheelchair for long periods of time without repositioning and chooses to tell certified nursing assistants I do not want to be changed at this time even when I know it is contraindicating my skin care plan.- Air mattress for pressure relief.Surveyor noted there were no refusals or education documented in the progress notes indicating R98 refused cares or repositioning or the importance of receiving cares and repositioning prior to 7/13/2025 which was after R98's documented skin concern to the right coccyx. On 7/16/2025, R98 had an initial wound assessment with wound physician-O with the following wound assessments:1. Right ischium pressure ulcer, unstageable 2.02 cm x 3.77 cm x 0.2 cm (length x width x depth), small serous drainage (thin, watery fluid indicating early stages of wound healing), 76%-100% slough (non-viable tissue that forms in wounds).2. Sacrum/right buttock pressure ulcer, unstageable5.83 cm x 5.25 cm x 0.1 cm, small serous drainage, 1-25% granulation tissue (new, pink/red tissue that forms as wounds heal), 51-75% slough.On 7/16/2025, the following treatments were initiated for R98's right ischium and sacrum/right buttock unstageable pressure ulcers:- Protect peri wound (around the wound) with skin prep.- Cleanse pressure area with 1/2 strength Dakin's solution.- Apply Santyl to wound bed.- Cover with bordered gauze.- Change daily and as needed (PRN). Surveyor reviewed R98's July MAR/TAR and noted staff did not initial treatments were being completed as ordered for 7 out of 15 days in July until staff initiated the treatment on 7/16/2025. On 7/23/2025, R98 had a wound assessment with wound physician-O with the following wound assessments:1. Right ischium pressure ulcer, unstageable,1.44 cm x 3.2 cm x 0.2 cm, small serous drainage, 76%-100% slough.2. Sacrum/right buttock pressure ulcer, unstageable.2.19 cm x 1.98 cm x 0.1 cm, small serous drainage, 1-25% granulation tissue, 51%-75% slough.3. Right heel suspected deep tissue injury (DTI)2.19 cm x 1.98 cm x 0.1 cm, purple in color, attached edges.Treatment ordered: cleanse with saline solution, apply skin prep twice a day (BID) and PRN.4. Left heel pressure ulcer, unstageable.0.61 cm x 0.52 cm x 0.1 cm, 100% eschar tissue (dry, dead tissue)Treatment ordered: cleanse with betadine daily and PRN. Surveyor reviewed R98's July and August MAR/TARs and noted the right heel and left heel treatment orders did not get initiated until 8/1/2025 with the following order:-Paint left and right heel with betadine and leave open to air daily and PRN Surveyor noted the right heel treatment initiated on 8/1/2025 was not the same treatment to be initiated when ordered on 7/23/2025 by wound physician-O. On 7/30/2025, at 13:23 (1:23PM), in the progress notes wound LPN-I documented (R98) was seen by wound team for multiple wounds: . sacrum wound, left and right heel eschar. (R98) is to be on bed rest except dialysis days. On 7/30/2025, R98 had a wound assessment with wound physician-O with the following wound assessments:1. Right ischium pressure ulcer, unstageable.2.24 cm x 2.11 cm x 0.1 cm, small serous drainage, 76%-100% slough. 2. Sacrum/right buttock pressure ulcer, Stage 3.2.65 cm x 2.35 cm x 0.1 cm, small serous drainage, 1-25% granulation tissue, 51-75% slough. 3. Right heel DTI.2.63 cm x 2.35cm x 0.1 cm, purple, attached edges Surveyor noted there was no assessment documented on R98's left heel on 7/30/2025. On 7/30/2025, R98's care plan was initiated for: Pressure ulcer actual: sacrum, left medial thigh (documented as trauma), unstageable right buttock, unstageable right and left heel. Assistance required in bed mobility, bed fast, bowel incontinence with the following interventions:- Evaluate need for pain reliever prior to cleaning and dressing changes.- Notify practitioner if symptoms worsen or do not resolve.- Provide pressure reducing wheelchair cushion.- Provide pressure reduction/relieving mattress.- Treatments as ordered.- Weekly wound assessment. On 8/1/2025, at 14:50 (2:50PM,) LPN-R documented therapy department informed LPN-R (R98's) level of consciousness (LOC) was not the same as usual. (R98) was not participating in therapy, was lethargic, trembling/shaking . STAT (immediate) labs and wound culture were ordered. Surveyor noted that the wound culture was ordered to be obtained from R98's left medial thigh wound that was documented as a trauma/non-pressure related injury. Cross-reference F684. Surveyor noted there was no further documentation regarding R98's status regarding the documented loss of consciousness for the remainder of R98's progress notes. On 8/2/2025, at 10:03AM, in the progress notes, LPN-R documented nurse practitioner updated on critical lab results. LPN-R informed by the dialysis center that (R98) is being sent to the hospital for further evaluation due to possible infection at the port site. On 8/2/2025, at 14:42 (2:42PM), in the progress notes, LPN-R documented . (R98) admitted to hospital with necrotic fasciitis (a subset of aggressive skin and soft tissue infections that cause muscle fascia and subcutaneous tissue necrosis) to wound and finger. Surveyor reviewed R98's hospital admission paperwork dated 8/2/2025 and noted the following documented:1. R98's admission diagnoses in the hospital on 8/2/2025 include: .- Fournier's gangrene in male (Primary, life threatening infection that rapidly spreads through the tissues of the genital and perineal areas).- Severe sepsis (infection that leads to widespread inflammation and organ damage).- Stage 4 pressure ulcer, left buttock.- Deep tissue injury of right heel.- Unstageable pressure injury of left heel.- Stage 4 pressure injury, right buttock. 2. R98's vital signs in the emergency room on 8/2/2025 at 11:32AM were documented:- Temperature, 98.5 degrees Fahrenheit- Heart rate, 117 (elevated)- Respirations, 16- Blood pressure, 99/62 (low)- Pulse oximetry, 99% R98's emergency room assessment and plan summary documented on 8/2/2025 included the following findings:- Two necrotic ulcers on the left and right buttocks, draining yellow discharge and has very foul odor.- Bilateral buttock pressure wounds with abscess and concern for possible progression to Fournier gangrene. Surgery consulted and will have incision and drain performed today (8/2/2025).- (R98) started on broad spectrum IV antibiotics, blood cultures sent for evaluation.- (R98) found to have infected sacral pressure wounds, abnormal labs.- Right buttock pressure ulcer was positive for Bacteroides (diverse group of bacteria that cause serious infection if enter other body tissues).- (R98) underwent bilateral buttock debridement that resulted in:- Right buttock: 6 cm x 3 cm, debrided down to subcutaneous fat.- Left buttock: 13 cm x 14 cm, debrided down to and including muscle.Findings: Necrotic tissue to bilateral buttocks, significant fat and muscle necrosis. Left buttock wound tracked down to the bone, right buttock wound tracked down to subcutaneous fat. On 9/10/2025, at 3:33PM, Surveyor interviewed DON-B and wound LPN-I who stated weekly skin sheets/assessments were being completed, however, in May 2025 wound LPN-I was given guidance from previous facility governing body to no longer document weekly skin assessments because the wound physician documentation and notes were enough. DON-B stated DON-B left the facility 12/31/2024 and the facility was doing weekly skin assessment sheets. DON-B came back to the facility in August 2025 and noted the weekly skin assessments were not being completed and restarted them to be completed by staff. DON-B and wound LPN-I were not sure why the weekly skin assessment sheets would have been stopped. Wound LPN-I and DON-B confirmed there are no weekly skin assessments for R98's pressure wounds other than what is documented in the progress notes and wound physician wound notes. Surveyor shared concern Surveyor is not able to tell exactly when R98's pressure injury concerns started. DON-B and wound LPN-I confirmed they both could not determine either based on what is documented. On 9/15/2025, at 8:06AM, Surveyor interviewed wound LPN-I who stated any nursing staff can document an assessment if there is a concern with a resident. Wound LPN-I stated staff will notify wound LPN-I if a resident has an area of concern and then wound LPN-I will assess the resident. Wound LPN-I stated the previous DON was notified wound LPN-I would need to have previous DON-DDD look at and sign off on the skin assessments for oversight. Wound LPN-I stated the previous DON never signed off on wound LPN-I's assessments or followed up on any concerns wound LPN-I brought forth. Wound LPN-I stated wound LPN-I was on vacation from 7/18/2025 – 7/23/2025 and was not sure what staff was following resident wounds during that time. Wound LPN-I stated nursing would do dressing changes per order, but not sure if anything else was done or what staff were managing/following resident wounds. On 9/15/2025, at 9:26AM, Surveyor interviewed LPN-P who stated nursing staff are to fill out a skin assessment if an area of concern is noted on a resident and that will signal to wound LPN that there is a concern with a resident. LPN-P stated the assessment should document the location of the wound, and the wound LPN will gather the wound description and measurements. Surveyor asked LPN-P if the wound LPN is not available what staff is to get the wound assessment and measurements. LPN-P stated that if a skin assessment is filled out it will signal whoever needs to look at it and they will get the assessment and measurements of the wound. LPN-P stated the physician should be called for notification of the concern and get orders if appropriate. LPN-P stated the resident should be put on the 24 hour report to be monitored. LPN-P was not sure if R98 was put on the 24 hour report on 7/13/2025 when R98's pressure injury was first noted. LPN-P could not recall if R98 was getting treatments prior or had any concerns with pressure injuries. On 9/15/2025, at 9:47AM, Surveyor interviewed LPN-R who stated LPN-R could not recall how R98 was acting on 8/1/2025 and 8/2/2025. LPN-R stated R98 had wounds on the buttocks but could not recall if R98 needed treatments or when those treatments were completed and by whom. LPN-R could not recall what lab work or what wound culture was needed on 8/1/2025 or if any further monitoring was done for R98 on 8/1 and 8/2 when LPN-R documented R98 had a change in level of consciousness. On 9/15/2025 at 2:19PM, Surveyor attempted to call wound physician-O two times. The call ended both times without an option to leave a voicemail. On 9/15/2025, at 2:30PM, Surveyor interviewed DON-B who stated all nursing staff can document wound assessments with the oversight or follow up of a registered nurse. DON-B stated a comprehensive assessment must be completed when an area of concern is noted and should document the location or the wound, measurement, description, who was contacted, and treatment initiated if applicable. DON-B stated the resident is then placed on the 24 hour board to make other staff aware that the resident is experiencing a concern and to monitor. DON-B stated DON-B was not DON at the time of R98's pressure wound concerns, but comprehensive assessments should have been completed when R98's pressure wound first appeared, the care plan should have been revised, and treatments initiated immediately. DON-B stated when R98 was experiencing a change in level of consciousness, R98 should have been monitored and charted on, DON-B stated R98 should probably have been sent to the emergency room on 8/1/2025 if not 8/2/2025 due to change in level of consciousness and not sent to dialysis. On 9/15/2025 at 3:15PM, Surveyor shared serious concerns with NHA-A, DON-B, wound LPN-I, and regional nurse consultant (RNC)-L of the facility's failure to not evaluate R98's clinical condition and risk factors, not define and implement interventions consistent with resident needs, goals, and standards of practice in a timely manner, or monitor and evaluate the impact of interventions for R98's pressure injuries to the right ischium, sacrum/right buttocks, and the right/left heels resulting in R98 needing surgical intervention and IV antibiotics due to infection. In an interview on 9/16/2025 at 8:18 AM, DON-B and LPN-I met with Surveyor to review R98's wound management. DON-B stated after DON-B left on 12/31/2024 and before returning on 8/7/2025, there were multiple changes in management and things were not done as they should have been done. DON-B stated systems were in place prior to 1/1/2025 and are being put back into place now that DON-B is back in the facility as the DON. 2.) R97 was admitted to the facility on [DATE] with diagnoses of diabetes, lupus, agranulocytosis (low white blood cells to help fight infection), heart failure, acute kidney failure, anxiety, and depression. R97's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R97 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and had impairment to both arms and legs. No skin concerns were documented on the MDS assessment. R97 had a Guardian. R97's Activities of Daily Living Care Plan was initiated on 11/29/2019 and had interventions in place on 12/24/2024 of transferring with a full mechanical lift with total assistance of two people, bed mobility, dressing, bathing, hygiene, grooming, showers, etc. with extensive assistance of one person, and toileting check and change with total assistance of two people. R97's Skin Integrity Care Plan was initiated on 12/9/2019 with the interventions to float heels, have a cushion in the wheelchair, a pressure reducing mattress, and turn and reposition every two hours and as needed. R97 had the following treatments in place:-Skin prep to the left heel every shift for protection initiated 1/16/2020.-Zinc oxide paste to the buttocks every shift related to pressure injury of the sacral region Stage 4 initiated 6/26/2020.-Skin prep to the right posterior thigh daily initiated 9/30/2024. R97 was in the hospital from [DATE] to 12/31/2024. The hospital documented R97 sustained a fracture to the left tibia and fibula from a fall which was surgically repaired. On 12/31/2024 at 2:07 PM in the progress notes, wound Licensed Practical Nurse (LPN)-I documented a late entry on 2/18/2025 documenting R97's skin check was completed and R97 had an immobilizer to the left leg. R97 had a skin issue to the right rear thigh in the form of a blister that was not evaluated, and an Aquacel dressing that was intact and was not to be removed until the follow up orthopedic appointment. LPN-I documented R97 refused to have the right rear thigh blister examined. Surveyor noted a Registered Nurse (RN) did not assess R97's skin upon readmission to the facility. R97's treatment orders of skin prep to the left heel and right posterior thigh and zinc oxide paste to the buttocks continued from pre-hospitalization. On 1/2/2025, R97 was seen by the Wound Physician. The Wound Physician documented R97 had a Deep Tissue Injury (DTI) to the left heel that measured 4 cm x 4 cm with purple/maroon discoloration and was present on admission per nursing staff. On 1/2/2025 at 10:06 AM in the progress notes, wound LPN-I documented R97 was seen by the wound physician to evaluate and treat the right heel DTI. A new treatment order for skin prep to the left heel was obtained and an order for Prevalon boots to bilateral feet for off-loading. Wound LPN-I made a late entry on 3/19/2025 documenting the facility acquired left heel DTI was Unstageable with 100% eschar and the skin was intact. Surveyor noted a DTI does not have the characteristic of eschar and the wound physician did not document the eschar. The treatment of skin prep to the DTI continued as previously ordered on 1/16/2020. R97 was seen by the wound physician on 1/9/2025, 1/16/2025, and 1/23/2025 with documentation of the left heel DTI continuing at the same measurements and appearance as the initial evaluation. R97 was to be encouraged to off-load pressure to the heels. On 1/30/2025, R97 went to an orthopedic clinic appointment so was not assessed by the wound physician. No assessment was completed by an RN. On 1/31/2025 at 7:25 AM in the progress notes, wound LPN-I documented immobilizer to the left leg was in place and the skin was checked for breakdown. Prevalon boots were in place for off-loading. R97's At Risk for Pressure Ulcer Care Plan was initiated on 2/4/2025 with interventions of heel boots (already in the Skin Integrity Care Plan), skin assessment to be completed per policy, and treatments as ordered. R97 was seen by the wound physician on 2/6/2025 and 2/13/2025 with documentation of the left heel DTI with measurements of 4 cm x 3.8 cm and the same appearance as the previous assessments.Wound LPN-I started a weekly wound log on 2/16/2025 that has measurements of the pressure injury. This wound log was not part of R97's medical record and was not verified or assessed by an RN. No descriptors were written on the log. The log was weekly until 4/12/2025. On 2/17/2025 at 12:28 PM in the progress notes, wound LPN-I made a late entry on 3/4/2025 documenting R97 had a facility acquired Stage 2 pressure injury to the left lateral foot measuring 4.5 cm x 2.5 cm x 0.1 cm with an intact fluid filled blister. The wound was not assessed by an RN and no treatment was obtained for the new area of concern. On 2/18/2025, R97 went to the outpatient wound clinic. At 12:13 PM in the progress notes, wound LPN-I documented the wound clinic had orders for the left lateral heel Unstageable pressure injury of applying iodoflex and gauze dressing three times weekly and the left heel eschar paint with betadine daily and leave open to air. The treatments entered on the Treatment Administration Record (TAR) were to cleanse the left heel with wound cleanser, iodoflex, which was equivalent to iodosorb paste, and a border gauze three times a week and to paint the left heel with betadine daily. Both treatments entered on the TAR were for the left heel and no treatment was entered for the left lateral heel/foot. On 2/20/2025, the in-house wound physician discharged R97 from services due to R97 being followed for wounds at the wound clinic.Surveyor noted no documentation was available in R97's medical record from the wound clinic with assessments of the wounds and the wounds were not assessed in the facility by an RN. LPN-I opened weekly wound assessment documents, but those assessments were never verified or signed by an RN. Surveyor noted the left heel and left lateral foot wounds became eschar and slough with eschar making them Unstageable per wound LPN-I's documentation in the progress notes. On 2/24/2025, R97 had an order to cleanse the left heel and left lateral foot with wound cleanser, iodoflex to the wound bed, and border gauze to be changed three times a week, as was ordered after the wound clinic appointment on 2/18/2025. On 2/26/2025 at 10:57 PM in the progress notes, nursing documented a conversation was had with the NP related to R97 needing to be assessed by psych services. R97 was noted to be crying on occasion about the left foot and the fear that the wounds will not heal and need to be amputated. Nursing documented R97's crying was related to pain. Psych services were obtained. On 3/4/2025 at 8:00 AM in the progress notes, wound LPN-I documented R97 went to the wound clinic for wounds to the left lateral knee, left heel, left lateral foot, left dorsal foot, and left medial ankle. At 10:50 AM in the progress notes, LPN-I documented the blister to the left lateral foot was newly discovered during wound care and measured 4.5 cm x 2.5 cm x 0.1 cm. LPN-I notified the Nurse Practitioner (NP), the Director of Nursing (DON), and R97's Guardian. The wound documentation was not verified or signed by an RN. At 2:27 PM in the progress notes, nursing documented the wound clinic ordered R97 to wear Prevalon boots at all times, place a pillow under the calf to offload the heel, and turn and reposition frequently. Surveyor noted these interventions were in R97's Care Plan but the wound clinic felt the need to restate those interventions, and the left lateral foot had a wound prior to 3/4/2025 making it unclear if this was an additional wound to the left foot. On 3/6/2025 at 9:16 PM in the progress notes, nursing documented R97 had a new order for amitriptyline 50 mg every evening for neuropathy pain. R97 complained of bilateral feet feeling like they are on fire. On 3/13/2025 at 10:12 PM in the progress notes, nursing documented R97 was yelling out earlier in the shift related to pain to the left foot. Pain medication was administered at 1:15 PM and not effective. The NP was contacted and ordered to increase the biofreeze gel from three times daily to every six hours. The psych NP was in house and at bedside to assess R97 with no new orders for psychotropic medications. The physician was notified and received a new order to add an additional dose of amitriptyline 25 mg for neuropathy pain in the morning and to give ibuprofen 800 mg with acetaminophen 1000 mg twice daily for 14 days. On 3/15/2025 at 10:17 PM in the progress notes, nursing documented R97 continued calling out when R97 had pain from left heel open areas. R97

Based on observation, interview, and record review, the facility did not ensure 3 (R58, R73, & R40) of 11 residents received adequate supervision and assistance devices to prevent accidents. 1.) R58 suffered a fall on 2/14/25 resulting in left sacrum fracture and right inferior pubic ramus fracture when interventions were not being implemented per R58's care plan. 2.) R73 had three unwitnessed falls, 6/25/2025, 7/1/2025, and 7/3/2025. The falls were not thoroughly investigated with a root cause analysis to determine appropriate interventions to prevent future falls. 3.) R40 did not receive supervision while smoking per R40's smoking care plan. Findings include: The facility's policy titled Falls Management Process dated 2011 with no revision date documents the following: . 1. In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present. 4. if the resident is conscious, provide reassurance and comfort . resident is not to be moved until assessed for injury by a nurse unless life-threatening situation exists. 5. if able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later). 6. upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. 7. obtain vital signs: blood pressure, pulse, pulse oximetry, and respirations. 8. obtain neurological checks (neuro-checks) per policy for any unwitnessed fall or any fall with evidence of injury to the head. 9. if no obvious injury or only minor injury, move resident to a comfortable position. If significant injury, severe pain, or abnormal assessments observed, call 9-1-1. 11. the nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. the nursing supervisor will determine the most appropriate intervention, implement, and update care plan. 13. resident fall will be noted on 24 hour report for three days for post fall monitoring, assessing for injury, full vital signs every 8 hours, and pain assessment. 14. the Director of Nursing will be notified immediately for falls resulting in injury and/or transfer. The facility's policy titled Falls Review Process dated 2011 with no revision date documents: Post Fall Director of Nursing/Designee will assess the resident and review fall documentation, including witness statements, resident interview, environment review of area where fall occurred, and equipment inspection. The event will be discussed and event documentation reviewed for completion in Interdisciplinary Team (IDT) meeting. Compare data from previous assessments. Discuss identified trends. Therapy referral and Medication Review initiated. Other referrals if applicable . Review Fall Risk Assessment for any potential new risk factors. Review plan of care/interventions to ensure all prior interventions are in place and still appropriate. Adjust/add interventions on the Plan of Care. Update and communicate interventions. Provide appropriate training for caregivers if appropriate. Educate resident/family if appropriate Discuss findings and interventions with the resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IPOC). The facility's policy, titled Resident Smoking, dated 7/15/25, documents in part, . Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: . 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, (sic) to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 1.) R58 originally admitted to the facility on [DATE] with diagnoses including major depressive disorder, other epilepsy (a neurological condition characterized by recurrent seizures), extrapyramidal and movement disorder (involuntary body movements), schizophrenia, and unspecified dementia, moderate, with other behavioral disturbance. R58 had a legal guardian. R58's Medicare 5 Day Minimum Data Set (MDS) dated [DATE] documented R58 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, R58 was always continent of bowel and bladder, R58 was independent with toileting hygiene, bed mobility, and sit to stand transfers, R58 required supervision for bed to chair transfers and toilet transfers, and R58 used a manual wheelchair and was independent with wheelchair mobility for 150 feet. The MDS documented R58 did not exhibit any behaviors of inattention, disorganized thinking, or altered level of consciousness. R58's care plan for potential for fall or seizure related injuries related to use of medication, cognitive deficits, impaired mobility, seizures, impaired vision, history of multiple falls, initiated 5/17/2013, documents the following interventions: . -call light or personal items available and in easy reach (date initiated: 8/17/2018, revision on: 9/26/2023) . -encourage resident to wear gripper socks (date initiated: 2/11/2025) . -encourage resident to request assistance to reach things out of reach. Keep shoes close. (date initiated: 10/30/2013, revision 12/2/2016) . -keep environment clean, well lit, and free of clutter, glare, and shadows (date initiated 5/17/2013, revision on 12/2/2016) . R58's care plan for self-care deficit related to cognitive deficits, impaired mobility, impaired vision, initiated 10/10/2013, documents the following interventions: . -transfer assistance of supervision (date initiated: 10/10/2013, revision on 2/12/2025) . -walking assistance of only with therapy (date initiated: 10/10/2013, revision on 2/12/2025) . -wheelchair locomotion: independent in wheelchair with anti roll back brakes (date initiated: 2/12/2025) . On 2/8/25, the facility completed a Fall Risk Evaluation for R58 with a score of 22.0, indicating R58 was a high risk for falls. Nursing progress note dated 2/14/25, at 4:19 AM, . resident found laying on left side and wheelchair flipped upside down. Resident stated . was going to the bathroom. Resident transported to the hospital per on-call nurse practitioner recommendation. The Post Fall Evaluation dated 2/14/25 documents the fall was not witnessed. Resident was attempting to self-toilet at the time of the fall. Wheelchair was not locked. Poor lighting in area: yes. Footwear at time of fall: bare feet. Bedside call light on when resident was found: no. Contributing factors note: poor lighting, unlocked wheelchair, and bare feet. Vitals (assessed at 4:30 AM): Blood pressure 135/97, pulse 132, pulse type: irregular – new onset. Pain score: 6. Surveyor did not note any documentation on the last time the resident was checked on or offered toileting assistance in the fall investigation provided. Surveyor noted facility staff did not provide supervision for R58 during bed to chair transfer or toilet transfer at the time of the fall as per the care plan and assessment of R58. Surveyor reviewed hospital history and physical (H&P) document in R58's electronic health record (EHR) from hospital stay 2/14/25-2/18/25. The hospital course documents R58 presented to the emergency department (ED) from nursing home on 2/14/25 after [R58] tripped over foot and fell and had complaints of pain to lower back, head, and neck. Imaging studies in ED showed nondisplaced fracture of the left sacral ala (fracture in the bone at the base of the spine) and nondisplaced fracture of the lateral cortex of the right inferior pubic ramus (fracture in the bone in the lower part of the pelvis). Orthopedic surgery was consulted and recommended pain control and therapy, no surgical intervention was indicated, weight bearing as tolerated (WBAT). On 9/9/25, at 10:56 AM, Surveyor observed R58 in R58's wheelchair with no anti roll back brakes located on the wheelchair per R58's care plan initiated 2/12/25. On 9/10/25, at 1:03 PM, Surveyor observed R58 lying in bed with R58's wheelchair next to the bed with no anti roll back brakes located on the wheelchair. On 9/15/25, at 10:30 AM, Surveyor observed R58 in R58's wheelchair with no anti roll back brakes located on the wheelchair. On 9/16/25, at 1:39 PM, Surveyor observed R58 lying in bed with R58's wheelchair next to the bed with no anti roll back brakes located on the wheelchair. On 9/16/25, at 1:36 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-S who stated R58 requires setup assistance or reminders for dressing and toileting cares. CNA-S stated R58 has been using the same wheelchair for as long as CNA-S has been there. On 9/16/25, at 1:45 PM, Surveyor interviewed Med Tech (MT)-AA who stated staff encourage R58 to do as much as R58 can with cares, but staff checks to make sure R58 is cleaned up and has appropriate clothing on. MT-AA did not recall R58's fall on 2/14/25. On 9/16/25, at 2:16 PM, Surveyor spoke with Licensed Practical Nurse (LPN)-BB via phone call, LPN-BB was the nurse on duty at the time of R58's fall on 2/14/25. LPN-BB stated R58 fell and broke R58's pelvis. LPN-BB stated R58 had a recent fall prior to the fall on 2/14/25 and was given a wheelchair, and prior to using a wheelchair, R58 was completely independent and walked around the facility all day. LPN-BB stated R58 was supposed to ask for assistance to get into the wheelchair if needing to use the bathroom. LPN-BB stated at the time of the fall, R58 got up independently and did not use the call light. LPN-BB stated R58 appeared to be at R58's baseline in the days leading up to the fall on 2/14/25. LPN-BB stated the wheelchair that R58 was using at the time of the fall did not have any anti roll back brakes or auto-locking system in place. LPN-BB stated R58 was not wearing any gripper socks or footwear at the time of the fall. On 9/16/25, at 3:29 PM, Surveyor informed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A of the concern that R58 sustained a fall on 2/14/25 resulting in multiple fractures. No further information was given as to why supervision was not provided during transfer into R58's wheelchair, why R58 did not have anti roll back brakes on the wheelchair, why R58 was not wearing gripper socks, or why the light was not on in R58's room per R58's established care plan at the time of the fall. 2.) R73 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, depression, anxiety, chronic pain syndrome, and alcohol abuse. R73's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R73 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and the Falls Care Area Assessment (CAA) from R73's Annual MDS dated [DATE] documented R73 was at risk for falls due to impaired mobility, cognitive deficits, and the use of psychotropic medications; R73 was assisted with transfers and bed mobility. R73 did not have an activated Power of Attorney. R73's Physical Functioning Deficit Care Plan initiated 5/18/22 documents interventions of bed mobility with limited assistance of one and limited assistance to use bathroom from wheelchair to toilet with grab bars. Per the Care Plan, R73 transferred with the assist of one person to stand and pivot from admission until 2/19/25. The Care Plan was revised on 2/19/25 to use a full mechanical lift and revised back on 3/25/25 to a stand and pivot transfer. R73's At Risk for Falls Care Plan initiated on 5/5/22 had the following interventions in place on 6/25/25:-Bed in low position while in bed; level with wheelchair seat for transfers.-Call light and personal items available and in easy reach.-Clear and monitor environmental obstacles.-Do visual checks during regular rounding and ask if (R73) needs anything, if they would like to transfer to and from wheelchair/bed, offer to toilet, and before leaving show how to use call light and remind to use if anything is needed.-Dump seat in wheelchair.-Dycem to wheelchair.-Elevate head of bed before getting out of bed.-Encourage participation in activities to improve strength or balance.-Encourage to allow staff to lay (R73) in bed for naps.-Encourage rest periods if (R73) is feeling fatigued.-Observe for side effects of medications.-Offer a reacher and encourage to use.-Offer to lay (R73) down after meals.-Offer to lay (R73) down in bed before dinner.-Provide education and reinforce use of call light.-Stop sign – call don't fall – placed in room.-Therapy referral as ordered and as needed.-Wheelchair of appropriate size; uses leg rests for transport. On 6/25/25 at 9:54 PM in the progress notes, a Registered Nurse (RN) documented the RN was called to R73's room by staff. Upon entering the room, the RN saw R73 semi-sitting on the floor with the wheelchair on R73's back. R73 stated R73 slid onto the floor. The RN assessed R73 and R73 was assisted back to bed with a full mechanical lift. R73 was not in any distress but complained of pain to the back and hip area. The Nurse Practitioner was notified, and an order was received for an x-ray of the back and bilateral hips. The RN completed a Post Fall Evaluation form documenting R73's wheelchair was not locked at the time of the fall, R73 was not using a cane or walker as instructed and R73 was not wearing oxygen as prescribed at the time of the fall. The Interdisciplinary Team (IDT) met on 7/3/25 to review R73's fall on 6/25/25 and determined the cause of the fall to be R73 was fatigued causing R73's bottom to slide forward out of the wheelchair. The IDT documented all fall interventions were in place at the time of the fall, R73 is care planned for impulsivity and putting self on the floor. The IDT recommended continuing the current plan of care. Surveyor noted the RN determined R73's wheelchair was not locked, R73 was not using adaptive equipment when transferring, and was not using oxygen as prescribed. This was not incorporated in the IDT root cause analysis. No revisions were made to R73's Care Plan. On 7/1/25 at 1:53 PM in the progress notes, Licensed Practical Nurse (LPN)-P documented R73 had an unwitnessed fall. R73 told LPN-P R73 tried to walk to the bed. R73 stated R73 hit their head. R73 complained of right leg/hip pain and neck pain with movement. R73 did not lose consciousness. R73 was sent to the hospital for evaluation and treatment. LPN-P completed a Post Fall Evaluation form documenting the wheelchair was unlocked at the time of the fall, R73 was not using cane/walker as instructed, and R73 was not wearing oxygen as prescribed at the time of the fall. LPN-P documented R73 did not ask for assistance prior to the fall. R73 returned from the hospital with no injuries noted and no new orders. No IDT notes were found for review of R73's unwitnessed fall on 7/1/25. No root cause analysis was completed or documented, and no changes were made to R73's At Risk for Falls Care Plan. Surveyor noted R73's falls on 6/25/25 and 7/1/25 had the same post fall evaluation concerns. The IDT did not meet until 7/3/25 to review R73's fall on 6/25/25 so no interventions were revised to prevent future falls. On 7/3/25 at 3:22 PM in the progress notes, an LPN documented R73 was found on the floor lying on the side after hearing R73 calling out for help. R73 stated they were trying to walk. R73 denied hitting the head. Water was on the floor and R73 stated R73 spilled the water when R73 fell. The LPN contacted the RN supervisor to assess R73 and no abnormal findings were discovered. The LPN completed a Post Fall Evaluation form documenting the wheelchair was not involved in the fall, R73 was not using a cane/walker as instructed, and R73 was not wearing oxygen as prescribed at the time of the fall. The IDT met on 7/3/25 to review R73's fall on 7/3/25 and determined R73 had been returning from therapy at the time of the fall and the wheelchair was behind R73. The IDT recommended R73 to be offered to lay down after therapy. Surveyor noted the LPN determined R73 was not using adaptive equipment when transferring and was not using oxygen as prescribed. This was not incorporated in the IDT root cause analysis. R73's At Risk for Falls Care Plan was revised on 7/3/25 with the intervention to offer R73 to be laid down after therapy. On 9/9/25 at 10:05 AM, Surveyor observed R73 lying in bed. R73's bed was in the low position. Surveyor asked R73 if R73 had fallen recently at the facility. R73 stated R73 fell once out of the wheelchair when R73 was trying to get into bed independently from the wheelchair. R73 stated R73 hit their head but did not get injured. On 9/10/25 at 3:49 PM, Surveyor asked Director of Nursing (DON)-B if there were any investigations for R73's falls. DON-B stated everything that was found for the falls had been provided which were the progress notes and the Risk Management tools used for Quality Assurance. Surveyor noted no interviews with staff that were working with R97 were obtained to help determine the root cause of the falls. On 9/11/25 at 9:42 AM, DON-B stated DON-B was aware the fall investigations were lacking in content. DON-B was not the DON at the time of R73's falls and the facility administration had identified the need for improvement with fall investigations. DON-B stated DON-B was aware that the fall packets that had been provided to Surveyor were not complete. On 9/15/25 at 3:15 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R73's three falls were not thoroughly investigated with a root cause analysis and the care plan was not revised with interventions to prevent future falls. On 9/17/25 at 8:21 AM, Surveyor observed R73 lying in bed eating breakfast. The head of the bed was elevated, and the bed was in a low position. R73's wheelchair had an air pocket-type cushion in place with Dycem under the cushion. Surveyor noted the cushion was not a dump seat as stated in the At Risk for Falls Care Plan. Surveyor had not observed R73 in the wheelchair during the survey. Surveyor asked R73 how often R73 gets out of bed and into a wheelchair. R73 stated sometimes R73 will get up for like therapy but otherwise stays in bed because that is where R73 likes to stay. On 9/17/25 at 8:26 AM, Surveyor asked LPN-Z what the facility process was when a resident has a fall. LPN-Z stated LPN-Z would assess the resident by getting vital signs and neurological checks and would notify the DON and have an RN assess the resident. LPN-Z stated the physician would be notified as well as the Power of Attorney. LPN-Z stated if the resident is taking an anticoagulant, LPN-Z would call the ambulance. LPN-Z stated the nurse on the floor would fill out and complete all the paperwork that goes with a fall. On 9/17/25 at 8:36 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-CC and CNA-DD how R73 transfers. CNA-CC stated sometimes R73 uses a full mechanical lift but has the ability for assistance for a pivot transfer. CNA-CC stated R73 can lift their legs, but tends to slide down when in the wheelchair. CNA-DD stated R73 refuses to get out of bed and has not had therapy for about two weeks. Surveyor asked CNA-CC and CNA-DD if they do anything to prevent R73 from falling. CNA-DD stated they put a pillow on the side of the bed under the sheet to keep R73 from rolling out of bed and they keep the bed low. CNA-DD stated R73 does not try to put themself on the floor and does not try to get out of bed. Surveyor asked CNA-CC and CNA-DD if R73 had a special cushion in the wheelchair. CNA-DD stated therapy gave R73 a flat cushion, and R73 slides themselves down out of the chair and in bed, too. Surveyor shared with CNA-CC and CNA-DD that R73's care plan says R73 should have a dump seat in the wheelchair. CNA-CC and CNA-DD did not know what a dump seat was. On 9/17/25 at 8:44 AM, Surveyor interviewed DON-B and Assistant DON (ADON) LPN-C regarding the dump seat that is on R73's care plan. DON-B and ADON LPN-C did not know what a dump seat was. ADON LPN-C stated R73 has a regular cushion in the wheelchair. The facility's policy, titled Resident Smoking, dated 7/15/25, documents in part, . Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: . 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, (sic) to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 3.) R40 was admitted to the facility on [DATE] with a diagnoses that include hemiplegia and hemiparesis following a cerebral infarction (stroke) affected right dominant side, congestive heart failure, vascular disease, depression and anxiety. R40's MDS (Minimum Data Set) annual comprehensive assessment dated [DATE], documents a BIMS (Brief interview for Mental Status) score of 10, on a scale of 0 to 15, indicating R40 has moderate cognitive impairment. R40 has an impairment in their range of motion (ROM) on one side for both upper and lower extremities. R40's Smoking and Safety assessment dated [DATE], documents, under Smoking and Safety Interaction: Does the Resident display any of the following? Checkmark is indicated for, Follows the facility policy on location and time of smoking. The remainder of the Smoking and Safety Assessment is incomplete. There are no check marks documented under Care Planning regarding: Smoking Care Plan and Smoking Cessation Care Plan nor Clinical Suggestions. R40's Smoking and Safety assessment dated [DATE], documents, under Smoking and Safety Interaction: Does the Resident display any of the following? Checkmark is indicated for, Follows the facility policy on location and time of smoking. The remainder of the Smoking and Safety Assessment is incomplete. There are no check marks documented under Care Planning regarding: Smoking Care Plan and Smoking Cessation Care Plan nor Clinical Suggestions. R40's Smoking and Safety assessment dated [DATE], documents, under Smoking and Safety Interaction: Does the Resident display any of the following? Checkmark is indicated for, Follows the facility policy on location and time of smoking. The remainder of the Smoking and Safety Assessment is incomplete. There are no check marks documented under Care Planning regarding: Smoking Care Plan and Smoking Cessation Care Plan nor Clinical Suggestions. Surveyor noted all of R40's Smoking and Safety Assessments, under Smoking and Safety Interaction: Does the Resident display any of the following? Limited or no ROM (Range of Motion) in arms and hands or unable to extinguish tobacco or marijuana safely - none is assessed. R40's Progress Note, dated 7/3/24, documents, in part .Visit Type: INITIAL CARDIAC PCC (sic) (Patient Centered Care) SOCIAL HISTORY(sic): Current smoker, denies alcohol use Tobacco: (patient screened on 07/03/2024) * In the PAST 12 MONTHS (sic), how often have you used tobacco or any other nicotine delivery product (i.e., e-cigarette, vaping or chewing tobacco)? Daily or Almost Daily * Smoking history: Over 10 years * Amount smoked per day: < (less than) 1/2 pack * Pack/years: +5 pack/year SMOKING CESSATION (sic): (Complete if patient identified as a current tobacco user), .Smoking and tobacco use cessation counseling was provided during the visit on 07/03/2024 for 5 minutes and the following items were discussed: * Patient is a current smoker, understands the negative health impacts, and options * Patient is not willing to attempt smoking cessation * Smoking cessation is important due to their health conditions of: CAD (coronary artery disease) * Methods of cessation that were discussed with the patient include: Nicotine patch, gum and lozenges * A quit date of August 2024 was discussed * Resources that were made available to the patient include: Verbal discussion. R40's Care Plan, date initiated 11/11/24, documents a Focus area to include R40 is at risk for smoking related injury related to: Smokes independently. The Goal documents, R40 will maintain Independence safely while smoking. Interventions include to assure smoking material is extinguished prior to patient leaving smoking area and complete smoking safety assessment per Living Center policy. On 09/10/25 at 12:50 PM, Surveyor interviewed R40 who stated R40 can smoke whenever R40 wants to and enjoys smoking a lot. Surveyor asked if there is any staff present while R40 smokes and R40 stated, no. R40 keeps R40's own cigarettes and lighter. On 09/09/25 at 1:15 PM, Surveyor observed R40 smoking along with 2 other resident smokers in the outside designated smoking area, referred to as the back patio. There was no staff supervision present. R40 was in wheelchair, wearing sweatpants, regular white socks with no shoes and a short-sleeved shirt. R40's right arm was in a sling and R40 was observed with a cigarette in left hand. Surveyor asked R40 if R40 wears a smoking apron or anything to protect him over his clothes when smoking and R40 stated, he does not know anything about it. 09/10/2025 2:15 PM Surveyor observed R40 smoking along with 3 other resident smokers on the back patio. There was no staff supervision present. R40 was in a wheelchair, wearing cotton sweatpants, regular white socks with no shoes and a short-sleeved shirt. R40's right arm was in a sling and R40 had a cigarette in left hand. R40's cotton sweatpants had a cigarette size burn hole in the left pant leg. R40 stated he forgot how he got the cigarette burn in his pants. Surveyor asked how R40 puts out his cigarette and R40 stated, tosses on ground. Surveyor asked if anyone steps on the cigarette and R40 said, no, just toss it. Surveyor asked R40 who lights R40's cigarettes and R40 stated, I do. Surveyor observed R40 until R40 tossed their cigarette onto the ground and no staff member was present to extinguish it. 09/10/2025 at 2:05 PM, Surveyor interviewed Director of Nursing (DON)-B and asked DON-B what practice is followed for supervision while smoking with residents who are cognitively impaired. DON-B stated, facility does not base smoking supervision on a resident's cognition but rather on the smoking safety assessment. Surveyor asked how often the smoking safety assessments are completed and DON-B stated, upon resident admission and quarterly. Surveyor shared with DON-B that there are only 3 smoking safety assessments for R40 dated 11/11/24, 6/24/25 and 8/28/25 with incomplete assessment details/documentation. Surveyor stated there was not a smoking safety assessment completed upon admission on [DATE] and the first smoking safety assessment occurred on 11/11/24 with 4.5 months lapsing from admission. The subsequent smoking safety assessment occurred on 6/24/25 with 7 months lapsing in between. DON-B stated the facility is now completing the smoking safety assessments upon admission and quarterly. Surveyor shared R40 was observed to have a burn hole in their sweatpants and that there was no supervision or a staff member present to ensure R40's cigarette was extinguished. Surveyor stated, there is a concern R40's care plan is not being followed for smoking interventions. DON-B stated, she understood and is aware R40's care plan is not being followed. There was no additional information provided at this time.

Based on interview and record review, the facility's Quality Assurance Committee did not make a good faith effort to identify and correct systemic deficiencies prior to the survey. This deficient practice has the potential to affect all 85 residents at the facility. During a recertification survey conducted on 9/9/25-9/30/25, it was determined 39 deficiencies existed including the deficient practice at F865, QAPI (Quality Assurance and Performance Improvement) Program/Plan, Disclosure/Good Faith Attempt.Four of the 39 deficiencies have been identified as immediate jeopardies related to wound care at F684, pressure injury care at F686, responsibilities of the medical director at F841 and facility administration at F835. F684 and F686 at the immediate jeopardy scope and severity are also substandard quality of care.Widespread deficient practice was identified at F727 related to sufficient staffing including concerns with not having a full time Director of Nursing in the facility; F812 for food storage and procurement; F851 related to accurate submission of staffing for payroll based journal; F865 related to QAPI; F880 related to systemic concerns related to infection control; F881 for antibiotic stewardship; F887 for failure related to COVID-19 immunizations; F925 for facility wide concerns related to pest management; and F946 and F949 related to failures to ensure adequate clinical training programs for staff that work with all residents residing in the facility.At the time of the recertification survey (9/9/2025-9/30/2025) the facility was not in compliance with the regulations at F689 accidents and hazards, F684 quality of care, and F692 nutrition and hydration after it was determined these regulations were not corrected on a revisit survey completed 9/2/2025. Cross-reference survey event IDs: HBE5-H2 and L0G2-H2. On 7/3/2025 immediate jeopardy had been identified at F692 related to nutrition and hydration concerns. Cross-reference survey event ID L0G211. On 7/28/2025 a survey was completed that identified immediate jeopardy concerns at F692 for nutrition and hydration concerns. Cross-reference survey event ID HBE511.The facility failed to have a system to establish priorities for improvement activities that focuses on high risk areas of concern for the residents in the facility. The facility failed to have a system to address through QAPI to analyze and act upon data to develop improvement plans, and the facility failed to ensure the committee developed and implemented action plans to correct identified quality deficiencies and sustain compliance.Findings include:The facility policy entitled, QAPI Change Process, dated 1/1/25, documents in part, . POLICY: The facility has established and utilizes a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained. Definitions: Quality Assurance and Performance Improvement (QAPI) (sic) is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality (QA) and Performance Improvement (PI). Quality Assurance (QA) (sic) is the specification of standards for quality of care, service and outcomes, and systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards. Performance Improvement (PI) (sic) is the continues study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement, and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement.On 09/16/2025 at 1:05 PM, Surveyor interviewed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B regarding their QAPI program and the systemic issues concerning the facility. Surveyor asked NHA-A for QAPI plan, QAPI meeting minutes and staff sign in sheets not yet provided following the survey Entrance Conference. NHA-A stated previous DON-DDD took the QAPI plan, meeting minutes and sign in sheets when previous DON-DDD resigned on July 31, 2025. Surveyor asked NHA-A, Since July 31, 2025, when previous DON-DDD departed, has there been a QAPI meeting? NHA-A stated it has been difficult to hold a meeting with the State being at the facility as much as they have been. There was a meeting scheduled for today, 9/16/25, but it was cancelled. Surveyor asked NHA-A who attends the QAPI meetings and NHA-A stated, NHA, DON, Medical Director, Infection Preventionist (IP)/Wound nurse and other department heads. Surveyor asked NHA-A, what are the current performance improvement plans (PIPs) the facility is working on. NHA-A stated the facility is working on four PIPs to include wounds, falls, admissions and infections but they are just now being formulated and not in written format. DON-B stated the facility has identified the PIPS through audits and State surveys. DON-B stated the majority of time has been dedicated to the current State plan of correction (POC) (referring to the POCs associated with survey event IDs L0G211/LOG2-H2 and HBE511/HEB5-H2) and the facility will formalize the PIPs through the POC process.Surveyor noted, no other PIP has been identified in 2025 besides the four currently being formulated and not implemented or completed.Surveyor asked NHA-A if NHA-A was apprised of the serious clinical concerns occurring at the facility, particularly related to harm level quality care. NHA-A stated, the previous Director of Nursing (previous DON-DDD) was in charge of the clinical aspects of the building and NHA-A should have been apprised of all clinical concerns but was not. NHA-A stated he did not realize the clinical issues were this bad, particularly with two residents, (referring to R97 and R98) with wounds resulting in immediate jeopardy. Cross-reference F684 and F686). NHA-A stated the department heads met every morning and afternoon to discuss clinical issues, or any other areas of concern and no issues were brought up to the level of harm, especially issues with lack of wound care and practices. NHA-A stated NHA-A trusted clinical leaderships' report during morning and afternoon meetings as accurate and NHA-A stated, there were always minor concerns brought to his attention but never the kind of issues brought forth with this survey.Surveyor asked NHA-A about the concerns regarding clinical leadership and the determination there were periods of time with no full time DON in the facility. Cross-reference F727.NHA-A stated DON-B resigned December 31, 2024, and previous DON-DDD became the DON effective 1/1/25. NHA-A stated, stated previous DON-DDD was on a leave of absence from 4/1/25 through 5/12/25. NHA-A stated the Regional Office for the Operator-FFF told NHA-A Operator-FFF would provide on-site clinical coverage during previous DON-DDD's leave of absence but did not. NHA-A stated Operator-FFF could be accessed by telephone, but no one was present at the facility until 5/8/25 when staff from Operator-FFF showed up to complete a mock survey. NHA-A stated this was a terrible period without clinical support and NHA-A had asked for the help but did not receive. NHA-A stated previous DON-DDD returned on 5/13/25 and his last day at the facility was 7/31/25. NHA-A stated the previous Assistant Director of Nursing's last day was also 7/31/25.NHA-A stated, NHA-A rehired DON-B and DON-B signed an offer letter on 8/4/25. DON-B stated, DON-B had to fulfill a 2-3 weeks' notice with their employer following the facility DON job offer. DON-B approximately worked 24 hours a week at her previous job and worked these hours around DON-B's full-time position at facility. DON-B state DON-B is now at facility Monday through Friday, full-time, standard business hours.Surveyor asked what the responsibility of the Infection Preventionist/Wound Licensed Practical Nurse (IP/Wound LPN)-I for the oversight of wound care and development of R97 and R98's wounds. DON-B stated that Operator-FFF changed the entire wound care program following DON-B's original departure on 12/31/24, requiring far less of what was previously required and minimized the process for wound care. DON-B stated that IP/Wound LPN-I knew that by taking away wound care responsibilities that were required previously, issues would occur. DON-B stated, Operator-FFF dismantled so many practices and now with DON-B returning to the facility since rehire on 8/4/25, DON-B is working on establishing procedures, putting out fires and trying to get things better.Surveyor asked why Operator-FFF would change wound care practices to practices that do not meet standards of quality care. DON-B stated Operator-FFF wanted to decrease the workload during receivership because Operator-FFF was losing the facility. DON-B stated, Operator-FFF eliminated weekly wound logs that contained wound measurements and the progress of wounds. No RN was following wound care. DON-B stated, Operator-FFF also eliminated the Falls investigation packet. Cross-reference F689.Surveyor asked NHA-A what the role of the Medical Director in the facility is. NHA-A stated the role of Medical Director- QQ is to participate in the QAPI meetings and provide feedback. NHA-A stated Medical Director- QQ oversees the Nurse Practitioners (NP's) seeing residents at the facility. Medical Director- QQ is the support for when there are issues or concerns with other physicians.Surveyor asked what the responsibility of Medical Director-QQ regarding the overall wellness and clinical care for the residents is; specifically, how were the NP's or Medical Director- QQ not aware of the severity of R97 and R98's wounds and other clinical concerns and systemic issues regarding care. DON-B stated, the NP's and Medical Director- QQ need to have the facility apprise them of any resident wounds as the NP's and/or Medical Director- QQ is not doing a full physical comprehensive assessment when visiting the residents unless they are aware of a particular situation. DON-B stated NP's and/or Medical Director- QQ is relying on the facility wound team to address wounds. Surveyor noted it is the role of the Medical Director to establish and coordinate the overall clinical program in the facility based upon current standards of practice. Surveyor also noted Medical Director-QQ is also the attending physician for many of the facility residents. Cross-reference F841.On 09/17/2025 at 8:03 AM Surveyor interviewed NHA-A and DON-B. Surveyor asked NHA-A and DON-B how the facility identifies systemic issues. DON-B stated, through the QAPI process and Interdisciplinary Team (IDT) meetings and then discuss as team. Then facility determines which department is affected, create root cause analysis to develop solutions and monitor with frequency and duration for effectiveness.Surveyor asked NHA-A and DON-B if the facility establish priorities for its improvement activities that focus on high-risk, high-volume or problem-prone areas, as well as health outcomes, resident safety, choice, autonomy and quality of care. DON-B stated yes, for example, right now facility will be addressing wounds. Surveyor noted this was as a result of care concerns identified to be immediate jeopardy by the Surveyors during the current recertification survey rather than the QAPI committee identifying the concern through analysis of facility data.Surveyor asked NHA-A and DON-B if the facility tracks adverse events and medical errors, analyze their causes, implement preventive actions and mechanisms that include feedback and learning throughout the facility. DON-B stated yes, through risk management.On 09/17/2025 at 11:36 AM, Surveyor interviewed NHA-A and DON-B and confirmed previous DON-DDD was on a leave of absence from 4/1/25 -5/12/25. NHA-A stated the acting DON was supposed to be previous clinical consultant-GGG from the Regional Office through previous vice president of operations (VPO)-HHH, but she was never present in the building until Operator-FFF had representatives showed up on 5/8/25. NHA-A stated, the facility did not notify the State of an acting DON. NHA-A confirmed previous DON-DDD resigned as of 7/31/25 and there was a gap in DON coverage until DON-B was hired on 8/4/25. Surveyor asked who the acting DON was from 7/31/25 to 8/4/25 and NHA-A stated, they did not have anyone else. NHA-A stated NHA-A hired DON-B as quickly as he could.Surveyor notes, NHA-A produced QAPI meeting templates with minutes, originally thought to been taken by previous DON-DDD indicating there was a monthly QAPI meeting in January, February, March and April of 2025 and an ad hoc QAPI meeting in July 2025 following a State survey. NHA-A confirmed there was no QAPI meeting during previous DON-DDD's leave of absence, leaving no DON in facility from 4/1/25 -5/12/25. There also were no QAPI meetings following previous DON-DDD's return from leave of absence (5/13/25) until an ad hoc meeting was held on 7/1/25 after receiving an immediate jeopardy citation. The facility cannot provide confirmation of compliance that the required attendees participated in the QAPI process/meetings even for any documents provided as there are no sign in sheets for the QAPI meetings held in January, February, March and April of 2025. None of the QAPI meeting minutes address the systemic clinical changes including revisions to the overall wound care program, discontinuing the falls investigation procedure following DON-B's original departure on 12/31/24. There is no PIP for 2025 that has been implemented and/or corrected, only PIPs in initial development.No further information was provided as to why the facility's Quality Assurance Committee did not make a good faith effort to identify and correct systemic deficiencies for residents prior to identification by the survey team throughout the survey activity this past year.

Based on interview and record review, the facility did not use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week and the facility did not ensure full time Director of Nursing (DON) coverage. This deficient practice has the potential to affect all 85 residents residing in the facility. *On 8/30/25, there was no RN who worked for 8 consecutive hours. *The Facility did not provide full time Director of Nursing (DON) coverage from 4/1/25 to 5/12/25 and again 7/31/25 until at least 8/4/25.Findings include: 1.) Surveyor reviewed nursing schedules and nurse staff postings for last 30 days from start of survey and noted the facility's nursing schedules and nurse staff postings did not indicate the presence of an RN in the facility on 8/30/25.Surveyor reviewed the Facility Assessment Tool under the staffing section licensed nurses providing direct care it is documented that there is RN coverage 24 hours per day. Surveyor noted that the regulation states a skilled nursing facility must ensure they have an RN providing services at least 8 consecutive hours a day, 7 days a week. On 09/15/2025, at 10:15AM, Surveyor interviewed Scheduler-H regarding an RN not being on the schedule for August 30th. On 09/15/2025, at 10:55AM, Scheduler-H confirmed that was a Saturday and there was no RN in the building. On 09/15/2025, at 2:30 PM, during the end of day meeting, with Nursing Home Administrator-A and Director of Nursing-B, Surveyor relayed concern that on 8/30/25 there was no RN in the building. No additional information was provided as to why the facility did not ensure that an RN was on duty for at least 8 consecutive hours a day, 7 days a week.2.) On 9/10/25, Surveyor requested documentation from facility of Director of Nursing (DON)-B hours worked and time spent in the building for nursing services.On 09/15/2025, at 10:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and was told that DON-B is a full-time employee, and they have an offer letter to prove it. Surveyor asked about DON-B working at (name of hospital) and was told they reduced their hours to PRN (as needed) when the DON position was accepted. There was a period when DON-B was working both jobs after DON-B gave notice to go from full time to PRN at (name of hospital). On 09/16/2025, at 1:05 PM, Surveyor interviewed NHA-A and DON-B regarding previous DON-DDD ending employment at the facility and was told they walked out on July 30, 2025. NHA-A also stated that previous DON-DDD was gone from 4/1/25 through 5/12/25 on a leave of absence. NHA-A stated that the previous governing body told NHA-A that they would provide clinical support but did not. NHA-A stated being able to call for clinical decision making but no one was present in the building. DON-B signed the offer letter on 8/4/25 and then had to fulfill notice of other job at (name of hospital) for 2 to 3 days a week for 2 to 3 weeks at 24 hours a week. DON-B worked around this schedule and put in full time work at this facility. Now DON-B is at the facility full time hours Monday through Friday, full days. The first day of the survey 9/9/25 DON-B had a planned day off, that's why they were not there.Surveyor noted that the facility was without full time DON coverage from 4/1/25 to 5/12/25 and again 7/31/25 until at least 8/4/25.

Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 85 residents that eat food prepared by the facility.*In the facility's main kitchen, observations of hair restraints for facial hair not being utilized, scoop used for flour was placed down in the flour bin, and not in the scoop holder and silverware not being stored in sanitary conditions.Findings include:The facility policy and procedure titled FOOD SAFETY REQUIREMENTS, dated 10/1/2022 documents: Policy, it is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. e. Equipment used in handling of food, including dishes, utensils, mixers, grinders and other equipment that comes in contact with food. 7. Staff shall adhere to save hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g., hairnet, at, and/or beard restraints) to prevent hair from contacting food.Flour scoop and silverware: On 9/09/2025, at 11:36 AM, Surveyor observed the main kitchen area. During observation of the main kitchen area Surveyor observed a red scoop sitting in a flour bin under the serving table. [NAME] Supervisor (CS)-LL stated the scoop should not be in there and there is a holder on the side of the flour bin that the scoop should be in. Dietary Director (DD)-G was present and observed the scoop in the bin as well. DD-G stated the scoop should never be left down in the flour and staff knows it needs to be in the holder. Surveyor questioned CS-LL about the silverware that was sitting next to the serving line if that is where they store the silverware and if it gets covered at any point. CS-LL stated Yes this is where it is stored and No, that the silverware does not get covered at any point, not even at the end of the night.Beard restraints:On 9/09/2025, at 11:51 AM, Surveyor observed the kitchen staff setting trays for lunch. Surveyor asked DD-G about the employees with facial hair not wearing beard hair restraints. DD-G informed Surveyor that the facility does not currently have those restraints, and that DD-G will get them ordered, 2 dietary aids and dietary director observed w/o beard nets at serving station while the lunch meal was being plated.On 9/09/2025, at 12:00 PM, Surveyor interviewed Dietary Aide (DA)-K who stated DA-K was never asked to put on a beard restraint even know DA-K currently has 2 inches of facial hair on DA-K's chin. DA-K is currently on the food line and setting trays for lunch. DA-K indicated being an employee in the kitchen since 2021 and DA-K has never worn a beard restraint. On 9/09/2025, at 12:00 PM, Surveyor interviewed Dietary Aide (DA)-J who stated DA-J has never seen a beard restraint here at this building. Surveyor asked DA-J if anyone here at the facility ever talked to DA-J about wearing one, DA-J stated No, or offered one to wear, No. DA-J was setting up trays with lunch food on the cart to go to the floor. DA-J had facial hair of 1 inch to chin area.On 9/11/2025, at 9:20 AM, Surveyor asked DD-G what the current staff is utilizing for beard restraints until there order arrives? DD-G informed Surveyor the facility is utilizing the head-hair restraints until the order comes in later today.On 9/11/2025, at 11:14 AM, Surveyor interviewed DA-MM, who indicated that at the end of the night DA-MM places the silverware over by the food line and does not need to place a cover or anything on top of the silverware during the night. DA-MM states it just gets set over there so it's ready for breakfast.Surveyor observed a sink right across from line area where silverware is being placed and stored throughout the night. Surveyor noted that after staff interview the silverware sits in this area while the staff is preparing the line for breakfast in the morning and has no cover to block from potential splashes.DD-G was observing the above-mentioned interaction between Surveyor and DA-MM, DD-G offered explanation to Surveyor. DD-G stated that DA-MM is a newer employee and doesn't know that the silverware needs to be covered. DD-G stated that kitchen staff are supposed to be covering, and DD-G covers the silverware when DD-G is working at the end of the night, so DD-G indicated not knowing what is going on with staff statements.On 9/11/2025 2:10 PM, Surveyor informed DD-G and Nursing Home Administrator(NHA)-A, of the concerns with the food safety requirements including scoop down in the flour bin, hair restraint use and the sanitary storage during the overnight hours of the silverware utensils. NHA-A stated, the kitchen staff just went over this, the kitchen staff were aware that they need to cover the silverware, items should be placed down for drying, i just went around and educated again.

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 85 residents residing in the facility. Staffing information for Quarter 3 (April 1 - June 30 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: 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 2025 (run on 9/4/25) which indicated the Facility had excessively low weekend staffing and a one-star staffing rating for the 3rd Quarter (April 1-June 30). Surveyor reviewed the Facility's weekend schedules from April 2025 through June 2025. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules included call ins, agency staff and staff who picked up shifts. Surveyor noted there did not appear to be excessive call-ins.On 09/10/2025, at 1:17 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-SS regarding weekend staffing and was told they recently got more staff. Surveyor asked what this meant and CNA-SS said they added a couple aids to the schedule which has been helpful. Surveyor asked about long wait times for residents and was told only during busy times, especially in the mornings or at mealtimes. Surveyor asked if there are not enough aides on the weekend are baths/showers not given and was told that typically baths/showers are not scheduled on weekends on this unit, they are done during the week. Surveyor asked if staffing is ever low and residents get left in bed and was told only by the resident's choice. Maybe they cannot get up as soon as they like all the time but always given option to get up. Surveyor asked if beds go unmade when short staff and was told it is CNA-SS routine to make the bed when resident is out so no issue.'sOn 09/10/2025, at 1:21 PM, Surveyor interviewed CNA-TT regarding staffing and was told it is great. CNA-TT could not pinpoint a particular time period staffing was short, just depends on availability of staff. When asked about call lights going unanswered on the weekend, CNA-TT replied that they rarely work weekends.On 09/10/2025, at 1:25pm, Surveyor interviewed housekeeping-UU who has worked at the facility two months. Surveyor asked if it seems like there is enough nursing staff and was told yes, housekeeping-UU has noticed the aides on the units will go to other units and help each other. Surveyor asked about call light times and was told sometimes staff ignore them and that frustrates housekeeping-UU. Surveyor asked if it seems like residents get left in bed when short of staff and was told no the majority get up. Surveyor asked if the beds are made, and the response was yes.On 09/15/2025, at 10:15AM, Surveyor interviewed Scheduler-H who has worked for the facility since May. Surveyor asked if there were staffing issues when started the job and was told for the most part has been able to staff by the numbers given. Scheduler-H did not notice an issue with being short of staff after starting the job. Surveyor asked what happens when have a call in, they offer in house bonuses and use COVR (an app) for agency nurses and CNA. Surveyor asked what do when cannot find coverage and was told generally found with incentives offered.On 09/15/2025, at 10:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and asked about the Facility Assessment stating 12 nurses per day, but schedule shows 10 per day. NHA-A stated when the census is 100-112 then they have 12 nurses, census has not been that high so have been running with 10 nurses. Surveyor asked NHA-A why the facility could have triggered for excessively low weekend staffing and one star staffing from April to June. NHA-A looked over payroll reports and called payroll, the reason they triggered for low weekend and one star is that on the weekends they offer bonuses for managers to pick up. Payroll is supposed to code them as working the weekend for coverage and that was not happening in April, May and June.On 09/15/2025, at 2:30 PM, during the end of day meeting, with NHA-A and Director of Nursing-B, Surveyor shared concern that the facility did not report PBJ data correctly.No additional information was provided as to why the facility did not accurately submit staffing information for Quarter 3 (April 1 - June 30) of the Payroll Based Journal (PBJ).

Based on observation, interview and record review, the Facility did not establish and maintain an Infection Prevention and Control Program (IPCP) based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 85 residents. * The IPCP did not have documentation of an effective water management program (WMP). * The IPCP 2025 surveillance logs were lacking pertinent information and documentation. * The Facility Assessment lacked infection prevention and water management information. * R75 did not have contact isolation initiated when infection was discovered. Findings include: The facility's policy titled, Infection Prevention and Control Program, implemented 10/1/22 documents, in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee . 5. Isolation Protocol (Transmission-based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC (Centers for Disease Control) guidelines. b. Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances. 16. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program. he facility's policy titled, Water Management Program, dated 1/01/2025 documents, in part: It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens . in the facility's water systems based on nationally accepted standards . Policy Explanation and Compliance Guidelines: 1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. a. Team members have been educated on the principles of an effective water management program, including how Legionella and other water-borne pathogens grow and spread. b. The water management team has access to water treatment professionals, environmental health specialists, and state/local health officials. 2. The Maintenance Director maintains documentation that describes the facility's water system. 3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. 5. Based on the risk assessment, control points will be identified . 8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible. 9. The effectiveness of the water management program shall be evaluated no less than annually. 14. Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of 3 years. Water Management Program: The 6/24/21 CDC Toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: 1. Establish a water management program team 2. Describe the building water systems using text and flow diagrams 3. Identify areas where Legionella could grow and spread 4. Decide where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met 6. Make sure the program is running as designed and is effective 7. Document and communicate all the activities The 6/24/21 CDC Toolkit documents, program team members should possess certain skills that are needed to develop and implement your water management program. The team should also include: -Someone who understands accreditation standards and licensing requirements -Someone with expertise in infection prevention -A clinician with expertise in infectious diseases -Risk and quality management staff The Facility's WMP dated August 15, 2025, documents that the Program Team for (the name of facility) consists of the Administrator and Director of Maintenance. The staff names listed were of individuals no longer employed at the facility. Additionally, Surveyor noted the Infection Preventionist is not listed as part of the team. On 09/15/25, at 10:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding the Water Management Committee not being identified in the Facility Assessment. Per DON-B there is no committee, just the maintenance department and they review information with IP (infection preventionist) and monthly report to QAPI (Quality Assurance Performance Improvement). On 9/16/25, at 11:07 AM, Surveyor interviewed Director of Maintenance (DOM)-GG about the water management plan. DOM-GG wasn't sure how much information they would have as they have only been on job three months and got no training. DOM-GG shared that if a room is not occupied, they test the water temperature and run the water 5-10 minutes. Surveyor asked about testing/monitoring controls for Legionella in the water and was told DOM-GG would need to start that. Surveyor asked if there were committee meetings held regarding water management and was told none as of yet. Surveyor asked about conferring with IP and was told that was not done.In the Water Management Plan document multiple control measures are listed and how to test each is identified. For example, water heater checks of the waterflow, and temperatures are listed and Surveyor was unable to locate any documentation of this being completed. Disinfectant levels are to be checked with a chlorine test kit, Surveyor was unable to locate any documentation of this being completed. Ice Machine was listed to receive regular cleaning and maintenance, Surveyor was unable to locate any documentation of this being completed. The testing documentation that was provided to Surveyor was Weekly Water Audit completed on 6/13/25, 7/7/25 and 8/28/25. The instructions document 1X (one time) weekly, check water in each Vacant room or other water source not currently in use. Per the CDC Healthcare Facility Water Management Program Checklist the control point locations should be identified and determine how control measures will be applied for water temperature, residual disinfectant, heterotrophic plate count (HPC), Total Organic Carbon. The tester has responsibility to then review trend data and report out of control results. Surveyor noted on the Distribution System Control Measures diagram provided there is a handwritten note Each wing includes a shower room. Each room contains shared bathroom and shower. Surveyor noted the resident room shower is small and not accessible for residents in wheelchairs or shower chairs, most use the shower room on the wing. This would be an example of a water source not currently in use for most resident rooms that is not being monitored. Surveyor was unable to locate any documentation that Legionella testing had been completed. On 9/16/25, at 1:25 PM, Surveyor interviewed Infection Preventionist (IP)-I and asked about involvement with the water management plan, to which IP-I replied that the course they just took says water management has to do with infection control but IP-I is not involved in it. The person who did role before has not been in the facility since April. On 9/16/25, at 2:18 PM, Surveyor interviewed DOM-GG again and was told the only audits done are the ones provided with the binder. DOM-GG stated that the ice machine was cleaned two times in the three months DOM-GG has been there but had no log to record the cleaning. DOM-GG told Surveyor that the weekly water audits are only done monthly because there are no vacant rooms in the building. Surveyor noted the shared showers were a water source not currently in use for most resident rooms and should part of risk factors monitored as part of the plan. On 09/16/25, at 3:20 PM, during the end of day meeting with facility Surveyor let NHA-A and DON-B know concerns that the water management plan does not include an up to date program team and does not include the IP. The WMP diagram of the building does not include what is tested and where. For example, where dead legs are located. There is no documentation of control measures and testing being completed. There are no committee meetings and no water testing documentation, including testing for Legionella. On 9/17/25, DON-B provided the Distribution System Control Measures diagram to Surveyor. It contains some needed documentation but is missing storage tanks, areas of stagnation (dead legs, vacant units/rooms, etc.), areas with hand-held showers, faucets with aerators/flow restrictors, areas with no residual disinfectant, areas where temperatures can support microbial growth, locations of commodes and hoppers, and sinks and sink locations. No additional information was provided regarding the lack of committee and IP involvement, control measures and water testing, the water management plan not including a diagram of the building with what is tested and where. Documentation of IP Surveillance On 09/10/2025, at 8:36 AM, Surveyor spoke with Infection Preventionist (IP)-I, regarding the requested Infection Prevention surveillance and program documentation. Per IP-I the Director of Nursing (DON)-B is on the phone with the (name of the electronic medical record) company, there are a couple things they are still trying to get that was requested. On 09/10/2025, at 9:51 AM, Surveyor interviewed DON-B and was told that the IPC (Infection Prevention and Control software) within (name of the electronic medical record) is disabled. To be able to add orders or update cases need to enable IPC. When DON-B goes to reports and tries to historically print records, just gets a blank screen. DON-B put date range in to report and nothing shows. DON-B had been employed previously at facility until the end of December. Documentation in binders up through December is available. DON-B looked and the previous owners disabled IPC on 8/7/25. The new management company involved is trying to get legend or access so information can be provided. Per DON-B IPC is a module that you buy extra from (name of the electronic medical record) and it has been disabled. On 9/15/25, at 9:00 AM, Surveyor interviewed DON-B and IP-I, over the weekend they used the Physician Order Report for residents with an antibiotic to create surveillance logs. The new ownership company needs to sign a contract with (name of the electronic medical record) for the IPC add on and even then there is no promise the previous data will be available. Surveyor noted IP-I was certified on 9/7/25 with completion of the Nursing Home Infection Preventionist Training Course by the CDC. Surveyor reviewed the surveillance logs provided by the Facility for 2025 and found no January facility map showing where infections were in building or the Line List Template used for other 2025 months. For February surveillance documentation there is a facility map with wound/skin notated in room [ROOM NUMBER] of D wing and Line List Template recording a fungal infection located in the binder. Surveyor randomly selected four residents that had a diagnosis that should be included on surveillance documentation and 2 of the 4 were not included. In February, R6 was admitted to Aurora [NAME] Medical Center on 2/8/25 with Influenza A and septic shock. R6 should have been documented in February surveillance records with Influenza A diagnosis, Surveyor was unable to locate documentation of R6's diagnosis within the February surveillance record. For August surveillance documentation there is a facility map and Clinical Physician Orders report documenting the surveillance cases. The second randomly selected (not recorded) resident that should have been included in the surveillance log is R1 who went to (name of hospital) on 8/3/25 and was diagnosed with pneumonia. On 9/16/25, at 11:00 AM, Surveyor interviewed DON-B regarding January surveillance not being included and was told DON-B was sure they did that but just cannot find it in the paperwork. Surveyor asked about the two of the four sampled residents not being on the surveillance logs and was told they only ran residents on antibiotics and did not look at hospitalized residents. Surveyor asked about information missing from the surveillance logs. For instance, there are no infection rates included, no antibiotic stewardship review and infectious organisms are not identified. DON-B is aware of the missing information. On 09/16/2025, at 3:20 PM, during the end of day meeting with Nursing Home Administrator (NHA)-A, DON-B and IP-I Surveyor shared the concern that for 2025 there is no January surveillance, no infection rates calculated, no McGeer's or antibiotic stewardship documentation, no infectious organisms identified and that with a sample of four residents, two that should have been included in the surveillance log were not. No additional information was provided regarding the 2025 surveillance logs lacking pertinent information and documentation. Facility Assessment lacks Infection Prevention and Water Management information Surveyor reviewed the Facility Assessment Tool provided. Surveyor noted that for Persons involved in completing assessment both the Director of Maintenance (for water management) and Infection Preventionist were excluded. There was not a designated water management committee documented. The infection preventionist and hours devoted to program was excluded. Surveyor noted nothing was listed for water management plan or infection preventionist involvement. On 09/15/2025, at 10:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding the infection preventionist (IP) and Water Management committee not being addressed in the Facility Assessment. Per DON-B there is no committee, just the maintenance department and they review with IP as needed and do a monthly report to QAPI (Quality Assurance Performance Improvement). On 09/16/25, at 3:20 PM, during the end of day meeting with facility Surveyor let NHA-A and DON-B know concerns that the water management plan or committee is not addressed in the facility assessment and there is no IP information in the Facility Assessment. No additional information was provided regarding the Facility Assessment lacking infection prevention and water management information. Personal Protective Precaution Concerns * R75 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, generalized anxiety disorder, Paraneoplastic neuromyopathy and neuropathy. R75's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 14, indicating cognition was intact, and is understood and understands others. R75 did not have an isolation care plan in place when surveyor observed R75's Electronic Health Record (EHR). On 9/10/2025, at 9:31 AM, Surveyor did not observe a plaque, or a sign on the personal door for R75 related to contact isolation. Surveyor observed R75 on the 24-hour board, a document used from shift to shift for nursing staff, to update staff on residents on that unit. R75 was observed on this board for antibiotic/conjunctivitis, dated 9/10/2025. On 9/10/2025, at 9:31 AM, Surveyor interviewed R75, who indicated that R75 is ready to get up and ready for the day and that R75 was informed that they are giving R75 eye ointment because R75 has pink eye (a contagious eye infection). On 9/10/2025, at 9:59 AM, Surveyor observed Certified Nursing Assistant (CNA)-W, go into R75's room and close the door. CNA-W did not don any Personal Protective Equipment (PPE) prior to entering R75's room. CNA-W observed multiple times entering and exiting R75's room. CNA-W came back out of room at 10:02 AM, went across the hall to room [ROOM NUMBER] then back into R75's room, then closed R75's door. CNA-W at 10:03 AM came back out of R75's room and went over to room [ROOM NUMBER], talked with the nurse and then went back into R75's room. During the observations above, Surveyor observed that there was not a sign on the door or an isolation cart by R75's room. Nothing by R75's room to notify staff that R75 would be in need of Personal protective Equipment (PPE) during cares. At 10:09 AM, Surveyor observed Licensed Practical Nurse (LPN)-P entering R75's room to apply cream to R75. There were no observations of any PPE use by staff, during the entering or exiting of staff into R75's room. On 9/10/2025, at 10:43 AM, Surveyor interviewed CNA-W, CNA-W stated that R75 needs complete cares from staff and that CNA-W washed R75's face. Surveyor asked if CNA-W needs any type of PPE when completing these tasks with R75, and CNA-W stated No. CNA-W indicated that CNA-W asked the nurse LPN-P earlier today about PPE being needed and CNA-W stated that LPN-P told CNA-W, no, regarding isolation for R75. On 9/10/2025, at 10:48 AM, Surveyor interviewed LPN-P, who stated that R75 was not on isolation for any reason and has not been on isolation at all recently. Surveyor observed a change of condition documentation from LPN-R, dated 9/7/2025. This change of condition documented that Provider was notified of a change in condition on 9/7/2025 and new orders received. Documented under signs and symptoms identified, 1a. documents, swollen, irritated eyes, with drainage. Orders: Erythromycin ointment 0.5%, apply 1 centimeter ribbon to both eyes four times a day for 7 days. On 9/11/2025, at 8:12 AM, Surveyor called LPN-R, who indicated that LPN-R would start isolation for R75 related to signs and symptoms R75 was displaying. LPN-R stated that R75 was added to the 24-hour board for monitoring and to update other staff of R75's new change of condition. LPN-R stated the only reason LPN-R didn't add a sign or bin for contact isolation is because during LPN-R's shift, central supply employees were already gone for the day. LPN-R indicated that 2nd and 3rd shift staff don't have access to these supplies after central supplies leaves. On 9/11/2025, at 8:30 AM, Surveyor interviewed Central Supplies-II, who indicated that 2nd and 3rd shift staff don't have access to supplies, after Central supplies-II leaves for the day. Central Supplies-II stated Central Supplies-II will start isolation the next day when Central Supplies-II is informed to start it. On 9/11/2025, at 8:56 AM, Surveyor interviewed Director of Nursing (DON)-B, who indicated that Central Supplies-II was just down here and informed DON-B that there is a key hanging and staff should be aware of this. DON-B indicated that DON-B can show Surveyor where the key is hanging. Surveyor informed DON-B that the staff working at the facility are the ones that need to be aware of the location for the key. DON-B stated that DON-B will be educating staff of the key's location. DON-B stated that an order for isolation should also be placed in the computer for residents needing isolation and will be educating staff on this. On 9/11/2025, at 3:12 PM, Surveyor informed Nursing Home Administrator (NHA)-A, of isolation concerns for R75. NHA-A informed surveyor that R75 now has the isolation bin and sign outside of R75's room to inform staff of the need for PPE. No additional information received as to why staff were completing cares with R75 and not using PPE during those cares.

Based on interview and record review, the facility did not ensure they implemented their antibiotic stewardship program potentially affecting all 85 residents in the facility.Review of the facility infection surveillance logs for residents on antibiotics indicated antibiotic use without documentation of appropriate use of the antibiotic.Findings include:The facility's policy titled, Infection Prevention and Control Program, implemented 10/1/22 documents, in part: 6. Antibiotic Stewardship:a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program.b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program.c. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program.d. The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program.The facility's policy titled, Antibiotic Stewardship Program, last reviewed 4/8/2025 documents, in part: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.4. The program includes antibiotic use protocols and a system to monitor antibiotic use.a. Antibiotic use protocols:i. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR (Situation, Background, Assessment, Recommendation) form prior to notifying the physician.ii. Laboratory testing shall be in accordance with current standards of practice.iii. The facility uses the (CDC's NHSN Surveillance Definitions) to define infections.iv. Criteria specific to each state are used to determine whether or not to treat an infection with antibiotics.v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use.vi. Reassessment of empiric antibiotics is conducted after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident.vii. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized.b. Monitoring antibiotic use:i. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness.ii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall bereviewed for appropriateness.iii. Random audits of antibiotic prescriptions shall be performed to verify completenessand appropriateness (process measure) .v. At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include: tracking C. difficile infections, antibiotic resistance, adverse drug events related to antibiotic use, or costs related to antibiotic use.8. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to:a. Actions plans and/or work plans associated with the program.b. Assessment forms.c. Antibiotic use protocols/algorithms.d. Data collection forms for antibiotic use, process, and outcome measures.e. Antibiotic stewardship meeting minutes.f. Feedback reports.9. Records related to education of physicians, staff, residents, and families.h. Annual reports.On 09/10/25, at 9:51 AM, Surveyor interviewed Director of Nursing (DON)-B and was told that the IPC (Infection Prevention and Control software) within (name of electronic healthcare record) is disabled. To be able to add orders or update cases need to enable IPC. When DON-B goes to reports and tries to historically print records, just gets a blank screen. DON-B put date range in to report and nothing shows. DON-B had been employed previously at facility until the end of December. Documentation in binders up through December is available. DON-B looked, and the previous owners disabled IPC on 8/7/25. The new management company involved is trying to get legend or access so information can be provided. Per DON-B IPC is a module that you buy extra from (name of electronic healthcare record) and it has been disabled.Surveyor noted without access to IPC unable to locate or determine if a resident was assessed for appropriate use of the antibiotic.On 9/15/25, at 9:00 AM, Surveyor interviewed Director of Nursing (DON)-B and Infection Preventionist (IP)-I regarding the antibiotic stewardship program and was told they follow the McGeer's criteria (The McGeer criteria are a set of clinical guidelines used for infection surveillance in long-term care facilities, focusing on identifying potential infections and guiding antibiotic stewardship.)Surveyor reviewed the monthly surveillance for January through present of 2025. Surveyor noted no antibiotic use documentation or McGeer criteria assessments in the medical record or surveillance log.On 9/16/25, at 2:24 PM, Surveyor interviewed IP-I and confirmed McGeer's is the criteria used to assess antibiotic use. Surveyor asked how they check a resident on an antibiotic meets the criteria to be on it. Per IP-I the previous DON would type it in the sheets when we talked about residents on antibiotics at the 24-hour meeting. Surveyor noted these sheets did not become part of the resident's permanent medical record.On 09/16/25, at 3:20 PM, during the end of day meeting with the facility, Surveyor let Nursing Home Administrator (NHA)-A and DON-B know concern that in 2025 there is no documentation that McGeer's criteria was used to assess a resident's need for antibiotics.No additional information was provided regarding the use of McGeer's criteria to determine appropriate use of the antibiotics.

Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 5 (R6, R33, R40, R65 and R75) of 5 residents reviewed for immunizations and employee records contained documentation related to COVID-19 immunizations for 1 of 1 staff reviewed.*R6's medical record does not contain any documentation as to whether R6 was offered, received, or declined the COVID-19 immunization.*R33's medical record does not contain any documentation as to whether R33 was offered, received, or declined the COVID-19 immunization.*R40's medical record does not contain any documentation as to whether R40 was offered, received, or declined the COVID-19 immunization.*R65's medical record does not contain any documentation as to whether R65 was offered, received, or declined the COVID-19 immunization.*R75's medical record does not contain any documentation as to whether R75 was offered, received, or declined the COVID-19 immunization.*Staff member (CNA-JJ) reviewed had no documentation of COVID-19 vaccination being offered, received or declined. Findings include:The facility's policy titled, Infection Prevention and Control Program, implemented 10/1/22 documents, in part: 8. COVID-19 Immunization:a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility.c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine. d. Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance. e. Staff will have the opportunity to receive the COVID-19 vaccination or apply for a religious or medical exemption to the vaccine for facility consideration as per current guidelines and facility policy. f. Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine. The facility's policy titled, Vaccine Information Statements, implemented 3/1/19 documents, in part: Prior to the administration of any vaccine, a copy of the most current, relevant CDC Vaccine Information Statement (VIS) will be provided to any child or adult receiving the vaccine or such information will be provided to the legal representative who has the authority to consent to the immunization of a minor child or incompetent adult. Intent of Policy: It is the intent of this policy to provide instructions for the use of CDC's Vaccine Information Statements (VIS) as required under the National Childhood Vaccine Injury Act (42 U.S.C. S3o0aa-26) as well as our current State law(s) governing immunization requirements. (Refer to CDC's VIS statement entitled Instructions for Using Vaccine Information Statements.) Policy Explanation and Compliance Guidelines: 1. Prior to the administration of each vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. 2. Vaccine Information Statements (VIS) will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of such vaccinations. 3. A notation will be made in each resident's medical record at the time vaccine information materials are provided indicating: a. The edition date of the Vaccine Information Statement provided, and b. The date the VIS was provided.4. Individuals receiving vaccines, or their legal representative, will be required to sign a consent form prior to the administration of such vaccine(s). The completed, signed, and dated record will be placed in the individual's permanent medical record. The facility's policy titled, COVID-19 Vaccinations, implemented 1/2/2025 documents, in part: Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice. 2. COVID-19 vaccinations currently in use include the updated 2024-2025 mRNA COVID-19 vaccines such as the Pfizer-BioNTech or Moderna brands and the protein subunit vaccine Novavax 2024-2025 formula. 3. The number of updated 2024-2025 COVID-19 vaccine doses and individual needs is based on age and vaccination history. For people who are not moderately or severely immunocompromised (See Table 1).: ii. People ages 5-64 years: Should receive 1 dose of an age-appropriate 2024-2025 COVID-19 vaccine. (People ages 12-64 years who are unvaccinated and receive the 2024-2025 Novavax COVID-19 vaccine for initial vaccination should receive 2 doses of 2024-2025 Novavax COVID-19 vaccine.) iii. People ages 65 years and older: Should receive 2 doses of any 2024-2025 COVID-19 vaccine, spaced 6 months (minimal interval 2 months) apart. (People ages 65 years and older who are unvaccinated and receive Novavax COVID-19 vaccine for initial vaccination should receive 2 doses of 2024-2025 Novavax COVID-19 vaccine followed by a third dose of any 2024-2025 COVID-19 vaccine dose 6 months (minimal interval 2 months) after the second dose.). 11. COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. 12. Following assessment for potential medical contraindications, COVID-19 vaccinations for residents may be administered in accordance with physician-approved standing orders. 13. The facility may administer the vaccine directly or the vaccine may be administered indirectly through an arrangement with a pharmacy partner or local health department. 14. The facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of such. 15. The facility will maintain documentation related to staff COVID-19 vaccination and include at a minimum: a. Education to the staff regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine; c. The COVID-19 vaccine status of staff and related information as indicated by NHSN. 17. Residents or their representatives and staff will sign the consent form prior to administration of the COVID-19 vaccine. This information will be retained in the resident's medical record or the staff's medical file. 19. Residents or resident representatives retain the right to accept, refuse or change their decision about COVID-19 immunization. If refused, the residents will adhere to the protocols set forth by specific facility policy. 20. The facility will abide by staff vaccination requirements or medical or religious exemptions based on state, local or employer guidance as indicated. (Insert any state, local or employer specific guidance as needed.) 21. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. 1.) R6's Annual Minimum Data Set (MDS) with an assessment reference date of 7/11/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R6 is cognitively intact. R6 is responsible for self.Surveyor reviewed R6's electronic medical record and was unable to locate whether R6 was offered, received, or declined the COVID-19 immunizations.On 09/16/2025, at 8:19 AM, Surveyor interviewed Director of Nursing (DON)-B and found out there have been no COVID-19 vaccinations offered since 2023 and no declinations have been found.On 09/16/2025, at 3:20 PM, during the end of day meeting with facility, Surveyor relayed concern to Nursing Home Administrator-A and DON-B that COVID-19 immunizations were not offered to 5 of 5 residents. Surveyor noted no further evidence of documentation of R6 being offered or refusing the COVID-19 vaccination was provided. 2.) R33's Annual Minimum Data Set (MDS) with an assessment reference date of 9/3/25, does not document a Brief Interview for Mental Status (BIMS) assessment, noted to be unable to complete. R33 has an activated Health Care-Power of Attorney. Surveyor reviewed R33's electronic medical record and was unable to locate whether R33 was offered, received, or declined the COVID-19 immunizations.On 09/16/2025, at 8:19 AM, Surveyor interviewed Director of Nursing (DON)-B and found out there have been no COVID-19 vaccinations offered since 2023 and no declinations have been found.On 09/16/2025, at 3:20 PM, during the end of day meeting with facility, Surveyor relayed concern to Nursing Home Administrator-A and DON-B that COVID-19 immunizations were not offered to 5 of 5 residents.Surveyor noted no further evidence of documentation of R33 being offered or refusing the COVID-19 vaccination was provided.3.) R40's Comprehensive Minimum Data Set (MDS) with an assessment reference date of 6/27/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 10, indicating that R40 has moderate cognitive impairment. Surveyor reviewed R40's electronic medical record and was unable to locate whether R40 was offered, received, or declined the COVID-19 immunizations.On 09/16/2025, at 8:19 AM, Surveyor interviewed Director of Nursing (DON)-B and found out there have been no COVID-19 vaccinations offered since 2023 and no declinations have been found.4.) R65's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/18/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R65 is cognitively intact. R65 is responsible for self.Surveyor reviewed R65's electronic medical record and was unable to locate whether R65 was offered, received, or declined the COVID-19 immunizations.On 09/16/2025, at 8:19 AM, Surveyor interviewed Director of Nursing (DON)-B and found out there have been no COVID-19 vaccinations offered since 2023 and no declinations have been found.On 09/16/2025, at 3:20 PM, during the end of day meeting with facility, Surveyor relayed concern to Nursing Home Administrator-A and DON-B that COVID-19 immunizations were not offered to 5 of 5 residents.Surveyor noted no further evidence of documentation of R65 being offered or refusing the COVID-19 vaccination was provided.5.) R75's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/17/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating that R75 is cognitively intact. R75 is responsible for self.Surveyor reviewed R75's electronic medical record and was unable to locate whether R75 was offered, received, or declined the COVID-19 immunizations.On 09/16/2025, at 8:19 AM, Surveyor interviewed Director of Nursing (DON)-B and found out there have been no COVID-19 vaccinations offered since 2023 and no declinations have been found.On 09/16/2025, at 3:20 PM, during the end of day meeting with facility, Surveyor relayed concern to Nursing Home Administrator-A and DON-B that COVID-19 immunizations were not offered to 5 of 5 residents.Surveyor noted no further evidence of documentation of R75 being offered or refusing the COVID-19 vaccination was provided.6.) Surveyor requested CNA-JJ's COVID-19 immunization information and the facility was unable to provide documentation that the vaccine was offered, received, or declined by CNA-JJ.On 09/16/2025, at 11:04 AM, Surveyor interviewed Business Office staff-KK about CNA-JJ being offered the COVID-19 vaccination and was told it is not offered to staff, only the Hepatitis B vaccination is offered.On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that staff are not offered the COVID-19 vaccination.Surveyor noted no further evidence of documentation of staff being offered or refusing the COVID-19 vaccination was provided.

Based on observation, interview and record review, the facility did not maintain an effective pest control program to address the flying bugs in the facility. *Surveyors observed active pest activity from flies/flying bugs in multiple areas of the Facility's B Unit. *Surveyors observed active pest activity from flies/flying bugs in multiple areas of the Facility's C Unit. Findings include: On 9/15/25 at 10:10 AM Surveyor observed R10's wound treatment. Surveyor noted several swarms of fruit flies hovering by R10's room door on Facility's C Wing. On 9/15/25 at 10:26 AM, Surveyor observed R4's wound treatment. Surveyor noted several swarms of fruit flies hovering by R4's room door and throughout R4's room on Facility's C Wing. On 9/15/25, at 9:52 AM, Surveyor interviewed Maintenance Director-GG regarding pest control for the facility. Maintenance Director-GG states the facility uses [Pest control company] to put bait stations outside the facility or to put a gel down on the floor if there is a concern with ants. Maintenance Director-GG stated Maintenance Director-GG sealed up some cracks where ants were coming in and [Pest control company] provides service once per month. Maintenance Director-GG stated if a resident complains of gnats flying around, Maintenance Director-GG goes into their room to make sure any old food is thrown out and checks the drains and cleans them out per [Pest control company] recommendation. Maintenance Director-GG states since cleaning out the drains, there haven't been as many flies. On 9/15/25 at 1:33 PM, Surveyors shared concerns with Director of Nursing (DON)-B that Surveyor had observations of fruit flies in R4 and R10's resident rooms while wound treatments were being conducted. On 9/17/25 at 8:44 AM, DON-B informed Survey team that there is no facility policy on pest control and if there is a problem identified the facility would call [Pest control company] to come out to take care of it On 9/9/25, at 10:10 AM, during an interview with R32, Surveyor observed a sticky fly strip hanging on a hanger in R32's room on B-unit. On 9/9/25, at 10:13 AM, Surveyor observed a fly flying around in room [ROOM NUMBER] on B-unit. On 9/9/25, at 10:44 AM, Surveyor observed a fly flying around in room [ROOM NUMBER] on B-unit. On 9/9/25, at 11:05 AM, during an interview with R85, Surveyor observed multiple flies flying around R85's room on B-unit. Surveyor asked R85 if there is a problem with flies, R85 replied R85 notices flies in the room. On 9/9/25, at 1:49 PM, Surveyor interviewed R2, who resides in the same room as R85, if there is a problem with flies. R2 states R2 tries to keep the door closed with the fan on to keep the flies away, but there are a lot around right now. On 9/10/25, at 8:23 AM, during an interview with R32, Surveyor observed multiple flies flying around R32's room on B-unit. Surveyor asked R32 if there is a problem with flies. R32 stated the gnats have been going on for a few months at least, and R32 put up the fly strip in the room to try to help. On 9/15/25, at 9:06 AM, Surveyor observed multiple fruit flies flying around in the hallway of B-unit. On 9/15/25, at 9:52 AM, Surveyor interviewed Maintenance Director-GG regarding pest control for the facility. Maintenance Director-GG states the facility uses [Pest control company] to put bait stations outside the facility or to put a gel down on the floor if there is a concern with ants. Maintenance Director-GG stated Maintenance Director-GG sealed up some cracks where ants were coming in and [Pest control company] provides service once per month. Maintenance Director-GG stated if a resident complains of gnats flying around, Maintenance Director-GG goes into their room to make sure any old food is thrown out and checks the drains and cleans them out per [Pest control company] recommendation. Maintenance Director-GG states since cleaning out the drains, there haven't been as many flies. On 9/15/25, at 1:33 PM, Surveyor shared concern with Director of Nursing (DON)-B that Surveyor had multiple observations of fruit flies and gnats flying around the hallway and resident rooms in B-unit, and Surveyor observed a sticky fly strip hanging in R32's room on B-unit. DON-B stated DON-B would make sure the fly strip was taken down. On 9/15/25, at 3:18 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A that Surveyor had multiple observations of fruit flies and gnats flying around the hallway and resident rooms in B-unit, and Surveyor observed a sticky fly strip hanging in R32's room on B-unit. On 9/16/25, at 1:30 PM, Surveyor observed multiple fruit flies flying around in the hallway of B-unit. On 9/17/25, at 8:44 AM, DON-B informed Surveyor that there is no facility policy on pest control, and if there is a problem identified the facility would call [Pest control company] to come out. On 9/9/2025, at 10:30AM, During an interview with R5, Surveyor observed flies in R5's room and R5 stated, These darn flies, and swatting them away. R5 stated there are always flies flying around R5's bedroom and the facility. On 9/9/2025, at 10:38AM, Surveyor observed fruit flies flying around the hallway. On 9/10/2025, at 12:43PM, Surveyor observed the noontime meal cart in the hallway with 2 flies flying around it. On 9/10/2025, at 12:59PM, Surveyor was standing in hallway around rooms [ROOM NUMBERS], Surveyor observed fruit flies and flies flying around Surveyors computer. On 9/10/2025, at 1:02PM, Surveyor interviewed certified nursing assistant (CNA)-T who stated the flies in the facility are very bad. CNA-T stated residents have fly swatters in their rooms and are always complaining about flies. CNA-T stated there used to be a bug zapper on the patio but has not seen it out there for awhile and the flies seem to get worse on hotter days. CNA-T stated that staff and residents have just grown accustomed to having the flies around because they are always there. CNA-T stated all the units in the facility have issues with flies and fruit flies, but CNA-T primarily works on B-unit. On 9/15/2025, at 9/15/2025AM, Surveyor observed multiple fruit flies flying around in the hallway around rooms 10, 11, 12, and 13. On 9/15/2025, at 9:58AM, Surveyor interviewed maintenance director-GG who stated has been employed with the facility for about 3 (three) months. Maintenance director-GG stated the facility has issues with ants getting into the building, cracks in the building have been sealed to prevent access. Maintenance director-GG stated [Pest control company] comes to the facility every month and walks around the perimeter of the building to inspect for pest activity, [Pest control company] also walks inside to inspect for any concerns. Surveyor asked if maintenance director-GG was aware of fly/ fruit fly concerns in the facility. Maintenance director-GG stated awareness that there have been complaints. Maintenance director-GG stated [Pest control company] said to clean out the sink drain pipes in the room to get rid of any possible causes to the flies. Maintenance director-GG stated if a resident complains of flies/ bugs then maintenance director-GG will clean out the sink pipe and has located straws in the sink pipes. Surveyor requested to review the last 3 months of services provided by [Pest control company]. Surveyor reviewed services provided by [Pest control company] on: 4/9/2025, 5/14/2025, 6/19/2025, 7/22/2025, and 8/19/2025 and noted the following documented observations/ recommendations:- On 4/9/2025 [Pest control company] documented observations of midges (any kind of small fly often referred as no-see-ums) noted in the interior light traps and recommended checking drain lines for standing water in sinks to prevent drain flies from breeding. This concern was documented as still pending from a start date of 9/13/2023 indicating an ongoing concern [Pest control company] has with the facility.- On 5/14/2025 [Pest control company] documented observations of moderate fly activity in every fly light and the fly light in the main lobby was unplugged. 2 holes were noted on the exterior of the facility that was recommended to be plugged/ closed to assist with insect/pest control.- On 6/19/2025 [Pest control company] documented observations of a lot of flying pest activity: moths and flies were inside fly lights caused by doors being left open for a long period of time before closing, and the light trap at the main entrance was unplugged again allowing flying pests to enter facility instead of being attracted to the fly light.- On 7/22/2025 [Pest control company] documented observations of fruit flies flying around drains in the facility. Upon further observation, straws were found wedged in one of the drains and was unable to remove the straws. Fly lights inspected and noted a large number of moths and other insects inside the fly lights indicating doors to the outside are left open for long periods of time allowing flying pests into the facility. Several resident rooms were observed to have ants due to food debris in the rooms. Fruit flies observed in room [ROOM NUMBER] on C-unit, room [ROOM NUMBER] observed to have a break in the wall by the toilet allowing moisture to build up allowing the fruit flies to flourish. Recommendations provided to maintenance director-GG to repair room [ROOM NUMBER] break in the wall, clean out/ inspect all drains in the facility, and ensure door to the exterior are not left open for extended periods of time.- On 8/19/2025 [Pest control company] documented observations of the fly light located in the smoking area, the fly light had a large number of moths and flies in the flight light not allowing flying pests to stick to the glue board. A large number of moths were noted hanging on the wall located by the fly light. Recommendation to inspect and replace fly light glue boards as needed to prevent buildup of flying pests. On 9/15/2025, at 3:15PM, Surveyor shared concerns with nursing home administrator (NHA)-A, director of nursing (DON)-B, and regional nurse consultant (RNC)-L regarding pest control in the facility and Surveyors observations of fruit flies and flies on B-unit and resident rooms. Surveyor requested to review the facility 'Pest Control policy. On 9/16/2025, at 1:31PM, Surveyor observed fruit flies along the whole hallway on B-unit. On 9/17/2025, at 8:44AM, DON-B stated the facility does not have a Pest Control policy. [Pest control company] is called whenever there is a concern. Surveyor noted that [Pest control company] has not been contacted regarding addressing the flying pest concerns other than when [Pest control company] is at the facility for their monthly check and each month between 4/2025 – 8/2025 there have been concerns brought forth regarding flying pest in the facility. On 9/17/2025, at 2:15PM, Surveyors observed a large number of ants located underneath the desk in the upstairs conference room. NHA-A and DON-B were made aware.

Based on interview and record review, the facility did not ensure that 7 of 8 sampled staff received training on the facility's compliance and ethics program.This has the potential to affect the 85 residents who reside at the facility and have the potential to receive direct and indirect care from these staff. Findings Include:On 9/30/25, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, evidence that the following staff members received training regarding compliance and ethics:Certified Nursing Assistant (CNA)-WW hire date 8/8/23CNA-TT hire date 9/19/23CNA-XX hire date 9/12/22CNA-YY hire date 10/3/23CNA-ZZ hire date 1/5/06Housekeeping-AAA hire date 1/25/24Speech Language Pathologist (SLP)-BBB hire date 5/16/23Registered Nurse (RN)-CCC hire date 2/1/23Surveyor reviewed completed trainings and noted there was not documentation that CNA-WW, CNA-TT, CNA-XX, CNA-YY, CNA-ZZ, SLP-BBB, or RN-CCC received training of the facility's compliance and ethics program on an annual basis.On 9/30/25, at 11:20 AM, Surveyor shared concerns with NHA-A that seven sampled staff did not have evidence of completing the facility's compliance and ethics program. NHA-A stated NHA-A would try to find any additional information. On 9/30/25, at 3:02 PM, NHA-A stated no additional information was located regarding compliance and ethics training for CNA-WW, CNA-TT, CNA-XX, CNA-YY, CNA-ZZ, SLP-BBB, or RN-CCC.

Based on record review and interview, the facility did not ensure 7 out of 8 staff chosen at random received behavioral health training to care for residents diagnosed with a mental, psychosocial, or other behavioral health conditions. This deficient practice has the potential for staff to lack current knowledge to work with the unique challenges mental health illnesses present and has the potential to affect all 85 residents that have the potential to experience behavioral health issues in the facility.Findings include:Surveyor notes, when asking Nursing Home Administrator (NHA)-A for a policy on required annual in-service training, NHA-A stated, the facility does not have a policy on in-service training. On 9/30/25 at 8:40 AM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, evidence that the following staff members received training regarding behavioral health:Certified Nursing Assistant (CNA)-WW, date of hire 8/8/23CNA-TT, date of hire date 9/19/23CNA-XX, date of hire 9/12/22CNA-YY, date of hire 10/3/23CNA-ZZ, date of hire 1/5/06Housekeeping-AAA, date of hire1/25/24Speech Language Pathologist (SLP)-BBB, date of hire 5/16/23Registered Nurse (RN)-CCC, date of hire 2/1/23Surveyor reviewed completed trainings in Relias (software for employee education) and noted there was no documentation that CNA- WW, CNA-TT, CNA-XX, CNA-ZZ, Housekeeping- AAA, SLP-BBB and RN-CCC received training of the facility's compliance and ethics program on an annual basis.On 9/30/25 at 11:20 AM, Surveyor interviewed NHA-A who stated, Human Resources is responsible for assuring staff receive the required training. Surveyor notified NHA-A that there was no evidence CNA-WW, CNA-TT, CNA-XX, CNA-ZZ, Housekeeping- AAA, SLP-BBB and RN-CCC received the behavioral health training. NHA-A stated, NHA-A would consult with team and get back to Surveyor if any additional information could be found. On 9/30/25, at 3:02 PM, NHA-A stated no additional information was located regarding behavioral health training for CNA-WW, CNA-TT, CNA-XX, CNA-ZZ, Housekeeping- AAA, SLP-BBB and RN-CCC. Surveyor notified NHA-A and DON-B that no training for behavioral health for the identified staff is a concern. NHA-A and DON-B acknowledged the missing training.

Based on interview and record review, the facility did not ensure residents whose Medicare part A benefits ended were provided with written beneficiary protection notifications for 4 (R15, R100, R101, R102) of 5 residents sampled for beneficiary notifications. The facility did not provide 4 Residents (R15, R100, R101, & R102) of 5 sampled residents a written Advanced Beneficiary Notice (ABN), which includes financial liability information and appeal rights, at the time Medicare Part A coverage ended. Findings include: The facility policy titled, Advance Beneficiary Notice Policy implemented [DATE], documents, in part: Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines.:c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered services(s) are ending, no matter if resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO).i. This notice is used when all covered services end for coverage reasons.ii. An exhaustion of benefits is not considered a termination for coverage reasons.5. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when Part B therapies are ending.6. The Business Office Manager, or designee, is responsible for issuing notices.Notice of Medicare Non-Coverage (NOMNC) (Form CMS 10123-NOMNC) is utilized to provide written notification to resident or resident representative that Medicare Part A coverage is ending in two or more days. The notification includes appeal rights and provides the third party reviewer name and phone number to begin an immediate appeal.Advance Beneficiary Notice (ABN) (Form CMS-10055) is utilized to provide written notification to resident or resident representative of services Medicare A will no longer cover, an estimated cost of those services, and three options which include each choice's effect on appeal rights.During the survey, a list of 5 residents whose Medicare A benefits have expired was provided to Surveyor. On [DATE], at the end of day meeting, Surveyor asked for the notices that should have been provided to the resident or families prior to the benefit ending.On [DATE], at 7:45am, Nursing Home Administrator (NHA)-A informed Surveyor they could only find one NOMNC, stating: the lady who used to do them worked at the facility for 30 years and passed away. They are still redistributing her work. NHA-A doesn't believe there are anymore that would have been completed.On [DATE], at 3:19pm, during the end of day meeting with the Facility, the concern that only one of 5 residents received proper notices that Medicare Part A benefits were ending was shared. No additional information was provided as to why the facility did not provide ABN information to residents or their representatives.

Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistance devices to prevent elopements or accidents for 2 of 4 residents (R1 and R4) reviewed for elopement and falls. *R1 was discovered on the ground outside the facility’s front door on 5/6/2025 at 3:45 AM. R1’s fall was not thoroughly investigated to determine the root cause of the fall and the elopement out of the building was not investigated. On 7/10/2025 at 3:00 AM, R1 was discovered to be missing from the facility. The police found R1 at 4:55 AM on a bench at a street intersection 1.2 miles away from the facility. R1’s elopement was not investigated.The facility’s failure to supervise a resident to prevent elopements in the middle of the night, its failure to ensure the front door alarm was always working, and its failure to do an investigation to determine a root cause of the elopements created a finding of immediate jeopardy that began on 5/6/2025. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 7/15/2025 at 2:48 PM. The immediate jeopardy was removed on 7/21/25, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following example: * R4 fell from bed on 6/28/2025 due to the wheels of the bed not being locked. The care plan intervention of the wheels being locked on the bed was observed not to have been in place during a transfer. Findings include: The facility’s policy and procedure titled “Elopement” with no date documents: “The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: …2. ‘Elopement’ occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door lacks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident’s risk, modify the resident’s behavior, or to minimize risks associated with hazards will be added to the resident’s care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 7. Procedure for Locating Missing Resident a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code). b. The designated facility staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company’s corporate office. d. DON or designee shall notify the physician and family member or legal representative. e. Police will be given a description and information about the resident, include any photos. f. All parties will be notified of the outcome once the resident is located. g. Appropriate reporting requirements to the State Survey agency shall be conducted. 8. Procedure Post-Elopement a. A nurse will perform a physical assessment, document, and report findings to physician. b. Any new physician orders will be implemented and communicated to the family/authorized representative. c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults. d. The resident and family/authorized representative will be included in the plan of care. e. Staff may be educated on the reasons for elopement ad possible strategies for avoiding such behavior. f. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. g. Documentation in the medical record will include: finding from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable.” 1.) R1 was admitted to the facility on [DATE] with diagnoses of cerebrovascular disease, moyamoya disease (a rare progressive cerebrovascular disorder characterized by the narrowing or blockage of the internal carotid arteries and the formation of abnormal blood vessels at the base of the brain leading to reduced blood flow to the brain causing strokes, transient ischemic attacks, and other neurological symptoms), and vascular dementia. R1’s admission Minimum Data Set (MDS) assessment dated [DATE] documented R1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R1’s Elopement Risk assessment dated [DATE] documented R1 was a risk of elopement with a score of 1 (1 or higher was at risk for elopement) due to R1 being admitted to the facility within the last 30 days and not accepting of the situation. R1 did not have a history of wandering or elopement from home per the risk assessment. Surveyor noted no Elopement Care Plan was initiated for R1 with this assessment. R1’s Physical Functioning Deficit Care Plan was initiated on 4/22/2025 and documented R1 needed transfer and walking assistance with distance supervision on 4/28/2025. R1’s At Risk for Falls Care Plan was initiated on 4/28/2025 with the interventions:-Call light and personal items available and in easy reach.-Clear and monitor environmental obstacles (tubing, cords, etc.).-Footwear to prevent slipping.-Keep bed locked. R1’s progress noted dated 5/6/2025 at 6:36 AM written by an RN (Registered Nurse) documented: At approximately 3:45 AM, the RN was informed by the pharmacy delivery driver that R1 was sitting down outside. The RN observed R1 sitting upright at the front outside the building. R1 stated R1 had been feeling a little tipsy because R1 had drank some alcohol and fell on their “butt”. R1 stated R1 was okay. The RN assessed R1; R1 was alert and oriented with some confusion. R1 sustained an abrasion to the right thumb. Staff members assisted R1 up from the floor and ambulated to R1’s room with assistance of staff. The RN searched R1’s room and did not find any alcohol. The Nurse Practitioner (NP) was notified and instructed staff to continue with neurological checks. R1’s POA was called and updated. The RN completed a Post Fall Evaluation documenting the cause of the fall to be wandering. R1’s progress note dated 5/6/2025 at 1:19 PM and written by Director of Social Services (DSS)-C documents: DSS-C was alerted of R1’s fall early that morning as a result of alcohol intoxication. The psych NP was notified, and a psych referral was made. DSS-C documented DSS-C spoke with R1 regarding behavioral expectations while in the facility and R1 expressed understanding regarding the risk associated with alcohol use.Surveyor was provided the Risk Management tool used by the facility for incidents/events. The documentation on the tool was the same as documented by the RN in the progress notes on 5/6/2025. According to timeanddate.com, the temperature in Glendale, Wisconsin at 3:55 AM was 45 degrees with no wind, humidity 93%. In an interview on 7/15/2025 at 8:51 AM, Licensed Practical Nurse Unit Manager (LPNUM)-H stated LPNUM-H was not employed at the facility at the time of the fall or elopement on 5/6/2025 but would review R1’s medical record to see if any more information was documented at that time. LPNUM-H provided a statement by the RN as part of the Risk Management tool dated 5/6/2025. The statement documented: “Resident came out of room, staff redirected (R1) back to (R1’s) room Resident stated ‘I slept all day, I want to move around’ Resident tried to go outside, staff brought (R1) back in, informed Resident it was too early to go outside. Door Bell was not working”. LPNUM-H stated from reading that statement, it could not be determined when R1 was trying to leave the building, if it was before R1 was found outside or after the incident of the fall outside. LPNUM-H stated the statement was unclear if the alarms when leaving the building were not working or if the doorbell to come back in was not working and would have meant R1 was locked out of the building. LPNUM-H stated the investigation into the fall and the elopement did not create a clear picture of what happened at that time with R1. LPNUM-H provided Surveyor with the Risk Management interdisciplinary team (IDT) meeting documentation. On 5/13/2025, the IDT determined the cause of the fall to be walking outside on uneven surfaces without the walker after drinking alcohol. R1 was found sitting on R1’s bottom outside. R1 reported that R1 was drinking and feeling tipsy. R1’s vital signs were stable, denied any pain, denied hitting the head, and neurological checks were initiated. Surveyor noted the IDT did not meet until 5/13/2025, seven days after the fall and elopement. R1’s At Risk for Falls Care Plan was revised on 5/12/2025 with the interventions:-Offer ADOA (Alcohol and Other Drug Abuse).-Refer to Psych. Surveyor noted the investigation of the fall and elopement did not include where R1 obtained the alcohol or if other physical disease processes were a factor. Surveyor noted the investigation did not include if the alarm system was working, when R1 was last seen to know how long R1 had been outside of the building, or any other behaviors R1 was exhibiting prior to leaving the facility. No elopement or wandering care plan was initiated at that time. On 5/8/2025, R1 was seen by the Psych (psychiatric) NP. The Psych NP documented staff reported that R1 fell that week due to being intoxicated. No additional alcohol use was reported after that incident. R1 did not have a history of alcohol use. R1’s Medication Administration Record (MAR) had an order to monitor R1’s behaviors and document those behaviors on every shift. Nurses documented R1 had wandering behaviors on 5/24/2025 AM shift, 6/6/2025 PM shift, and 6/7/2025 AM shift. No elopement or wandering care plan was initiated at that time. On 6/12/2025, R1 was seen by the Psych NP. The Psych NP documented staff reported that R1 was having increased confusion, restlessness, and agitation this week, which started when R1 got a new roommate. Staff report that R1 was difficult to redirect currently. The Psych NP documented the Psych NP called and spoke with R1’s POA to discuss medication options for R1’s agitation. The Psych NP recommended an increase in R1’s antipsychotic medication dose, but R1’s POA refused the dose increase stating R1 “is only agitated because something is wrong, and this place needs to fix why (R1) is agitated.”Nurses documented on R1’s MAR R1 had wandering behaviors on 6/13/2025 AM and PM shift. On 6/18/2025 at 7:59 PM in the progress notes, DSS-C documented DSS-C met with R1’s POA and discussed R1 likes to take short walks in the community. R1’s POA indicated R1’s POA was okay with R1 signing themselves out and going on a walk unsupervised. DSS-C advised against this and discussed the risk vs benefit. R1’s POA expressed understanding. DSS-C offered an intervention that R1 could request staff to accompany on short walks, time permitting, otherwise POA advised the POA can be called to come in and accompany R1 when R1 would like to go out for a walk. R1’s At Risk for Elopement Care Plan was initiated on 6/18/2025 related to attempts to leave living center to go on short walks. The following interventions were initiated at that time:-Assess for risk of elopement per living center policy.-Assess for secure unit.-Evaluate effect of cognitive impairment upon resident’s ability to understand changes in surroundings.-Redirect patients from doors.-Take picture of patient upon admission for identification for updating elopement book. R1’s Behavior Care Plan was initiated on 6/18/2025 with behaviors that include going for short walks near the facility “WITHOUT” notifying staff and R1’s POA has given permission for R1 to take short walks unsupervised however staff encourages R1 to request an escort for safety. The following interventions were initiated at that time:-Attempt interventions before my behaviors begin.-Help R1 maintain their favorite place to sit.-If R1 seems restless, please offer to escort R1 on a short walk in the community/or call POA to escort R1 on a walk.-Make sure R1 is not in pain or uncomfortable.-Offer R1 something likes as a diversion. On 6/18/2025 at 5:30 PM until 6/21/2025 at 11:45 AM, facility staff were documenting 15-minute checks on R1. On 6/18/2025, R1’s Elopement Risk Profile page was placed in the Wandering/Elopement binder indicating R1 was at risk for elopement. The profile page documented R1’s identifying information as well as the presence of dementia and impulsivity. The profile page documented R1’s favorite spot outside was under a bridge across from a grocery store approximately 0.3 miles from the facility. No documentation was found preceding the elopement and wandering behavior care plans being initiated, the reason R1 was placed on 15-minute checks, or the reason R1 had a profile page in the Wandering/Elopement binder. No documentation was found indicating R1 had been leaving the building or wanting to take walks. On 6/19/2025, R1 was seen by the Psych NP. The Psych NP documented staff reported that R1 was having continued restlessness and agitation. R1 was moved to a different room this week, but the agitation continued. R1 was very difficult to redirect. R1 was pacing the unit and was up by the nurses’ station frequently. R1’s POA was at the facility and the Psych NP along with the unit nurse tried to talk to R1’s POA about R1’s agitation. The Psych NP recommended a few medication options, as R1 was reporting feelings of nervousness and restlessness. R1’s POA refused to increase R1’s current antipsychotic dose or to start any new medications stating R1 “is not that bad”, and R1 “doesn’t need more medications”. Nursing staff documented on R1’s MAR R1 had wandering behaviors on 6/19/2025 PM shift, 6/23/2025 AM shift, 6/24/2025 AM shift, and 7/9/2025 night shift. On 7/10/2025 at 8:30 AM in the progress notes, RN-I documented RN-I noticed R1 was not in R1’s room at 3:00 AM. Everywhere was checked and R1 was not found in the building or its environment. 911 was called and police officers showed up and helped with the search. A police officer brought R1 back to the facility at 4:55 AM stating R1 was found at an intersection sitting on a bench. (The exact location was documented in the progress note.) Director of Nursing (DON)-B was notified of the incident as well as the Unit Managers. Surveyor noted the intersection R1 was found sitting on a bench was 1.2 miles from the facility. The facility is located on a heavily trafficked 4-lane divided road with a grassy median with center turn lanes and sidewalks. The speed limit of the street is 30 miles per hour. R1 would have crossed multiple intersections including an on/off ramp intersection and under/overpasses. According to timeanddate.com, the temperature in Glendale, Wisconsin at 4:15 AM was 59 degrees, humidity 100%. There was no wind. Surveyor noted R1’s medical record did not have any documentation after the progress note on 7/10/2025 at 8:30 AM. R1 did not have any vital signs taken upon return to the facility. No head-to toe-assessment was completed to check for injuries. No follow up documentation was found regarding behaviors or aftereffects of being out of the facility for greater than two hours in the middle of the night. R1’s Care Plan was not revised. In an interview on 7/14/2025 at 10:34 AM, Surveyor asked Receptionist-G if the facility had a book or binder of residents at risk for elopement. Receptionist-G stated yes, it is right here at the front desk and provided the binder to Surveyor. Surveyor noted the Elopement Policy was at the front of the binder and three residents had an Elopement Risk Profile page. R1 was not included in the Wander/Elopement binder at the front desk. Surveyor asked Receptionist-G if the residents in the binder were the residents that had a Wanderguard in place. Receptionist-G stated no, the binder has all residents that may get out. Receptionist-G stated DSS-C is the one that updates the binder; all the residents with a Wanderguard on are on the C Unit. Surveyor asked Receptionist-G what doors are equipped with alarms. Receptionist-G stated all the doors have alarms and the front door gets locked at 8:00 PM. Surveyor asked Receptionist-G if there was a sign-out book for residents leaving the building. Receptionist-G stated yes and showed the book to Surveyor. Receptionist-G stated residents do not have to sign out in the book if they are just going for a walk. Receptionist-G provided the names of four residents that do sign out in the book when they are going to leave the building to go to the grocery store. R1 was not a resident that Receptionist-G named. Surveyor asked Receptionist-G if R1 was a resident that was at risk for eloping or leaving the building without anyone knowing. Receptionist-G stated there are no problems with R1; R1 will sit outside the front door and if R1 starts to get up to go somewhere, Receptionist-G will point at R1 through the window to tell R1 “no” and then R1 comes in or sits back down. Receptionist-G stated sometimes she has to go to the front door so R1 can hear Receptionist-G, but R1 has never caused a problem. Surveyor noted the reception desk is adjacent to a glass wall so the bench outside the front door is easily visible. Surveyor asked Receptionist-G if R1 had ever gotten out of the building and far away. Receptionist-G stated she was not aware of any elopements. In an interview on 7/14/2025 at 1:07 PM, Surveyor asked DON-B for the investigations the facility did on R1’s elopements. DON-B stated there are no investigations. Surveyor asked DON-B how many times had R1 eloped. DON-B thought R1 had eloped twice stating after the first elopement there was a discussion with R1’s POA and the POA said it was okay for R1 to go for a walk by themselves. Surveyor noted the discussion with R1’s POA was on 6/18/2025 where there was no documentation of an elopement or R1 taking walks out in the community. On 7/14/2025 at 1:23 PM, Surveyor observed the front desk with no staff and no staff was in view of the front door. Surveyor noted one resident outside the building in an electric wheelchair by the bench located by the front door. On 7/14/2025 at 2:03 PM, Surveyor observed R1 awake, lying in bed. Surveyor asked R1 if R1 likes to go for walks. R1 stated yes, he goes after breakfast and before dinner, and sometimes after dinner. Surveyor asked R1 if R1 ever goes for a walk at night. R1 denied ever going for a walk at night. R1 stated there is a log to sign out but you do not have to sign out, you can just go. Surveyor again asked R1 about leaving the building in the middle of the night. R1 stated R1 had never left in the middle of the night. In an interview on 7/14/2025 at 3:25 PM, Surveyor asked Nursing Home Administrator (NHA)-A and DON-B how the alarming system works for the front door. NHA-A stated the door is locked at 8:00 PM and you must punch a code to get out, otherwise the alarm goes off, and to get in, you have to ring the doorbell. In an interview on 7/14/2025 at 3:38 PM, Surveyor asked LPN-F about R1’s behaviors. LPN-F stated R1 wanders but is easily redirected. LPN-F stated R1 wanders aimlessly; R1 will be sitting in the back hallway and then goes to R1’s room, then goes to the front, back and forth. LPN-F stated R1 does not hurt anyone with the wandering. Surveyor asked LPN-F if R1 had ever gotten out of the building. LPN-F stated R1 had gotten out to the street one time. LPN-F was not sure how far R1 got. LPN-F stated R1 had never gotten out of the building when LPN-F was working. LPN-F stated LPN-F tries to put eyes on R1 every 30 minutes. On 7/15/2025 at 8:32 AM, Surveyor asked Receptionist-G for the Wander/Elopement binder. Receptionist-G stated the binder is kept at the nurses’ station. The binder that was at the reception desk the day before was no longer at the reception desk. Surveyor found 4 separate Wander/Elopement binders, three located at the main nurses’ station and one located on the C Unit. A total of 8 residents were in the binders including R1. In an interview on 7/15/2025 at 8:40 AM, LPN-F stated the elopement binder for the hall LPN-F was working was at the nurses’ station. LPN-F was not sure where the other three hallway binders were kept. In an interview on 7/15/2025 at 8:51 AM, Surveyor asked LPNUM-H about the circumstances of R1’s elopement on 7/10/2025. LPNUM-H reviewed the charting in R1’s medical record from the progress note on 7/10/2025. LPNUM-H stated on nightly rounds on 7/10/2025, R1 was not in their room. The whole building was searched and 911 was called. R1 was brought back to the building at 4:55 AM by the police. R1 was sitting on a bench. LPNUM-H stated R1 does not have a Wanderguard and when they see R1 leave, they ask R1 to sign out. LPNUM-H stated R1’s care plan says R1 likes to leave the building and R1’s POA has given permission for R1 to go on walks unsupervised. Surveyor asked LPNUM-H if R1 was safe to go for an unsupervised walk at 3:00 AM. LPNUM-H stated there are not enough staff on the night shift to take R1 for a walk at 3:00 AM. LPNUM-H stated R1 was not safe to go for a walk in the middle of the night. Surveyor asked LPNUM-H if there was an investigation into the elopement. LPNUM-H stated the nurse on staff would notify the DON of an event like that. LPNUM-H could not find anything in R1’s medical record to indicate that R1’s elopement was investigated. Surveyor shared the concern with LPNUM-H that Surveyor was unable to find any documentation after R1 returned to the facility that a skin check was done or vital signs taken to assess for injury. LPNUM-H agreed there were no assessments in R1’s medical record after R1 returned on 7/10/2025. LPNUM-H stated it would make sense to do a complete assessment to make sure R1 was not injured; it may not be a change in condition but vital signs and a skin check for injuries should have been completed. In a phone interview on 7/15/2025 at 9:35 AM, Surveyor asked RN-I to review the events of R1’s elopement on 7/10/2025. RN-I stated RN-I checks every resident when RN-I comes on duty at 10:30 PM. RN-I stated RN-I saw R1 at 11:00 PM and checks on R1 every time RN-I walks down the hall. RN-I stated another resident requested a pain medication and when RN-I went past R1’s room, R1 was not there. RN-I stated RN-I checked the bathroom and when R1 was not there, RN-I called the Certified Nursing Assistant (CNA) to help look for R1. RN-I stated residents are checked every two hours on night shift and the CNA saw R1 at Midnight and 1:00 AM. RN-I stated at 3:00 AM, R1 was not seen. RN-I stated they looked outside because on a previous day, R1 had wanted to go outside to go to their car. RN-I stated that was at 2:00 AM on a previous day, but since R1 had said that, RN-I thought to look outside. RN-I stated they looked out the front door, the side door, the parking lot in back and the bus stop. RN-I stated then they called 911. Surveyor asked RN-I if RN-I did an assessment of R1 when R1 was returned to the facility. RN-I asked R1 if R1 was okay and R1 said yes. RN-I said R1 did not have any issues so RN-I thought R1 was okay. Surveyor asked RN-I if R1 had gotten outside in the past. RN-I stated R1 could be easily redirected and was not aware of R1 getting out of the facility before. Surveyor asked RN-I if RN-I had to make up a report or anything for an investigation. RN-I stated RN-I talked to the DON and the Unit Manager that day. Surveyor asked RN-I if the door had alarmed. RN-I stated no alarm had gone off to alert them that R1 was outside. In a phone interview on 7/15/2025 at 9:51 AM, Surveyor asked R1’s POA if R1’s POA had a conversation with DSS-C about R1 going for walks unsupervised. R1’s POA stated yes, R1’s POA had a conversation and did say it was okay for R1 to go on walks by themselves. Surveyor asked R1’s POA if R1’s POA was aware of R1 leaving the facility in the middle of the night. R1’s POA stated yes, they informed R1’s POA of R1 leaving and R1’s POA was not okay with R1 going for a walk alone in the middle of the night. R1’s POA stated R1 should not go for a walk at 2 in the morning and R1’s POA was going to talk to the facility staff about that. In an interview on 7/15/2025 at 10:06 AM, Surveyor shared the concerns with DSS-C that R1’s fall on 5/6/2025 was not investigated as to how or why R1 was outside at 3:45 AM, there was no documentation preceding 6/18/2025 when R1’s care plan was updated with wandering/eloping behaviors and 15-minute checks were initiated, and when R1 eloped on 7/10/2025, there is no investigation into the elopement such as working alarms on the door and the care plan was not revised to increase supervision. DSS-C stated the changes in R1’s care plan and the 15-minute checks had something to do with a care conference but could not recall the exact events. DSS-C stated DSS-C would look into DSS-C’s soft files and get back to Surveyor. On 7/15/2025 at 10:22 AM, Surveyor shared the concerns with NHA-A and DON-B R1’s elopements on 5/6/2025 and 7/10/2025 were not investigated, R1’s care plans were not revised after the elopements, and R1’s medical record lacked documentation of behaviors of wandering other than a checkmark on the MAR indicating wandering was occurring. R1’s wandering and elopement care plans were initiated on 6/18/2025 with no documentation as to the preceding events that indicated R1 needed these to be in place and R1 was put on 15-minute checks at that time as well with no indication of why. When R1 returned to the facility on 7/10/2025 after being gone for at least two hours in the middle of the night, and found 1.2 miles away, no assessments were done to determine if R1 had any injuries or psychological effects of the event. Surveyor shared the concern that even though R1’s POA stated it was okay for R1 to go on walks in the community unattended, that would not include walks in the middle of the night; the fact that the police were called to assist in finding R1 shows that walking in the middle of the night is not a safe activity. Surveyor shared the concern that there was no investigation into the elopements and there was no assessment of the alarm system to see if it was functioning to prevent other residents from eloping as well. In an interview on 7/15/2025 at 10:46 AM, Surveyor asked Director of Maintenance (DM)-K how long DM-K had been employed at the facility. DM-K stated DM-K had worked at the facility for about one month. Surveyor asked DM-K if there have been any problems with the alarm system on the front door or any alarmed door. DM-K stated when DM-K first started working the door alarms were working. DM-K stated the side door is always alarmed but the front door is open at 7:00 AM and automatically locked at 8:00 PM and when it is locked, the alarm is activated. DM-K stated every morning, DM-K does rounds and checks on all the doors and alarms. DM-K stated on 7/10/2025 in the morning, the power box was unplugged. DM-K was not sure if it got bumped or something, but DM-K plugged it back in and knows it was working after it was plugged back in. DM-K showed Surveyor the plug at the front door. The doorway has double glass doors with a small space leading to a second set of outer double glass doors. The alarm is only for the inner double glass doors and the power plug referenced before is to the upper right corner of the inner glass doors within reach of adult-sized people. DM-K showed Surveyor where a screw normally holds the plug in place, but the screw was missing. DM-K was not sure how long the screw had been missing allowing the plug to become unplugged. DM-K stated sometimes storms will knock out the power because it is an old building. Surveyor asked DM-K in the last month how many times the alarms system had been affected by a power outage. DM-K stated twice. Surveyor asked DM-K how the door is secured when the alarm system is not functioning. DM-K stated the doors have to be manually locked, but then they cannot be opened in case of a fire. DM-K stated the alarm system was not working on Monday, 7/14/2025 when DM-K came to work and checked it in the morning. DM-K was not sure what the problem was so had someone who specializes in alarm systems come in to do repairs. Surveyor had noted someone working on the front doors the prior day. DM-K stated the alarm was working on Thursday 7/10/2025 after DM-K had plugged it back in. DM-K stated DM-K did not work on Friday, Saturday, or Sunday so did not know when the alarm system had stopped working. DM-K stated currently the door alarm is not working because parts had to be ordered. &nb

Based on observation, interview, and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R9) of 1 resident reviewed for weight loss and fluid management.R9 experienced severe weight loss over a period of 3 months, while receiving enteral feeding. The weight loss was not prescribed; no new interventions were implemented, and no assessments were completed to prevent R9's weight loss. R9 experienced fluid deficit resulting in hospitalization after labs were taken that indicated R9 was dehydrated. Starting on 6/18/25, vitals were not taken on R9 even after labs were ordered due to signs of dehydration and lethargy until R9 was sent to the hospital on 6/23/25. The facility's failure to assess R9's weight loss and implement new interventions created a finding of immediate jeopardy that began on 6/23/25. Surveyor notified the Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A of the immediate jeopardy on 6/26/2025 at 4:14 pm. The immediate jeopardy was removed on 7/3/25 when the facility implemented a removal plan, however, the deficient practice continues at a scope of severity of E, (potential for more than minimal harm/pattern,) as the facility continues to implement their removal plan. Findings include:The facility policy and procedure titled, Weight Monitoring, with no creation or revision date, documents, in part: Process: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that it is not possible or resident preferences indicate otherwise.Compliance Guidelines:Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem .5. A weight monitoring schedule will be developed upon admission for all residents .:b. Residents with weight loss - monitor weight weekly .d. All others - monitor weight monthly6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as:a. 5% change in weight in one month (30 days)b. 7.5% change in weight in three months (90 days) .7. Documentation:a. The physician should be informed of a significant change in weight and may order nutritional interventions.b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss .The facility policy and procedure titled, HYDRATION POLICY AND PROCEDURE, with a review date of 01/2025, documents in part: . 4. Any resident that is identified by nursing as being at risk for dehydration is referred to the dietician to and is followed up on by the dietitian immediately. 5. Any resident that is identified as at risk for dehydration by nursing is brought to the attention of the facility at team meetings to be discussed with the interdisciplinary team. 6. Any resident identified as at risk for dehydration will be followed by the dietitian and interdisciplinary team as needed. The facility policy and procedure titled, NOTIFICATION OF CHANGES POLICY, with an implementation date of 03/01/2025, documents in part: Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments.R9 was admitted to the facility on [DATE] with pertinent diagnoses that include hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness affecting one side of the body, often due to brain damage or stroke) following nontraumatic intracerebral hemorrhage (a type of stroke where bleeding occurs within the brain tissue itself, not due to injury) affecting right dominant side, dysphagia (difficulty swallowing), aphasia (complete inability or refusal to swallow), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood) and gastrostomy (a surgically created opening in the abdomen that connects to the stomach, often for the purpose of feeding or administering medication). R9's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/25/25, does not document a Brief Interview for Mental Status (BIMS) score. R9 is documented to have adequate hearing and no speech (absence of spoken words). The MDS documents that R9 was assessed to have no behaviors exhibited during the look back period. R9 has an indwelling catheter and is always incontinent of bowel. R9 is coded for using a feeding tube for nutrition and the portion of total calories the resident received through parental, or tube feeding was 51% or more. The average fluid intake per day by IV (intravenous) or tube feeding was coded as 501 cc/day or more. R9 has an activated legal representative.R9's care plan documents: Resident is at risk for malnutrition related to multiple medical diagnoses including DM (diabetes mellitus), coronary artery disease, hyperlipidemia, Heart Failure, Dysphagia-Oropharyngeal Phase, Aphasia, Vitamin D Deficiency, Cerebral Infarction, Substance abuse, HTN (hypertension), hx (history) of pressure ulcers, need for enteral nutrition to provide total nutritional needs, need for skilled nursing care. Date Initiated: 01/22/2025Interventions include: Educate patient on risks of not following diet restrictions.Date Initiated: 01/22/2025o Monitor I&O (intake and output)Date Initiated: 01/22/2025o Monitor labs. Monitor skin integrity. Monitor for malnutrition/sig (significant) weight changes. Monitor for s/s (signs/symptoms) of dehydration.Date Initiated: 01/22/2025Revision on: 06/25/2025o Monitor meal consumption dailyDate Initiated: 01/22/2025o Obtain and update food/beverage preferencesDate Initiated: 01/22/2025o Provide tube feeding and free water flush per MD order.Date Initiated: 01/22/2025Revision on: 06/25/2025Surveyor noted R9 had interventions that were not consistent with enteral feeding of monitor meal consumption daily and obtain and update food/beverage preferences. Surveyor noted the revisions to the care plan were implemented after the survey began.R9's physician order dated 3/14/25 documents: Enteral Feed Order two times a day Nepro with Carb Steady at 60 cc/hour for a total of 720 . calories on at 1800 and off at 0600. R9's physician order dated 4/23/25 documents Water flush 250ml . every 4 hours for GT (gastrostomy tube) related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION.Surveyor reviewed R9's electronic medical record (EMR) and found R9's weights progressively declined from 3/16/2025 to the last weight taken on 6/7/25. A weight of 230.5 pounds was recorded on 4/14/25 which was marked technical error on 6/25/25 and again on 4/28/25 which was also marked technical error on 4/28/25. On 3/16/25 R9's documented weight was 193.4 pounds. On 5/1/25 R9's documented weight was 186.0 pounds. On 6/7/25 R9's documented weight was 175.0 pounds. Surveyor noted that R9 experienced a severe weight loss of 10.51% from 3/16/25 to 6/7/25 (3 months) and 6.2% from 5/1/25 to 6/7/25 (1 month).R9's annual Nutrition Data assessment dated [DATE], is based on the weight of 230.5 pounds which shows weight gain, not the progressive loss realized with the correct weight on 5/1/25. The assessment is completed based on weight gain of 5% or more in the last month. Surveyor noted R9 was weighed on 5/1/25 and 6/7/25 and a weight loss was evident. Surveyor was unable to locate an assessment completed after 4/28/25 until a progress note was written on 6/23/25. R9's laboratory results dated [DATE] documents: Blood Urea Nitrogen 78 (H) (high) (reference interval 6-23 mg/dL) (micrograms per deciliter); Creatinine 2.27 (H) (reference interval 0.70-1.30 mg/dL). Surveyor noted that R9's high blood urea nitrogen (BUN) levels could indicate dehydration as BUN measures the amount of urea nitrogen in your blood, which is a waste product filtered by the kidneys. When dehydrated, the kidneys conserve water, leading to a higher concentration of urea nitrogen in the blood, hence elevated BUN levels. Surveyor also noted that R9's high creatinine levels could indicate dehydration as the kidneys normally filter creatinine from the blood and excrete it in urine. When an individual is dehydrated, their kidneys have less fluid to work with, which can result in higher creatinine levels in the blood. Surveyor noted that despite R9's abnormal laboratory results on 6/19/25, R9 did not receive increased water flushes or increased tube feeding supplements to address possible dehydration and or a fluid deficit. R9's dietary progress note written by the dietician on 6/23/25, documents: Resident seen secondary to nursing request for weight loss, increase in sleeping and weakness . GI (gastrointestinal) Symptoms: No N/V/D (nausea/vomiting/diarrhea). Regular bowel movements (BM) noted, last BM on 6/23 . Tube feeding: two times a day Nepro with Carb Steady at 60 ml/hour for a total of 720 ml 1800 and at 0600 which provides 2548 calories, 116 grams protein and 1500 ml free water (including 250 ml free water flush every 4 hours). Resident will have no significant weight changes per MDS criteria. Weight goal: maintenance. Resident will consume and tolerate tube feeding at goal rate with no s/s of dehydration or malnutrition . RD (registered dietician) to clarify tube feeding: Nepro tube feeding via pump at 150 ml/hr x (times) 12 hours which provides 1770 calories, 81 grams protein and 727 ml free water (2227 ml free water including the 250 ml q (per) 4 hour free water flush). This meets 100% of estimated nutritional and hydration needs . Resident does trigger for significant weight loss over the last month. Weight loss not planned/desired due to high BMI (body mass index). Etiology: resident did have increased energy expenditure for wounds healing- suspect weight will plateau or gradual weight gain will happen as wound are now resolved. Mild weight fluctuations expected with use of Lactulose as well. Discussed resident with nurse manager. MD/IDT/POA (medical doctor/interdisciplinary team/power of attorney) aware of recent weight trend. Care plan reviewed and updated.Surveyor noted no documentation of the facility discussing weight loss with R9's POA or medical doctor was located.R9's nursing note dated 6/23/25 documents: NP (nurse practitioner) notified of (R9's) wife requesting Baclofen to be changed from BID (twice a day) to daily (possibly causing tiredness), NP in agreement. Water Flushes via G-tube 75 ml(milliliters)/hr (hour) continuous to prevent dehydration.Resident sent to the ER (emergency room) and admitted to the hospital with dehydration and hypernatremia. R9's hospital admission Medicine admission History and Physical notes dated 6/23/25 documents: Resident's wife reports lethargy started 4-5 day ago, with dry mouth, decreased urine output and less responsive. [Resident] residents in a nursing facility, [resident] uses sign and tries to talk to communicate, but for the past few days, [resident] has been sleeping round the clock and not communicating. Under the Assessment & Plan section of R9's hospital admission History and Physical it documents: Hypernatremia likely secondary to dehydration. Na (Sodium) 150 on admission, repeat NA 152 s/p (status post) 2L (liters) NS (normal saline) in ED (emergency department); AKI (acute kidney injury) on CKD (chronic kidney injury) Prerenal likely due to dehydration and/or decrease po (per os) intake. Baseline Cr (creatinine) appears to be around 1.4. Cr 2.26 on admission, improving. Surveyor noted that R9 was admitted to the hospital and diagnosed with hypernatremia, abnormal labs and dehydration. Surveyor reviewed a Nurse progress note, dated 06/23/2025, in R9's Electronic Health Record (EHR), which documented R9 was started on a continuous water flush via g-tube at 75 ml (milliliters) per hour to prevent dehydration. On 06/26/2025, at 09:23 AM, Surveyor interviewed Nurse Practitioner (NP)-I via phone. NP-I indicated that on 06/18/2025, R9's family member expressed concern that R9 was lethargic, which NP-I then ordered labs on R9. NP-I indicated that NP-I received a call from a nurse on 06/19/2025 regarding R9's abnormal labs and informed NP-I that the nurse believed R9 was not receiving the full amount of ordered water flushes, due to pump issues. NP-I informed Surveyor that R9's labs indicated that R9 was dehydrated and NP-I encouraged the facility to ensure that R9 was receiving the total amount of water flushes ordered, to improve R9's hydration status. NP-I indicated that NP-I did not rule out any infectious processes and that R9 only had a mildly elevated [NAME] Blood Cell Count (WBC). NP-I then ordered to have R9's labs redrawn in 2 weeks. On 06/20/2025, NP-I received a call from DON-B to inform NP-I that staff would be educated on the pumps and ensure R9 would receive the ordered water flushes. On 06/23/2025, NP-I received a call from RN-K to inform NP-I that RN-K started a continuous water flush for R9 due to lethargy (a state of persistent tiredness, sluggishness, and lack of energy). NP-I indicated that NP-I was in agreement with R9 receiving the continuous water flush, but that R9 was sent out to the hospital a few hours later. NP-I indicated that NP-I was not notified of R9's weight loss and double-checked emails and messages, the only concerns were of the lethargy made by R9's family member.On 6/26/25, at 10:59 am, Surveyor interviewed NP-I about R9's labs showing R9 was dehydrated on 6/19/25. NP-I wanted to ensure R9 was getting the water flushes already ordered. NP-I went over the orders for 250ml/hr and the nurse said not sure if R9's getting the full amount due to pump issues. NP-I said let's ensure R9 is getting the 250ml/hr every 4 hours and recheck the labs in two weeks. Per NP-I on 6/20/25, the unit manager and Director of Nursing (DON)-B called and said they will do education with the nurses. NP-I did not want to increase fluid intake in case R9 was not getting what was ordered, so wanted to wait two weeks to recheck so not to overload fluids. On 6/26/25, at 11:12 am, Surveyor interviewed DON-B regarding the pump issues discussed with NP-I on the 20th and education given to staff. Per DON-B, they talked to NP-I regarding the lab values and the concern of nurses not giving flushes. DON-B talked to the nurses and checked the MAR (medication administration record) and determined the flushes were being given and no education was needed. Per DON-B, after the lab values were received on the 19th, no new orders were given per NP-I and NP-I wanted the labs repeated later.Surveyor reviewed R9's MAR and Treatment Administration Record (TAR) for June 2025. Surveyor noted R9's order for 250 ml/hour water flushes every 4 hours, was documented as not completed on 06/14/2025 at 2 PM and 10 PM, 06/15/2025 at 10 PM, 06/19/2025 at 10 AM and 2 PM, and 06/21/2025 at 2 PM. On 06/26/2025, at 11:24 AM, Surveyor interviewed NP-I regarding the missing water flushes. NP-I indicated that NP-I would expect to be notified of the missing water flushes and considers the water flushes as a medication order. NP-I indicated that the facility should have been closely monitoring R9's fluid and hydration status and updating NP-I with any changes or concerns. On 6/26/25, at 12:04 pm, a voicemail message was left for the dietician and no return call was received at time of write up.On 6/26/25, at 12:58pm, Surveyor interviewed DON-B and asked if DON-B was aware of the weight loss R9 experienced. Per DON-B, they review the 24-hour report so was aware. Surveyor asked if any dietician assessments were completed between April 28th and June 23rd as R9 had weight loss occurring and Surveyor found no evidence of interventions or assessments being completed. DON-B informed Surveyor she would look into and get back to Surveyor. Surveyor reviewed the facility provided document titled, Change in Condition Evaluation, dated 06/23/2025. Surveyor noted R9 did not have a full set of vitals obtained at the time of R9's change in condition assessment. Surveyor noted R9's most recent pulse was documented on 05/23/2025, most recent respirations documented on 04/24/2025, and most recent oxygen saturation documented on 04/24/2025.On 06/26/2025, at 01:10 PM, Surveyor interviewed DON-B regarding R9's change of condition. DON-B indicated that DON-B would expect an assessment, including a full set of vitals, and for the resident to be on the 24-hour board. Surveyor asked DON-B about R9's vital signs at the time of R9's change in condition. DON-B indicated that a full set of vital signs should be obtained at the time of a change in condition assessment. DON-B informed Surveyor that DON-B would look to see if vital signs were documented in progress notes.On 06/26/2025, at 04:18 PM, Surveyor asked the facility for the 24-hour board from 06/18/2025 to current. Surveyor noted that R9 was on the 24-hour board from 06/19/2025, due to a medication for a lip sore, until R9 was sent out to the hospital on [DATE].On 6/26/25, at 4:05 pm, Surveyor interviewed DON-B and asked who updated the dietician and DON-B stated, the unit manager or nurses would if there was weight loss. The current dietician just started a few weeks ago.On 07/03/2025, at 10:13 AM, Surveyor interviewed Registered Dietitian (RD)-Q. RD-Q started at the facility around 06/01/2025. RD-Q indicated that RD-Q Q reviews weights and completes nutrition assessment needs of residents on a quarterly basis and as needed. Surveyor asked RD-Q about a weight that was crossed out and documented as an error in R9's EHR on 06/25/2025. RD-Q informed Surveyor that RD-Q did cross off R9's weight on 06/25/2025 due to suspecting an inaccurate weight. RD-Q indicated that R9's weights are normally between 186 pounds to 197 pounds. RD-Q noted a significant weight loss within one month. Surveyor asked RD-Q if RD-Q reviewed R9's MAR/TAR to ensure R9 was receiving R9's water flushes. RD-Q indicated that while reviewing R9's orders and EHR, RD-Q questioned R9's tube feeding order and noted tube feedings were only marked with a check mark as completed in R9's MAR/TAR indicating R9 was not being monitored for total amount of tube feeding intake. RD-Q spoke with UM-R to clarify R9's tube feeding order and to inquire how much intake R9 was receiving. RD-Q explained to Surveyor that UM-R and RD-Q were interpreting R9's order differently which indicated R9 was only receiving about half of what R9 should have been receiving for tube feeding intake. R9's physician order dated 3/14//25 with a discontinued date of 6/25/25 documents, Enteral Feed Order two times a day Nepro with Cab Steady at 60 cc (cubic centimeters)/hour for a total of 720 ccs and __calories on at 1800 and off at 0600.Surveyor noted that the above physician order was ambiguous and open to different interpretation as some staff could interpret it to mean R9 was to be fed twice a day between hours of 6PM and 6AM for a total of 1440 ccs or twice a day at 60 ccs per hour for a total 720 ccs. The facility did not provide any documentation or evidence that R9 received the adequate amount of nutritional intake per R9's tube feeding intake. Surveyor noted that the facility did not have any documentation of the total of number of Nepro with Cab Steady ccs that R9 received on a daily basis as a result of the ambiguous feeding order in place for R9 prior to 6/25/25. On 06/25/2025, RD-Q then changed R9's tube feeding order to reflect and clarify R9's nutritional needs. Surveyor asked RD-Q if RD-Q would expect the Doctor to be notified of any missed tube feedings or water flushes. RD-Q indicated that RD-Q would expect the nurses to be able to inform RD-Q of reason for missed tube feedings/water flushes and the Doctor to be notified immediately. RD-Q indicated that R9 is completely dependent on tube feedings for 100% of R9's nutrition and hydration status, and the order that needed clarification had the potential to cause error in how much R9 was receiving for tube feedings. RD-Q informed Surveyor that R9 would become malnourished and/or dehydrated if R9 had been receiving less then what was ordered for tube feedings. On 07/03/2025, at 10:49 AM, Surveyor interviewed UM-R. UM-R informed Surveyor that RD-Q was reviewing R9's nutrition and wanted clarification on R9's tube feeding order. UM-R indicated that UM-R was interpreting the order incorrectly, and R9 potentially had only been receiving half of the ordered amount of tube feedings. UM-R indicated that the order was not clarified with the Doctor or Nurse Practitioner. On 07/03/2025, at 12:29 PM, Surveyor interviewed DON-B. Surveyor asked DON-B if DON-B was aware of an order for R9 that needed clarification regarding R9's tube feedings. DON-B indicated that RD-Q informed DON-B of R9's order needing to be clarified. DON-B indicated RD-Q changed R9's tube feeding order to clarify how much tube feeding R9 should be receiving. DON-B indicated that the NP has not yet been notified due to R9 being currently hospitalized but indicated the NP will be notified and R9's orders will be reviewed upon R9's return to the facility.Surveyor noted that the facility clarified R9's enteral feeding order on 6/25/25 to read: 1 time a day for nutrition Nepro tube feeding via pump at 150ml/hr for 12 hours (on at 1800 and off at 0600) with 50 ml free water flush before and after feeding.R9 experienced severe weight loss over a period of 3 months, while receiving enteral feeding. The weight loss was not prescribed, and no new interventions were implemented, or assessments completed to prevent R9's weight loss. R9 experienced fluid deficit resulting in hospitalization even after labs were taken that indicated R9 was dehydrated. Vitals were not taken on R9 starting 6/18/25 when labs were ordered due to signs of dehydration and lethargy until sent out to hospital on 6/23/25. The facility's failure to assess R9's weight loss and implement new interventions created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 6/23/25. Surveyor notified the Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A of the immediate jeopardy on 6/26/2025 at 4:14 pm. The immediate jeopardy was removed on 7/3/25 however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement the following removal plan: Education was provided to all nursing staff on the following policies:- Weight management policy, hydration policy, process to follow related signs and symptoms of dehydration. - Educated on changes of condition and using the e-interact form- Education provided to medical director and nurse practitioner related to addressing labs with abnormal values.- Education was provided to all licensed nursing related to using e-interact COC which includes taking vitals and ensuring providers are notified at the time of the change of condition. - Education provided to nursing staff that dietician needs to be notified within 24.- Education provided to staff prior to working their next shift.- The policies for weight management, hydration were reviewed by the medical director and IDT, no changes were made.- Random audits will be conducted weekly x3 months then reviewed at QAPI for recommendations.

Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice based on the comprehensive assessment of the resident for 2 (R406 and R89) of 12 sampled residents. * The facility did not assess and provide care and treatment to R406 based upon R406's individual diagnoses and complex care needs and did not evaluate conditions that might trigger flare ups in lupus symptoms or metabolic encephalopathy. In March of this year (2023), R406 started to experience a change in condition that included R406 stating that she could not hear causing R406 to be upset and worried about changes that were starting in her condition. At this time R406 had an initial evaluation by Psy NP K (Psychiatric Nurse Practitioner) where R406 expressed feelings of depression and anxiety. There were no changes to R406's plan of care to address her hearing loss and feelings of anxiety and depressions and fears about her changes in her medical status. R406 could not be seen by an audiologist for almost 2 months following the hearing loss. R406 continued to express concern regarding her hearing loss and how it made her feel with no changes in her plan of care. On 3/29/23, R406 was sent to the hospital for altered mental status. There is no documentation to indicate what the altered mental status changes were for R406. The hospital documentation upon discharge indicates: the principal problem was acute metabolic encephalopathy with baseline cognitive impairment. This may be multifactorial including some element of metabolic derangement associated acute kidney injury and dehydration as well as component of infection, exact source not immediately clear. Monitor with treatment. Active problems included acute kidney injury, hyperkalemia, elevated lactic acid level primarily due to volume depletion, pyuria with possible urinary tract infection, left lower lobe consolidation versus atelectasis, benign essential hypertension well controlled at this time, diabetes mellitus, obstructive sleep apnea, paraplegia being wheelchair bound at baseline, cognitive impairment at baseline, currently worse as noted above, seizure disorder, history of pulmonary fibrosis, obesity, and a questionable history of lupus. The hospital discharge documentation also noted (R406) had been evaluated 8/2022 and recommendations were made to come off hydroxychloroquine and prednisone, however this had not yet been addressed by the facility. Upon return from the hospital the facility did not initiate assessments into R406's fluid intake or changes in her nutritional care plan to address fluid concerns. Additionally, the facility did not establish a plan of care related to R406's diagnosis of acute metabolic encephalopathy and monitoring of R406's altered mental status related to R406 having an existing diagnosis of Lupus. The facility regarded R406's changes to be behavioral in nature but did not revise her behavioral care plans. The facility completed assessments on R406's behaviors and safety related to smoking and elopement while the resident was still hospitalized and without the details of her diagnoses from the hospital. R406 continued to demonstrate changes in her mental status including mumbling and confusion without clear assessment or revision in the plan of care. R406 was noted to have several episodes of altered mental status on 4/13/23 and was eventually not responsive to verbal or physical stimuli and was transferred to the hospital. R406 was again diagnosed with acute metabolic encephalopathy. Upon readmission the facility continued to not address R406's diagnosis of acute metabolic encephalopathy or assess to address occurrences of urinary tract infections or hydration and symptoms of delirium vs behaviors. The only revision to R406's nutrition plan of care was regarding edema that R406 experienced upon readmission to the facility. At this time orders for R406 to receive insulin fell off of R406's orders in the facility despite hospital discharge details including R406's diagnosis of diabetes as a factor in her diagnosis. Orders for R406 to receive insulin were not reviewed or restarted until the Surveyor asked about R406's diabetes care during the survey. R406 was hospitalized on [DATE] as R406 experienced lethargy with confusion and emesis. On R406's admission History and Physical dated 5/3/2023, the hospital NP charted (R406) was unable to provide a history due to altered mental status. At baseline, (R406) is alert and can hold a conversation but becomes intermittently confused and may not know the day or year. (R406) had two episodes of emesis and was reported to be significantly altered compared to baseline. (R406) had diarrhea and appeared uncomfortable in the emergency room with tachycardia and diffuse abdominal tenderness. (R406) was disoriented. The hospital NP reviewed prior hospitalization s of altered mental status with encephalopathy with noted similarities. The acute problem list included acute encephalopathy, urinary tract infection, diarrhea, abdominal pain, and acute kidney injury. R406 returned to the facility with no changes to the plans of care for R406 related to altered mental status, ongoing acute kidney injury and metabolic encephalopathy. R406 was identified as being at risk for dehydration in July of 2021 with no revisions to the plan of care with current hospitalization s and change in condition. R406 continued to demonstrate changes in their overall level of functioning, behaviors and safety including attempts to elope from the facility, sustaining a burn from hot liquids that R406 was assessed to not be able to handle safely and smoking in bed. R406's family shared trauma history with the facility regarding R406 sustaining burns prior to residing in the facility that was not assessed, or care planned. While R406 was experiencing these changes in condition, including the activation of a power of attorney for healthcare while hospitalized , the facility initiated a conversation with R406 about a facility-initiated discharge related to nonpayment. On 5/25/23 the facility attempted to have R406 chaptered as an involuntary admission to the hospital indicating R406 was a danger to herself and in crisis indicating R406 needed to be hospitalized related to self-injurious behavior regarding the burn R406 sustained and decline in the wound. R406 agreed to transfer and was not chaptered (involuntarily committed to the hospital). The facility did not communicate with the admitting hospital regarding R406's serious mental health status that warranted initiation of chaptering R406. R406 returned from the hospital with no evaluation or note of their mental status and no indication R406 was in imminent danger related to the condition of the burn/wound related to R406's refusal of care or picking at the wound. R406 continued to demonstrate changes in behavior, mentation and overall physical health that were not addressed by the facility. R406 eventually was moved from the unit in which she resided to the dementia unit. The facility's failure to assess and provide care and treatment to R406 based upon R406's individual diagnoses and care needs created a situation of immediate jeopardy starting on 5/6/23. Surveyor notified ANHA A (Assistant Nursing Home Administrator) of the immediate jeopardy on 7/13/2023 at 3:46 PM. The immediate jeopardy was removed on 7/17/23; however, the deficient practice continues at a scope/severity of D as the facility continues to implement and monitor their removal plan and as evidenced by the following example. *R89 had two unwitnessed falls on 6/29/2023. The second fall on 6/29/23 occurring at 9:45 AM did not have neurological checks documented from 9:45 AM until R89 was transferred to the hospital at approximately 7:00 PM. Findings include: 1. R406 was admitted to the facility on [DATE] with diagnoses of: systemic lupus erythematosus (SLE), pulmonary fibrosis, diabetes, tubulo-interstitial nephropathy in systemic lupus erythematosus, neuropathy, epilepsy, paraplegia, cerebral infarction, and hemorrhage of anus and rectum. Surveyor noted R406 does not have a history of significant psychiatric diagnoses. Systemic lupus erythematosus (SLE) is defined by the Lupus Foundation of America, https://www.lupus.org/resources/what-is-systemic-lupus-erythematosus-sle, as the most common form of lupus and can cause inflammation of multiple organs or organ systems in the body, either acutely or chronically. Symptoms of SLE vary from person to person and may come and go and change over time. The most common symptoms include skin rashes, pain or swelling in the joints, swelling in the feet and around the eyes (typically due to kidney involvement), extreme fatigue, and low fevers. Some of the more serious complications of SLE involving major organ systems include inflammation of the kidneys which can affect the body's ability to filter waste from the blood and can be so damaging that dialysis or a kidney transplant may be needed, inflammation of the nervous system and brain causing memory problems, confusion, headaches, and strokes, and inflammation of the brain's blood vessels can cause high fevers, seizures, and behavioral changes. Central nervous system lupus can also cause some rare but serious problems including psychosis (seeing and hearing things that do not exist, false beliefs). Lupus in the autonomic nervous system can cause a wide range of symptoms including changes in heart rate or blood pressure and stomach problems like vomiting or diarrhea. According to the Lupus Foundation, emotional stress, exhaustion, and physical trauma can be environmental triggers that cause a flare up in lupus symptoms. https://www.lupus.org/resources/common-triggers-for-lupus According to CNS Lupus Clinical Presentation, Among the neurologic manifestations of systemic lupus erythematosus (SLE), the most common are the organic encephalopathies (35-75% of case series), which comprise all potential variations of acute confusion, lethargy, or coma; chronic and subacute dementias. They can also manifest as psychiatric symptoms, including depression, mania, psychosis, or other affective disturbances. https://emedicine.medscape.com/article/1146456-clinical. R406's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R406 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and the facility assessed R406 as needing extensive assistance with bed mobility, dressing, and toilet use, and limited assistance with transfers and hygiene. R406's Power of Attorney (POA) was not activated at that time. On 3/9/23, R406 had an initial evaluation by Psy NP K. Psy NP K charted the chief complaint for R406 was to establish care with R406, medication management, and anxiety. R406 reported feeling down and depressed due to recent hearing loss and wanting to discharge home. R406 denied hopelessness. R406 reported anxiety and worry due to three days of hearing loss and hoping it was not permanent. R406 denied suicidal ideation, self-harm urges, hallucinations, and delusions. Per nursing, R406 was anxious and awaiting an ENT (ear, nose, and throat) appointment. Surveyor noted there was no changes to R406's care plan to address anxiety or concerns related to potential hearing loss and impact on the resident. On 3/22/2023 at 1:14 PM in the progress notes, nursing charted R406 had complaints of pain 10/10 to the left ear with yellowish drainage noted. R406 was sent out to the hospital for evaluation and treatment. At 5:17 PM in the progress notes, nursing charted R406 returned from the hospital with a recommendation to see ophthalmologist (sic-erroneously entered, should have read audiologist) due to hearing loss and needing hearing aids. R406 had an appointment scheduled for 5/23/2023. On 3/23/2023, R406 was seen by Psy NP K. Psy NP K charted R406 reported feeling down due to hearing loss and needing hearing aids. R406 denied suicidal ideations or hopelessness, anxiety, sleeping, or appetite concerns. Nursing did not have any concerns at that time. Psy NP K charted the assessment and plan for adjustment disorder with mixed anxiety and depressed mood was situational and exacerbated due to recent medical condition. Nortriptyline was increased and continue to monitor for further behavioral disturbances and continue to provide reassurances; maintain safety. Psy NP K charted the assessment and plan for SLE was stable and chronic. Increase nortriptyline and continue to monitor and provide reassurances; maintain safety. Surveyor noted there was no change to R406's care plans to address the physical and mental changes R406 was experiencing at this time for staff to carry out to support R406. Surveyor noted there was no assessment of R406's safety concerns or revisions to R406's plan of care related to safety. On 3/29/2023 at 12:29 PM in the progress notes, nursing charted R406 was sent to the hospital for evaluation and treatment for altered mental status. R406 was admitted to the hospital. Surveyor noted there was no documentation or assessment in R406's medical record to indicate what the characteristics were of the altered mental status being demonstrated by R406. The hospital history and physical dated 3/29/2023 states R406 presented to the emergency department for evaluation of increased confusion and hallucination, onset apparently just today. R406 was awake, attentive, and converses, but significant disorientation such that a reliable history could not be obtained. R406 had recently gotten over COVID-19 without significant respiratory symptoms but had significant diarrhea during this time. R406 had a history of recurring urinary tract infections. The hospital documentation continues to indicate: the principal problem was acute metabolic encephalopathy with baseline cognitive impairment. This may be multifactorial including some element of metabolic derangement associated acute kidney injury and dehydration as well as component of infection, exact source not immediately clear. Monitor with treatment. Active problems included acute kidney injury, hyperkalemia, elevated lactic acid level primarily due to volume depletion, pyuria with possible urinary tract infection, left lower lobe consolidation versus atelectasis, benign essential hypertension well controlled at this time, diabetes mellitus, obstructive sleep apnea, paraplegia being wheelchair bound at baseline, cognitive impairment at baseline, currently worse as noted above, seizure disorder, history of pulmonary fibrosis, obesity, and a questionable history of lupus. The hospital discharge documentation also noted (R406) had been evaluated 8/2022 and recommendations were made to come off hydroxychloroquine and prednisone, however this had not yet been done. Surveyor noted according to an article found at https://www.healthline.com/health/metabolic-encephalopathy: Metabolic-encephalopathy occurs when problems with your metabolism cause brain dysfunction. Causes range from low blood sugar to excess fluid in your brain. Symptoms range from confusion to coma. Prompt treatment is essential. Metabolic-encephalopathy is a serious medical condition. It may be due to severe issues in your brain or other vital organs. The symptoms of Metabolic-encephalopathy also overlap with those of time-sensitive medical emergencies such as stroke. If you're experiencing sudden and unexplained symptoms of Metabolic-encephalopathy, seek medical attention immediately. Review of R406's nutrition care plan initiated 3/18/22 indicates: I am at risk for malnutrition (MNA score 7- malnourished) r/t (related to) PMHx (past medical history) paraplegia, cognitive deficits, chronic pain, HLD (high cholesterol), HTN (high blood pressure), T2DM (type 2 diabetes). Therapeutic diet. BMI (body mass index) is within overweight range but appropriate for age. Daily laxative use. Supplement ordered, hx (history of) significant weight changes. Goals: I will maintain adequate nutritional status as evidenced by maintaining weight within +/- 5% of CBW (current body weight) no s/s (signs/symptoms) of malnutrition, and consuming at least 75% of at least 3 meals daily through review date - initiated 3/18/22 revised 8/15/22, 2/18/23, 2/25/23, 4/26/23, 5/10/23, 6/15/23 and 6/30/23. Surveyor noted no change in the goal language except dates as part of the revisions. Interventions include: Encourage adequate fluid and meal intake - initiated 3/18/22. I will be weighed as ordered - initiated 3/18/22. Monitor labs as available - initiated 3/18/22. Monitor/document/report to MD PRN for s/s of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts a swallowing, refusing to eat, appears concerned during meals - initiated 3/18/22. Monitor/record/report to MD PRN for s/s of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss 3 lbs in one week, > (greater than) 5% in 1 month, >7.5% in 3 months, >10% in 6 months - initiated 3/18/22. My food preferences will be recorded & updated PRN - initiated 3/18/22. Provide and serve diet as ordered: CCHO (consistent carbohydrate diet) diet/regular texture/thin liquids - initiated 3/18/22. Provide supplement per MD order: Sugar free house supplement 120 mL TID (three times daily) - initiated 3/21/22. RD to evaluate and make diet change recommendations PRN - initiated 3/18/22. Surveyor noted there is no indication R406 was reassessed upon return from the hospital regarding fluid needs or intake or that changes were made to R406's nutritional plan of care to address R406's dehydration and acute kidney concerns related to her metabolic encephalopathy. The nutrition plan of care does not have a revised intervention until 4/26/23 when the facility adds to monitor for edema. On 4/5/2023, while R406 was in the hospital, the facility did a Smoking and Safety assessment that determined R406 was a safe smoker. The Smoking Care Plan was not revised. On 4/5/2023, while R406 was in the hospital, the facility did an Elopement assessment and determined R406 was not at risk for elopement. On 4/5/2023 at 1:18 PM in the progress notes, while R406 was in the hospital, the facility did a quarterly review. The review stated R406 presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions yielding labile mood. R406 presents with dysthymic mood, sleep disturbances, fatigue, overeating, difficulty concentrating and remaining on task, restlessness, and irritability. R406 presents with persecutory delusions and paranoia that are exacerbated when boundaries are set with (R406) that (R406) does not like resulting in hostility and agitation. (R406) will typically begin to perseverate and/or fixate on the topic and has been known to hold grudges against staff members who set boundaries (R406) does not like. (R406) is able to self-propel using an electric wheelchair and does not present at an elevated risk for elopement at this time. (R406) is a known smoker. Surveyor noted the above assessments and documentation regarding R406 were all completed without the presence of R406 and review/involvement/observation of R406 at the time of the assessment. Additionally, Surveyor noted the behavioral assessment/quarterly review of R406 dated 4/5/23 was without the presence of R406 in the facility and was without the consideration of the resident's hospitalization details. This review was not revised to take into consideration R406's diagnosis of acute encephalopathy and the cognitive changes noted associated with the diagnosis. On 4/6/2023 at 10:13 PM in the progress notes, nursing charted R406 was readmitted to the facility. R406 was readmitted to the facility with an order on 4/6/2023 for Risperdal 0.5 mg every 12 hours as needed for agitation. The medication was never given by the facility and the order was discontinued on 4/13/2023. On 4/8/2023, the facility did a Smoking and Safety assessment that determined R406 follows the facility's policy on location and time of smoking. The Smoking Care Plan was not revised. On 4/8/2023, the facility did a Hot Liquid Safety Evaluation and determined R406 had hand tremors or abnormal muscle movement which could cause the possibility of spilling liquids and an interim measure for safety was a clothing protector or lap protector. The interim measures from the Hot Liquid Evaluation were not incorporated into R406's care plan, nor implemented. Surveyor noted there was no assessment into the frequency that R406 handles hot liquids including types nor was there an assessment or care plan of the supervision needed to ensure safety despite the determination R406 could not safely handle hot liquids. R406's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R406 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, PHQ-9 of 6, and the facility assessed R406 as needing extensive assistance with bed mobility, dressing, and toilet use, and limited assistance with transfers and hygiene. On 4/13/2023, R406 was seen by Psy NP K. Psy NP K charted R406 appeared confused and mumbling. Per the primary NP, R406 came back from the hospital with acute encephalitis and nursing staff reported R406 had altered mental status. Surveyor noted R406 was diagnosed with encephalopathy, not encephalitis. Encephalopathy is a disease process affecting the brain while encephalitis is an inflammation of the brain usually caused by a virus. Encephalopathy and encephalitis have different etiologies and different treatments. Surveyor noted no assessment to determine extent of confusion and mumbling and whether related to possible delirium/dehydration vs. other cause. No change was noted to R406's plan of care for staff to address the confusion or mumbling. On 4/13/2023 at 2:16 PM in the progress notes, nursing charted R406 was non-responsive to verbal and tactile stimuli and was sent to the hospital for evaluation and treatment. Nursing charted R406 had several episodes of altered mental status earlier on day shift. No facial droop was noted and R406 had an episode of facial flat affect with a blank stare. R406 was admitted to the hospital. The hospital admission history and physical dated 4/13/2023 stated (R406) was oriented only to person and unable to answer any questions or follow commands. R406 received Haldol in the emergency department for agitation. The hospital NP reviewed R406's chart and noted R406 had been admitted on [DATE] for a similar clinical picture. On 3/29/2023, R406's encephalopathy was thought to be multifactorial in the setting of infection, dehydration, and electrolyte disturbances and R406's mentation improved with the treatment of dehydration, urinary tract infection, and electrolyte imbalances. The assessment and plan for the current hospitalization was for acute metabolic encephalopathy with no infection noted, acute kidney injury, lactic acidosis, hyperkalemia, hyponatremia, chronic myocardia injury, diabetes type 2, hypertension, and seizures. On 4/18/2023, R406's Power of Attorney (POA) was activated while in the hospital. On 4/21/2023 at 3:21 PM in the progress notes, nursing charted R406 was readmitted to the facility. At 10:10 PM in the progress notes, nursing charted R406 was alert and oriented times 2-3 with some confusion noted, but overall conversed well. R406 denied any pain at that time but does complain of pain when legs are moved, and the legs were edematous throughout. The NP was updated. The NP ordered a CBC and CMP lab work and tubi grips to both legs with elevation. No weeping was noted from the legs. R406 had a motorized wheelchair. On 4/22/2023 the facility did a Smoking and Safety assessment that determined R406 follows the facility's policy on location and time of smoking with no concerns. On 4/22/2023 the facility initiated a Hot Liquid Evaluation but did not complete it as the form was blank except for the date. R406's malnutrition care plan initiated 3/18/22 included an intervention dated 4/26/23 to monitor for the development of edema. Despite the improvement in R406's condition in the hospital with hydration, the facility did not develop a care plan to address adequate hydration. Surveyor reviewed R406's diabetic medications and blood sugar readings. R406 took insulin, both long acting and sliding scale, until 4/26/2023 when the insulin was discontinued. R406 took Empagliflozin 10 mg daily from 4/26/2023 through 5/6/2023 when it was discontinued. R406 was not taking any diabetic medication after 5/6/2023. Nursing staff was monitoring R406's blood sugar twice daily after 5/6/2023. R406's blood sugars ranged from 98-326 in 5/2023, 129-484 in 6/2023, and 159-321 in 7/2023 with the majority of blood sugars in the higher range. No documentation was found that the physician or NP were notified when R406 had extremely elevated blood sugars. In an interview on 7/13/2023 at 4:09 PM, Surveyor shared with NP T the concern R406 had elevated blood sugars in the 300's and 400's in May, June, and July 2023. Surveyor asked NP T if NP T was notified of the elevated blood sugars. NP T stated elevated blood sugars were expected because R406 had a short, tapered burst of prednisone for wound healing (5/31/2023). NP T did not say if NP T was aware that R406 had elevated blood sugars. On 7/13/2023, R406 had a new order for Glipizide, a diabetes medication, after Surveyor shared the concern blood sugars were not being monitored. Low or high glucose levels can be triggers for metabolic encephalopathy. https://www.healthline.com/health/metabolic-encephalopathy#causes On 4/27/2023, R406 was seen by psych Psy NP K. Psy NP K charted care was discussed with nursing staff and chart was reviewed. R406 stated they were waiting for insurance to see if the insurance would cover hearing aids. R406 was sent to the hospital again for altered mental status and the previous visit had the diagnosis of acute encephalitis. (Surveyor noted Psy NP K documented R406 had encephalitis and not encephalopathy as per hospital record.) Per nursing, R406 was stable on readmit. Surveyor noted upon readmission R406 was noted by staff to have edema and presented with some confusion. Psy NP K charted the assessment and plan for altered mental status was R406 was readmitted and stable at that time, R406 was recently diagnosed with acute encephalitis. Staff were to monitor for worsening symptoms and the primary care physician was aware of changes. Psy NP K charted the assessment and plan for the adjustment disorder with mixed anxiety and depressed mood was exacerbated due to the recent medical condition. Nortriptyline was discontinued per pharmacy recommendations, and staff were to continue to monitor R406 for further behavioral disturbances and to continue to provide reassurances and maintain safety. Psy NP K charted the assessment and plan for SLE was the SLE was stable and chronic with the Nortriptyline discontinued per pharmacy recommendations. No recent flare ups and continue to monitor, provide reassurance, and maintain safety. Surveyor noted R406's care plans did not get updated to reflect the anxiety and depression or discontinuation of the medication at this time. On 4/28/2023 at 12:43 AM or PM? in the progress notes, a quarterly review was done. The review stated (R406) presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions yielding labile mood. (R406) presents with persecutory delusions and paranoia that are exacerbated when boundaries are set with (R406) that (R406) does not like resulting in hostility and agitation. (R406) will typically begin to perseverate and/or fixate on the topic and has been known to hold grudges against staff members who set boundaries (R406) does not like. (R406) can self-propel using an electric wheelchair and does not present at an elevated risk for elopement at this time. (R406) is a known smoker and following the assessment, (R406) can safely participate in the facility smoking program. Surveyor noted this quarterly review references many behaviors and explanations for behaviors with out clear documentation of an assessment to determine frequency or establish a plan of care to address these behaviors. Surveyor noted this quarterly review does not include consideration of R406's repeated diagnosis of acute metabolic encephalopathy or cognitive changes associated with the diagnosis to differentiate what R406 is experiencing or expressing. On 4/28/2023, R406 was seen by an audiologist who stated hearing aids would be beneficial. A medical authorization was obtained from R406's primary care physician. In an interview on 7/12/2023 at 2:32 PM, R406 stated they told R406 that R406 needed hearing aids or could have surgery and R406 decided the hearing aids might not be the best thing and would let them know if R406 decided to have surgery. R406 did not have hearing aids at the time of the interview. Surveyor noted R406 first demonstration of concern and identified anxiety causing a change in R406 was on 3/7/23 almost two full months prior. R406's plan of care was not updated to address R406's possible hearing impairment or to monitor R406 as they decided to pursue surgery vs. other treatment to decrease R406's anxiety related to this issue. On 5/3/2023 at 12:36 PM in the progress notes, nursing charted R406 had emesis twice with signs of lethargy but responded to the nurse and stimulation. R406 was sent to the hospital for evaluation and treatment. The progress note indicates R406 did not want to go to the hospital but R406's POA agreed to send so R406 was sent to the hospital. The eInteract at 12:56 AM or PM? indicates R406 has increased confusion, general weakness and requires increased assistance with activities of daily living (ADLs) and lethargy. Vitals documented show elevated pulse and a blood pressure of 115/56. On R406's admission History and Physical dated 5/3/2023, the hospital NP charted (R406) was unable to provide a history due to altered mental status. At baseline, (R406) is alert and can hold a conversation but becomes intermittently confused and may not know the day or year. (R406) had two episodes of emesis and was reported to be significantly altered compared to baseline. (R406) had diarrhea and appeared uncomfortable in the emergency room with tachycardia and diffuse abdominal tenderness. (R406) was disoriented. The hospital NP reviewed prior hospitalization s of altered mental status with encephalopathy with noted similarities. The acute problem list included acute encephalopathy, urinary tract infection, diarrhea, abdominal pain, and acute kidney injury. On 5/6/2023 at 3:45 PM in the progress notes, nursing charted R406 was readmitted from the hospital. At 4:19 PM in the progress notes, nursing charted R406 was alert with some confusion, R406 was redirected and aware of environment and self. Surveyor noted there was no revision to R406's plan of care to address R406's 3rd hospitalization /diagnosis of acute metabolic encephalopathy. There was no evaluation of what might be triggering these episodes. On 5/7/2023, a Smoking and Safety assessment was completed with no safety concerns identified. On 5/7/2023, a Hot Liquid Evaluation was completed. The assessment indicates R406 had cognitive impairment, behaviors, and a history of spilling liquids. Interim measures in place to enhance safety while rehab screen was identified as pending on the assessment: cup with lid or other adaptive cup, staff assistance, clothing protector and/or lap protector, and to drink hot liquids at a table only. Surveyor reviewed R406's Care Plan and medical record. The interim measures from the Hot Liquid Evaluation were not incorporated into R406's care plan until 7/13/23. On 5/7/2023 at 2:13 PM in the progress notes, nursing charted R406 was very confused and tried to leave the building [TRUNCATED]

Based on observation, record review, and interview, the facility did not ensure resident's with dementia received the appropriate treatment and services to attain their highest practical physical, mental and psychological well-being. This was observed with 2 (R203 and R202) of 2 resident reviewed with dementia. *R203 has a diagnosis of dementia with psychotic disturbance. R203 did not have a comprehensive assessment identifying specfic behaviors along with non-pharmalogical interventions, an individualized plan of care to address behaviors effecting others including physical abuse to another dementia resident. The facility did not provide purposeful and meaningful activities that address R203's interests and peferences. The facility documented R203 would wander about the secured unit and on 6/20/23, R203 hit R202 in the face with his closed fist. * R202 has a diagnosis of severe dementia with behavioral disturbances. R202 did not have a comprehensive assessment identifying specific behaviors along with non-pharmalogical interventions, a individualized plan of care to address behaviors and vulnerability for abuse. The facility did not provide meaningful activities that address R202's interests and preferences. It is documented R202 spent most of her time wandering the secured unit. R202 obtained bruises on her arms, wandered into other resident rooms, had verbal altercations with staff and a resident, and was physically abused by another resident with dementia. On 6/20/23, R202 was hit in the face by R203. Findings include: (Cross Reference F600 and F679) 1. R203 was admitted from the hospital to the facility on [DATE] with diagnoses that include: unspecified dementia, unspecified severity, with psychotic disturbance, anxiety disorder, bipolar disorder, current episode mixed, mild, altered mental status, personal history of transient ischemic attack. R203's Hospital Referral paperwork documented on 3/24/23, [R203's name] is a 73 y.o. (year old) male with significant PMH (Primary Medical History) of dementia, agitation .who presented to the ED (Emergency Department) with altered mental status. Patient showed up in the lobby of [name of hospital] after being found walking around in the street saying he did not feel good. Patient brought in by a bystander.Patient reported living alone. History of paranoia and dementia. Patient has not been compliant with antihypertensive medication because of his paranoia. Approximately, 1 year prior to diagnoses of dementia daughter noted increasing paranoia.While in ED patient was found wandering and yelling at staff stating he would like to go home. He was uncooperative and security was called. Provided a meal tray patient stated there is poison in that, I won't drink it. Continued to ambulate through the halls with security. R203's Hospital Discharge Summary, dated 5/18/23 documents, .Start these medications: .Depakote sprinkles (anticonvulsant) 125 mg (milligrams) every 12 hours, Olanzapine (Zyprexa, antipsychotic) 5 mg nightly, Melatonin 6 mg nightly . Hospital course by problem list: Principal Problem: Confusion, Agitation, Vascular Dementia, sequela of CVA (cerebrovascular accident), moderate severity, Paranoia. Patient with known history of dementia presented with significant agitation found wandering the streets. Patient appears paranoid. Patient was started on Olanzapine 5 mg nightly. Psychiatry was consulted and recommended continued Olanzapine a well as Depakote sprinkles or liquid 125 mg twice daily. Due to patient's paranoia, medication was administered by crushing medication and mixing them with food. Discharge on Olanzapine 5 mg nightly, Divalproex Sprinkles (Depakote sprinkles) 125 mg every 12 hours. R203's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/26/23, documents a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment for daily decision making; a Patient Health Questionnaire (PHQ-9) score of 4, indicating minimal depressive symptoms, potential for psychosis with delusions experienced (misconception or beliefs that are firmly held, contrary to reality); wandering occurring 1 to 3 days over the last seven days; very important to have family or a close friend involved in discussions about your care, be able to use the phone in private, have a place to lock things up to keep them safe, have books, newspapers and magazines to read, listen to music, be around animals, keep up with the news, do things with groups of people, to do your favorite activities, go outside to get fresh air when the weather is good, participate in religious activities or practices; requires extensive assist of 2 plus staff for bed mobility, extensive assist of 1 staff for dressing, toilet use and personal hygiene, supervision of 1 person for walking in the corridor and off the unit, independent with set up for eating; not steady but able to stabilize without staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface to surface transfers; frequently incontinent of urine and occasionally incontinent of bowel. R203's Care Area Assessment (CAA) documents: Cognitive Loss: Res. (Resident) has cognitive deficits d/t (due to) dementia, Alzheimer's etc. Res. has impaired short-term memory and temporal orientation. Resident is able to make some needs known. Res. is attending ST (Speech Therapy) daily 5-7 x (times)/ week for cognition, memory, problem solving, sequencing .and is progressing. Res is at risk for decline as disease progress [sic]. Will proceed to care plan to monitor and prevent or minimize effects of any decline. Behavioral Symptoms CAA documents: Res has displayed wandering behaviors and goes in other rooms looking for things he can't find. Res. is easily directable most of the time. Surveyor notes the facility did not complete a CAA related to activities. R203's care plan documents: Resident holds dx (diagnoses) of unspecified dementia, unspecified severity, with psychotic disturbance yielding impaired cognition. Resident will demonstrate confusion aeb (as evidenced by) wandering unit looking for doctor who is waiting for him etc. Resident benefits from staff offering diversions such as individual activities and family visits, date initiated 6/6/23. Interventions include: -Involve in enjoyable activities which orient to reality and don't depend on orientation; date initiated 6/6/23; -Listen to patient when verbalizing concerns over disease symptoms and address issues raised; date initiated: 6/6/23; -Medication as ordered by physician; date initiated 6/6/23. Surveyor notes the facility did not identify what activities could be provided to R203 that would be found enjoyable and provide diversion when agitated. R203's care plan documents: Behavior Management. Resident demonstrates poor frustration tolerance aeb shouting and cursing at staff. Resident's poor cognition function yields difficulty in redirecting his behavior, however, anticipating his needs aids in prevention; date initiated 6/6/23. Interventions include: -Attempt interventions before my behaviors begin, date initiated 6/6/23; -Give me medications as my doctor has ordered; date initiated 6/6/23; -Help me maintain my favorite place to sit, date initiated 6/6/23; -Help me avoid situation or people that are upsetting to me, date initiated 6/6/23; -Let my physician know if I [sic] my behaviors are interfering with my daily living, date initiated 6/6/23; -Make sure I am not in pain or uncomfortable, date initiated 6/6/23; -Please refer me to my psychologist/psychiatrist as needed, date initiated 6/6/23; -Please tell me what you are going to do before you begin, date initiated 6/6/23; -Speak to me unhurriedly and in a calm voice, date initiated 6/6/23. R203's care plan documents: I am not doing the activities I used to enjoy being cognitively unable to do them, decreased physical mobility, date initiated: 6/1/23. Interventions include: -If needed, ask my family/friends to help identify activities I might enjoy, date initiated 6/1/23. Surveyor notes the facility did not identify the individual diversional activities that could provide distraction from R203's wandering and going into peers' rooms. The facility did not identify where R203's favorite place to sit was located, what interventions could be used prior to R203's behaviors escalating, and to address R203 agitation related to dementia. R203's Resident Preference Evaluation dated 5/31/23 was left blank. This evaluation identifies a resident's preference for their daily routine and care needs, activity preferences, and personalized care planning. Surveyor notes the facility did not identify, care plan, and implement care and treatment in accordance with R203's personal preferences to address R203's dementia and dementia related behaviors. R203's Social Service Initial Evaluation dated 5/26/23 documents R203's spiritual needs as Baptist, educational background as High School, no employment history was documented; has a mental health issue, specifically anxiety; a diagnoses of dementia/Alzheimer's; receives psychoactive medication; oriented to time with fluctuating memory; exhibits wandering behavior; mood/behavior has not change over the last 6 months and R203 has not experienced any recent, significant losses, and has no discharge plans at this time. Surveyor notes the facility did not identify and assess R203's behavioral expressions or indications of distress nor identify person-centered interventions staff could use to address agitation and aggressive behaviors related to dementia. On 6/20/23, R203's Medical Record documents: Writer heard yelling up the hallway and ran to see what was going on. Writer observed this resident in [room number, not R203's room] with another resident [R202] and he was yelling loudly at her. They were both standing in the middle of the room. Writer and CNA (Certified Nursing Assistant) immediately separated both residents from each other and while assisting the other resident out of the room this resident made contact with his closed fist to the other residents left cheek. Resident states that he is upset that the other resident started eating his breakfast this am (morning). Doctor [name of doctor] was updated on physical altercation. On 7/11/23 at 2:25 PM, R203 was observed standing in his room looking through his dresser drawers. R203's roommate was sleeping in their bed. On 7/11/23 at 2:31 PM, Surveyor observed R203 ambulate down the hall from his room walking towards the day room. R203 had green gripper socks on and was pushing his wheelchair in front of him. Staff called out Hey Mr. [first name of R203]. Where are you going? Staff redirected R203 away from the day room and back down the hallway towards the direction of R203's room. On 7/11/23 at 2:35 PM, Surveyor walked past R203's room to the end of the hallway near towards the nursing station. R203 came up to Surveyor and stated, I don't like the way you are looking at my door. Get away from my door .If you want to come in my room, then come in my room. Surveyor asked R203 for permission to enter his room and R203 approved. R203 informed Surveyor he does not like it at the facility, he doesn't like his roommate, and he doesn't want to be there. R203 informed Surveyor he came there because he fell and cracked his hip and his head. R203 then began to talk about the limited personal belongings he had at the facility and wanting to leave. Surveyor notes R203's Behavior Management care plan was updated on 6/21/23, after the verbal and physical altercation with R202, to include interventions of: -Activities to provide more appropriate activities. Staff to encourage res. (resident) to be more involved with activities, date initiated: 6/21/23; -Res to see psych (psychiatric) NP (Nurse Practitioner) ASAP (As Soon As Possible) and ongoing, date initiated: 6/21/23. Surveyor notes the facility did not assess R203's behavioral expressions or indications of distress to identify specific behaviors, and triggers nor identify person-centered interventions staff could use to address agitation and aggressive behaviors related to dementia. The facility did not identify what activities would be more appropriate for R203 to attend and participate in or how staff should approach R203 to encourage participation in more activities. On 6/29/23, R203's Medical Record documents: Psych Initial Evaluation, which documents: .Patient seen awake in his room. He states his mood today is not too good. He reports feeling down and depressed due to having to be here. He denies hopelessness. He reports anxiety. He reports sleeping concerns due to being here. He denies appetite concerns but does not like the food. Per nursing, physically aggressive behaviors toward staff and other residents. Mood: not too good. Affect: agitated. Thought process: logical. Thought content-without AVH (auditory verbal hallucinations), without delusions. Judgement/insight: Fair. Impulse control: physical aggressiveness. Assessment and Plan: -Bipolar disorder, current episode mixed, mild. Physically aggressive behaviors with mood swings. Increase Olanzapine (Zyprexa/antipsychotic). Monitor moods. Provide redirection. -Unspecified Dementia, unspecified severity, with psychotic disturbance: Physically aggressive behaviors. Dx (diagnoses) of encephalopathy. Severe agitation. Monitor behavior. Continue Buspirone (antianxiety). -Anxiety Disorder: Physically aggressive behaviors. Dx of encephalopathy. Severe Agitation. Monitor behavior. Continue Buspirone. Insomnia unspecified: sleep issues. Doesn't want to be in the facility. He doesn't like his roommate.Continue melatonin. Monitor Sleep. Other medications increased. Patient is a [AGE] year-old man with bipolar mixed, anxiety and insomnia being seem for a [sic] initial psychiatric evaluation. Patient physically aggressive with staff and other residents. Increase Olanzapine. Discontinue Depakote due to possible side effect of worsening agitation. Patient appears upset about having to be at the facility and feels like he is being forced to stay. Plan to address sleep next visit if continues. Staff to monitor and contact with concerns. Follow up in 1 month. Surveyor notes the facility did not identify targeted behaviors for R203 related to the use of the antianxiety, and antipsychotic medication or monitor the effectiveness of the medications. (Cross Reference F758) On 7/11/23 at 1:53 PM, Surveyor spoke with AA I (Activity Assistant) who stated R203 will participate in activities, likes to sing, and his brother visits daily. AA I stated R203 can become upset and will swear. AA I stated she provides reassurance and tells R203 that he cannot use that type of language. AA I stated R203 likes to play cards, but they are not real card games. AA I stated she lets R203 make up the card games. AA I stated she will do physical and mental exercises with the residents, such as asking residents if it is 12:00 AM or 12:00 PM and what places they have traveled to. AA I stated R203 will color, but can't see colors and will go outside and eat popsicles when the weather is nice. AA I stated if R203 becomes agitated, she lets the proper people handle it - the CNAs (Certified Nursing Assistants) and nurses. Surveyor asked AA I what type of training she received related to dementia care. AA I stated from her years of experience working with residents with dementia she just keeps trying different things to see what works and what the resident likes. AA I stated her training in dementia care has come from years of experience doing the job. AA I stated she has been employed by the Facility since February 2023. On 7/11/23, at 3:46 PM Surveyor informed ANHA A (Assistant Nursing Home Administrator), DON B (Director of Nursing), and RCC C (Regional Corporate Consultant) of the above. 21855 2. R202 medical record was reviewed by Surveyor. R202 was admitted on [DATE] from the hospital with diagnoses of: Severe Dementia with psychotic disturbance, pneumonia due to Coronavirus, Chronic Obstructive pulmonary Disease, and Major Depressive Disorder. R202 has an activated Power of Attorney for Healthcare. R202 Admission Minimum Data Set (MDS) assessment completed 4/6/23 indicates severe cognitive impairment. The Behavior Care Area Assessment (CAA), Cognitive/Dementia CAAand Psychotropic drug use CAA were identified as care areas. These CAA's do not include a descriptive narrative in the CAA Summary that is specific to R202 dementia, behaviors and medication use for dementia/behaviors. Behaviors and Pyschotropic Medication Use. R202 had a Social Service Initial Evaluation completed 3/31/23 for Admission to the facility. The Evaluation indicates a check box for mental illness with the list of the psychotropic medications. This Evaluation Section Resident Status indicates a check box for mood and behaviors. It is checked for: Disruptive to others; Pleasant; Impulsive and cooperative. The Evaluation indicates does not have long and short term memory with moderately impaired decision making skills. There is no documentation that identifies specific behaviors related to R202 daily rountine with behavioral interventions. On 7/5/23 at 1:00 PM, Surveyor spoke with SW G (Social Worker) regarding a FRI (facility reported incident) between R202 and R203 on 6/20/23. SW G indicated R202 typically wanders around the unit. Staff do redirect with a diversional activity. R202 wanders because they like to move around. SW G did not identify triggers for the wandering into other resident rooms. R202 has also tried to leave the alarmed unit and has a wanderguard. On 7/12/23 at 2:28 PM, Surveyor spoke with SW G. SW G indicated they do weekly behavior meetings and review medications and behaviors. They have not documented specific behaviors and have not done quantitative monitoring. SW G indicated R202 behaviors were not bad and they were redirectable. R202 was pleasant and would just wander on unit. SW G indicated nursing would do the plan of care and monitoring. R202 physician Admission orders on 3/30/23 include: -Depakote Sprinkles (mood stabilizer)125 mg every 8 hours for dementia with behaviors. -Prozac (antidepressant) 10 mg every day for depression. -Seroquel (antipsychotic) 100 mg at bedtime for mood/behavior every day. -Seroquel 25 mg 3 times a day for mood/behavior. -Remeron (antidepressant) 30 mg at bedtime every day for depression/appetite. R202 Progress Notes include in part: -3/31/23 5:44 AM restless and yelling out most of shift. -4/1/23 6:05 AM combative, redirecting does not last more then a minute, R202 can not sit still and needs to be watched constantly. R202 flooded back conference room. -4/1/23 at 2:17 PM very confused and disoriented, ambulating continuously around unit, attempting to go in and out of resident rooms. Resistive to cares and difficult to redirect, very impulsive and combative at times, R202 got out of bed and walked over to their roommate quickly and was redirected away from roommate. 1:1 care initiated and a wanderguard was placed. 4/20/23 R202 1:1 supervision ends from 4/1/23. R202 had a Initial Psych Evaluation on 5/11/23 by Psy NP K (Psychiatric Nurse Practitioner). The Assessment and Plan indicates: -Major Depressive Disorder, R202 reports symptoms. Prozac and Depakote medication increased today, continue to monitor moods, continue to provide supportive care. -Severe Dementia with Psychotropic Disturbance, R202 has increased agitation with advanced memory loss, continue medications for associated behaviors, continue to monitor for behavior disturbances, maintain safety and wanderguard in place. In the Summary the Prozac and Depakote was increased, and R202 reports anxiety and depression. R202 may need to be moved to a different locked down unit. Nurse aware and staff to monitor and contact with concerns. R202 had a Follow-Up Psych Evaluation on 5/25/23 by Psy NP K. The Summary includes: -Major Depressive Disorder, R202 reports symptoms. Prozac and Depakote medication increased today, continue to monitor moods, continue to provide supportive care. -Severe Dementia with Psychotropic Disturbance, continue medications for associated behaviors. Continue to monitor behaviors. Monitor safety. R202 continues to want to go home. Discussed with multiple staff members. May need to be moved to a different locked down unit. Nurse aware and staff to monitor and contact with concerns. R202 had a Follow-Up Psych Evaluation on 6/7/23 by Psy NP K. The Summary includes: R202 has advanced dementia and often wanders so a wanderguard is in place. R202 talks of their children and does get upset when they are not there. R202 recently moved to a locked unit for safety. Surveyor noted R202 has been in a alarmed unit. The facility does not have a secured/locked unit. There is no behaviors identified with prescribed medication treatment. On 7/11/23 at 1:23 PM, Surveyor spoke with Psy NP K. Psy NP K indicated R202 did not need a secured unit. They were referring to the Memory Care unit. R202 would be pleasant when interviewed. R202 wandered on unit and family would visit. Psy NP K was not aware of any aggression or altercations. R202 Plan of Cares -Behavior Management start date of 4/1/23 for Resident holds dx (diagnoses) of Dementia with Psychotic Features and Depression which may yield behaviors of cursing, exit seeking, attempting to go after their roommate, becoming combative with cares, etc. Resident benefits from staff anticipating her needs and delivering consistent care when anticipated. The Goal is I will calm down with staff and my behavior will stop with staff interventions. The Interventions started 4/1/23: 1:1 with staff as needed; Attempt interventions before my behavior begin; Help me to avoid situations or people that are upsetting to me; Offer me something I like as a diversion. There is no individualized interventions related to specific behavior. -There is no Activity plan of care started until 5/9/23. Which indicates I am not doing the activities I used to enjoy decreased physical mobility. The Goal is I will find new activities I enjoy doing by my next review. The Interventions do not include any identified activity. -There is no individualized plan of care for the specific psychotropic medication R202 receives. The plan of care does not identify the behavior that is targeted with the prescribed medication, along with individualized interventions. Activities (Cross reference F679) On 7/6/23, an Activity Participation Review (R202 was discharged [DATE]) assessment indicates R202 is involved in small groups, arts and crafts 2 x a week. R202's favorite activities are creative art, entertainment, and spiritual. R202 is creative with drawing. Attends bible study 1x a week. R202 enjoys TV, movies and being involved with other residents. Programmatic Interventions used to reduce behaviors: exercise, spiritual and individual activity in a quite area. R202 Plan of Cares were reviewed. There is no Activity plan of care started until 5/9/23. Which indicates I am not doing the activities I used to enjoy decreased physical mobility. The Goal is I will find new activities I enjoy doing by my next review. The Interventions do not include any identified activity. On 7/10/23 at 2:15 PM, Surveyor spoke with AD H (Activity Director) who indicated they do the activity plan of care and anyone can update it. AA I (Activity Assistant) does the C Unit (Dementia Unit) activities. AD H indicated R202 participates in religious activities and arts and crafts. R202 family comes in almost daily to visit. AD H is aware of R202 wandering into other resident rooms on the unit. R202 is not seeking anything in those rooms. R202 is confused. The staff try to keep R202 busy when their family isn't around. AD H indicated they did R202's activity assessment on 7/6/23 because they were catching up. AD H did not indicate why activity preferences were not on the plan of care or completed when R202 was in the facility. On 7/11/23 at 1:52 PM, AA I and ANHA A (Assistant Nursing Home Administrator) spoke with Surveyor. AA I indicated R202 anxiety level will rise up when their family leave; R202 did not understand why they were at the facility. AA I indicated staff would walk with R202, attend groups for a short time, go outside, watch TV. R202 would just wander into other resident rooms and try to leave the unit. R202 was directable most of the time. AA I does not complete any of the activity assessments or care plans. The Activity Calendar for the C wing was reviewed for the last 3 months. The day of the week does not correlate with the actual date. The activity is the same every day. For example: Tuesdays have Arts and Crafts at 10:30 AM and 2:30 PM; The 3rd Sunday of the month is manicures and nothing additional the rest of the Sundays. AA I indicated AD H approves and reviews the activity calendar. AA I indicated they do Bingo and chats. Bruises and Verbal/Physical Altercation with R203 R202's medical record was reviewed by Surveyor. R202 has an activated Power of Attorney for Healthcare. R202 was admitted to the facility on [DATE] from the hospital. R202 has diagnosis of Severe Dementia. R202 Progress Notes include: -3/30/23 at 5:07 PM includes a Admission Assessment. R202 has no skin concerns. -3/31/23 5:44 AM restless and yelling out most of shift. -4/1/23 6:05 AM combative, redirecting does not last more then a minute, R202 can not sit still and needs to be watched constantly. R202 flooded back conference room. -4/1/23 at 2:17 PM very confused and disoriented, ambulating continuously around unit, attempting to go in and out of resident rooms. Resistive to cares and difficult to redirect, very impulsive and combative at times, R202 got out of bed and walked over to their roommate quickly and was redirected away from roommate. 1:1 care imitated and a wanderguard was placed. The Progress Note on 4/2/23 at 12:19 AM indicates family members in to see R202 prior on the evening shift. Family members voiced concern of bruise to bilateral arms. R202 pleasantly confused and easily redirected. The Progress Note on 4/3/23 at 11:41 AM includes bruising remains on bilateral arms, family in visiting and remains on 1:1 supervision. R202 medical record does not include where the bruises originated from. R202 was 1:1 supervision at the time of discovery. R202 Admission assessment does not indicate bruises on the forearms. R202 Hospital Discharge on 3/30/23 does not indicate arm bruising. R202 family identified the bruises and voiced concerns. There are no measurements or characteristics note of the bruising. On 7/6/23 at 9:20 AM, Surveyor spoke with LPN D (Licensed Practical Nurse). LPN D indicated R203 was mad at breakfast that R202 spit in their food. They provided R203 with a new breakfast tray and moved R202 to a different table. R203 seemed okay with new tray. Then later after breakfast, LPN D heard yelling from a resident room. R202 was yelling get away from me as R203 was yelling. LPN D assisted R202 out of the room ambulating. When they passed by R203 to exit the room, R203 punched R202 in the face. LPN D indicated this happened before lunch and thought R202 and R203 were placed on 15-minute checks; however, wasn't quit sure. LPN D indicated the Nurse Practitioner was here that morning and prescribed Ativan (anti-anxiety) medication for R202. The Ativan was not available to administer in the morning. R202 was more anxious that morning and not redirectable. LPN D indicated the staff on the unit were aware to keep R202 and R203 separated. This was the first time R203 hit someone. R202 wanders on the unit and has not not touched someone's food before. R202's medical record indicates they had a fall in their room on 6/21/23 at 11:00 AM. R202 obtained injuries from this fall and was sent out to the hospital. R202 did not return back to the facility. R202 was on 15-minute checks during this timeframe. On 7/6/23 at 9:55 AM, Surveyor met with ANHA A and RCC C (Regional Corporate Consultant) and this FRI (facility reported incident) was reviewed. R202 was sent out to the hospital from a fall on 6/21/23. The facility was going to update the plan of care upon return to the facility. On 7/11/23 at 2:51 PM, Surveyor spoke with PR L (Pharmacy Representative). PR L indicated that any staff can call for a code number to get a medication out of contigency. R202 Ativan was taken out of contingecy on 6/20/23 at 1:20 PM. The medication would have been available from contigency after the script from the physician was ordered. On 7/13/23 at 9:53 AM, Surveyor spoke with LPN D. LPN D indicated they would have administered R202 Ativan the morning of 6/20/23. The medication did not come through until the afternoon. LPN D did not know they could call the pharmacy for the medication. LPN D gave the Ativan to R202 because it was now available and talking did not help redirect R202. R203 and R202's medical records were reviewed by Surveyor. There were no revisions to the plan of care for R203's behaviors at breakfast and punching R202. R202 behaviors that precipitated the verbal and physical altercation. On 7/11/23 at 3:47 PM at the facility exit meeting, Surveyor shared the concerns with R202.

Based on record review and interview, the facility failed to protect a resident right to be free from verbal and physical from another resident. This was discovered in 1 (R202) of 4 facility reported incidents (FRIs) reviewed. * On 6/20/23, R202 had increased anxiety above baseline. R202 ate and then spit into R203's breakfast. R203 yelled and threatened R202 that he (R203) was going to get R202 for spitting in his food. The facility did not increase the supervision of R202 and R203 after R203's threat against R202. A short time later, R203 found R202 on the unit and R203 punched R202 in the face. It was after R203 punched R202 in the face the facility placed R202 and R203 on 15 minute checks, although there is no documentation of checks being completed. Although ANHA A (Assistant Nursing Home Administrator) and RCC C (Regional Corporate Consultant) reported R202 did not have any mark from being punched in the face with no bodily injury, Surveyor noted a reasonable person would not expect to be punched in the face and would experience a negative psychosocial outcome. Findings include: The facility's policy and procedure for Abuse, dated 10/1/22, was reviewed by Surveyor. The policy indicates: III. Prevention of Abuse, Neglect and Exploitation D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict. Surveyor reviewed a FRI regarding R202 and R203 that occurred on 6/20/23. The Initial report was submitted to the Office of Caregiver Quality (OCQ) on 6/20/23 at 1:29 PM by DON B (Director of Nursing). The report indicates R203 punched R202 in the cheek on 6/20/23 at 10:27 PM. (this time indicated on FRI report is not correct). This FRI was reported for the physical abuse only, and through investigation of the physical abuse, includes the verbal altercation the led up to the physical altercation. The FRI contained an Investigation Summary dated 7/3/23 completed by ANHA A. The Summary indicates on 6/27/23 [sic] R203 was eating their meal when R202 starting eating R203's food and then spit in it. R203 was upset and yelling at R202. R203 then hit R202 in the face. The staff members separated the residents. R202 is no longer a resident at the facility. R203 was referred to psych services. The Summary does not include the correct dates and times of the event. It does not include what interventions were implemented to prevent further abuse from occurring. It does not include an investigation into R202 eating and spitting into R203's food. There is a statement from LPN D (Licensed Practical Nurse) on R202 and R203. LPN D's statement dated 6/20/23 for R202 indicates: -They heard R202 yelling from another resident's room. R203 was also in this room yelling at R202 for eating their breakfast. LPN D separated both R202 and R203 from each other. LPN D led R202 out of the room, and as they were assisting R202 out of the room, R203 punched R202 in the face. R202 and R203 were assisted by staff back to their own rooms. R202 can become restless and agitated, attempts to exit the unit, always looking for their family, and can become angry and curse at staff. LPN D's statement on 6/20/23 for R203 indicates: -R203 was yelling at R202 in a resident room on the unit. R203 was upset that R202 was eating their breakfast. As LPN D was assisting R202 out of the room R203 closed fisted R202 in the face. R203 was assisted back to their room. R203 has Dementia with psychotic disturbances, very argumentative towards staff and other residents, resistive with cares at times. The Investigation included 1 Certified Nursing Assistant (CNA) staff working on the unit. CNA Q provided a statement via email dated 6/26/23 at 11:00 AM. The statement indicates: R202 put their fingers in R203 food. R203 started fussing and saying he was going to get her cause she spit in my food. R203 was told R202 did not spit in their food and R203 was given a new tray. R202 was removed and R203 was sent down the hall. Then everything seemed okay. Then there was yelling from a resident room. R203 was yelling at R202. LPN D was in the room defusing the situation. Then R203 punched R202 in the face. R203 was upset R202 spit in their food. The were separated and went and told DON B about it. On 7/6/23 at 9:20 AM, Surveyor spoke with LPN D. LPN D indicated R203 was mad at breakfast that R202 spit in their food. They got R203 a new breakfast tray and moved R202 to a different table. R203 seemed okay with new tray. Then later after breakfast, LPN D heard yelling from a resident room. R202 was yelling get away from me as R203 was yelling at R202. LPN D assisted R202 out of the room, ambulating, when they passed by R203 to exit the room. R203 punched R202 in the face. LPN D indicated this happened before lunch. LPN D thought R202 and R203 were placed on 15-minute checks; however, wasn't quit sure after R203 punched R202. LPN D indicated the Nurse Practitioner was here that morning and prescribed Ativan (anti-anxiety) medication. The Ativan was not available to administer in the morning. R202 was more anxious that morning and not redirectable. LPN D indicated the staff on the unit were aware to keep R202 and R203 separated. This was the first time R203 hit someone. R202 wanders on the unit and has not touched someone's food before. On 7/6/23 at 9:55 AM, Surveyor met with ANHA A and RCC C and this FRI was reviewed. RCC C indicated R203 did receive a psych evaluation and medications were adjusted. R202 was sent out to the hospital from a fall on 6/21/23. They were going to update the plan of care when R202 returned.The facility does not have a policy and procedure for 15-minute checks and 1:1 supervision. R203 and R202's medical record were reviewed by Surveyor. There was no revisions to the plan of care for R203's verbal threat towards R202 and later punching R202 in the face. There was no revisions to the plan of care for R202 behaviors that precipitated the verbal and physical altercation. On 7/6/23 at 11:28 AM, ANHA A and RCC C spoke with Surveyor. They indicated R202 did not have any mark from being punched in the face from R203. They did not feel they needed to report to OCQ within the 2 hours. There was no bodily harm that occurred. They placed R202 and R203 on 15-minute checks. R202 ate the rest of his meals in the dining room and R203 ate her meals in their room. R202 and R203 had a Mood assessment completed afterwards. R202 and R203 did not have any psychosocial affect from the occurrences. RCC C indicated the breakfast incident was resolved. R203 received a new meal tray and ate their breakfast. R202 was removed from the area. Surveyor noted a reasonable person would not expect to be punched in the face and would experience a negative psychosocial outcome. ANHA A provided additional staff statements dated 7/6/23 for FRI clarification. LPN D's statement indicates R202 and R203 were placed on 15 minute checks after the physical altercation. R202 did not remember what had occurred. CNA Q's statement indicates R202 and R203 were place on 15-minute checks after the incident. There were no further concerns. On 7/6/23 at 1:38 PM DON B and RCW E (Regional Corporate Wounds) spoke with Surveyor. They indicated R202 and R203 were on 15-minute checks after R203 hit R202. Surveyor noted the faciltiy did not have the 15-minute checks documentation. They did not start 15-minute checks after the verbal altercation at breakfast. They did not indicate the intervention rationale of 15-minute checks when R202 and R203 are up ad lib on the unit. DON-B indicated they assessed R202 and R203 after the physical altercation and there was no concerns. R202 had no visible injury. On 7/11/23 at 1:52 PM, AA I (Activity Assistant) and ANHA A spoke with Surveyor. AA I indicated they were over on R202's and R203's unit by 10:20 AM on 6/20/23. AA I indicated they did not see the breakfast event and came after the physical altercation. AA I heard about R203 punching R202 through hearsay. AA I was not directed to do anything. AA I spent time with R202 from 10:20 AM to 12:15 PM. R202 would wander on unit and go into other resident rooms. R202 would think it's their room. AA I was not with R202 at lunch time. AA I indicated R202 was scared of R203 from punching them. R203 was upset about R202 spitting in their food. On 7/12/23 at 9:41 AM, Surveyor spoke with DON B regarding the police contact. DON B indicated they called the police at 4:00 PM as they were covering their checklist. DON B did not indicate why the police were not notified right away after R203 punched R202 in the face. On 7/11/23 at 3:47 PM at the facility Exit Meeting, Surveyor shared the concerns with the altercations with R202 and R203 and the occurrences on 6/20/23 not being thoroughly investigated with preventative measures for each resident involved. (Cross reference: F657, F744,)

Not corrected from Survey Events: MT9J11 dated 3/21/23, MT9J12 dated 5/15/23, and TK7G12 dated 7/24/23 Based on observation, record review, and interview, the facility did not ensure the environment remained free of accident hazards as is possible and residents received adequate supervision to prevent accidents for 4 (R406, R201, R202, and R203) of 5 residents reviewed for accidents. *R406 was assessed by the facility on 4/8/2023 and 5/7/2023 to be at risk when handling hot liquids. No interventions from these assessments were put in place to prevent accidents with hot liquids. During cares at bedtime on 5/13/2023, R406 was found to have a burn to the right upper thigh with no assessment at the time of the discovery. R406 was sent to the hospital for treatment where blisters were noted to the right upper thigh. R406 sustained a third degree burn that has caused pain to R406. According to R406, in the evening of 5/13/23, she (R406) was warming up soup in the microwave. When R406 was cleaning out the microwave, R406 bumped the cup and spilled the soup. The facility's failure to supervise, provide assistive devices, and assistance with a hot liquid caused R406 to sustain a third degree burn to the right upper thigh. Example 1 rises to a scope and severity level of actual harm/isolated. * R406's smoking care plan interventions include in part R406 is not to have cigarettes or smoking material on person and to observe for unsafe smoking behaviors or attempts to obtain smoking material from outside sources, immediately inform facility management. Smoking assessments dated 4/5/23, 4/8/23, 4/22/23, 5/7/23 documented R406 follows the facility's smoking policy with no concerns. R406's care plan was not updated to reflect the assessments. On 5/25/2023 at 9:28 PM in the progress notes, nursing was alerted to R406's room by smoke odor and observed R406 smoking in bed. There were no updates noted to R406's care plan. * R406 tried to elope on 5/7/2023 and an elopement assessment was not completed until 5/10/2023 after R406 got out of the building; it was not until then that an elopement care plan and Wanderguard were implemented. *R201 had a fall the first day. There was no baseline care plan with interventions to address R201's fall risk. The fall itself was not thoroughly assessed to identify fall risks. *R202 fell off a gurney at time of admission to the facility. There was no fall assessment, and identified risk factors to implement fall preventions. *R203 was assessed as a high fall risk upon admission to the facility. R203 had three falls that were not thoroughly assessed to identify fall risks. The Falls Care Plan was not implemented until after the three falls had occurred, which put R203 at risk for future falls. Findings: 1. R406 was admitted to the facility on [DATE] with diagnoses of: systemic lupus erythematosus, pulmonary fibrosis, diabetes, tubulo-interstitial nephropathy in systemic lupus erythematosus, neuropathy, epilepsy, paraplegia, cerebral infarction, and hemorrhage of anus and rectum. R406's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R406 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R406 as needing extensive assistance with bed mobility, dressing, and toilet use, and limited assistance with transfers and hygiene. R406's Power of Attorney (POA) was activated on 4/18/2023. On 3/29/2023 at 12:29 PM in the progress notes, nursing charted R406 was sent to the hospital for evaluation and treatment for altered mental status. R406 was admitted to the hospital. On 4/5/2023 at 1:18 PM in the progress notes, while R406 was in the hospital, the facility did a quarterly review. The review stated R406 presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions yielding labile mood. R406 presents with dysthymic mood, sleep disturbances, fatigue, overeating, difficulty concentrating and remaining on task, restlessness, and irritability. R406 presents with persecutory delusions and paranoia that are exacerbated when boundaries are set with R406 that R406 does not like resulting in hostility and agitation. R406 will typically begin to perseverate and/or fixate on the topic and has been known to hold grudges against staff members who set boundaries R406 does not like . On 4/6/2023 at 10:13 PM in the progress notes, nursing charted R406 was readmitted to the facility. (R406 had been hospitalized for altered mental status with diagnoses of acute metabolic encephalopathy and urinary tract infection.) On 4/8/2023, the facility did a Hot Liquid Safety Evaluation and determined R406 had hand tremors or abnormal muscle movement which could cause the possibility of spilling liquids and an interim measure for safety was a clothing protector or lap protector. The interim measures from the Hot Liquid Evaluation (clothing protector of lap protector) were not incorporated into R406's care plan, nor were they implemented. On 4/13/2023 at 2:16 PM in the progress notes, nursing charted R406 was non-responsive to verbal and tactile stimuli and was sent to the hospital for evaluation and treatment. R406 was admitted to the hospital. On 4/18/2023, R406's POA was activated while in the hospital. On 4/21/2023 at 3:21 PM in the progress notes, nursing charted R406 was readmitted to the facility. (R406 had been hospitalized for altered mental status with diagnoses of acute metabolic encephalopathy.) On 4/22/2023 the facility did a Hot Liquid Evaluation. The form did not have any factors marked as a concern or interim measures marked. The form was blank. On 4/28/2023 at 12:43 PM in the progress notes, a quarterly review was done. The review stated R406 presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions yielding labile mood. R406 presents with persecutory delusions and paranoia that are exacerbated when boundaries are set with R406 that R406 does not like resulting in hostility and agitation. R406 will typically begin to perseverate and/or fixate on the topic and has been known to hold grudges against staff members who set boundaries R406 does not like . On 5/3/2023 at 12:36 PM in the progress notes, nursing charted R406 had emesis twice with signs of lethargy but responded to the nurse and stimulation. R406 was sent to the hospital for evaluation and treatment. On 5/6/2023 at 3:45 PM in the progress notes, nursing charted R406 was readmitted from the hospital. (R406 had been hospitalized for altered mental status with diagnoses of acute metabolic encephalopathy and urinary tract infection.) At 4:19 PM in the progress notes, nursing charted R406 was alert with some confusion, R406 was redirected and aware of environment and self. On 5/7/2023, a Hot Liquid Evaluation was completed. R406 had cognitive impairment, behaviors, and a history of spilling liquids. Interim measures in place to enhance safety while rehab screen was pending, cup with lid or other adaptive cup, staff assistance, clothing protector and/or lap protector, and to drink hot liquids at a table only. Surveyor reviewed R406's Care Plan and medical record. The interim measures from the Hot Liquid Evaluation were not incorporated into R406's care plan nor were they implemented. On 5/13/2023 at 10:22 PM in the progress notes, LPN R (Licensed Practical Nurse) charted LPN R was informed by a Certified Nursing Assistant (CNA) that R406 had an injury to the right thigh. LPN R assessed R406, and the injury appeared to be a burn. R406 stated they had spilled hot water or soup on themselves. R406 denied pain at that time. R406 had been having increased confusion. LPN R spoke to R406's POA who stated, OMG she burning [sic] herself again. The POA also stated R406 had spilled soup on R406 before . LPN R notified DON B (Director of Nursing) and NP T (Nurse Practitioner) and received an order to send R406 to the hospital for evaluation and treatment. Surveyor did not find any documentation of the size or characteristics of the area prior to R406 being sent to the hospital. Surveyor did not find any further investigation into R406's reported history of burning self. On 5/13/2023 at 11:35 PM on the Emergency Department Provider Notes, the physician documented R406 with dementia apparently knocked over a bowl of soup at noon yesterday and burned the right thigh. There was no reported genital involvement or other injuries. The facility wrapped R406's leg and sent R406 to the hospital this evening for evaluation. R406 initially did not want pain medication. The physical exam documented a regular partial-thickness burn wound to the right medial thigh with the greatest dimension 17 x 11 cm with multiple bulla (blisters), some ruptured and some unruptured. The physician debrided some of the bulla and applied Silvadene ointment and nursing applied a nonadherent dressing. The physician felt R406 was safe to discharge with pain medicine, tetanus update, and twice daily Silvadene and dressing change. R406 was to follow up with the burn clinic early that week. On 5/14/2023 at 7:00 AM in the progress notes, nursing charted R406 returned to the facility. No assessment of the burn was found in R406's medical record on 5/14/2023 when R406 returned to the facility. On 5/15/2023, R406 was seen by the wound physician. The right anterior thigh burn measured 11.68 cm x 12.28 cm with fluid-filled blisters. Silver sulfadiazine treatment daily was in place. R406's Altered Skin Integrity Care Plan for the burn to the upper right thigh was initiated on 5/15/2023 with the following interventions: -Conduct weekly skin inspection. -Evaluate the need for pain reliever prior to cleansing or dressing changes. -Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor; notify physician of significant findings. -Treatments as ordered. -Weekly wound evaluation. Surveyor noted the Altered Skin Integrity Care Plan for the burn did not address the amount of supervision, limitation, or assistance R406 may need with hot liquids to prevent future injury. R406's care plan did not include interim measures identified in the 4/8/2023 and 5/7/2023 Hot Liquid Evaluation such as clothing protector and/or lap protector, staff assistance, etc. On 5/22/2023, R406 was seen by the wound physician. The right anterior full-thickness burn measured 12.19 cm x 11.79 cm x 0.1 cm with 100% slough. The wound was debrided down 0.2 cm and subcutaneous tissue with 10% slough remaining to wound bed. The treatment was changed to Santyl daily. On 5/25/2023, R406 was evaluated at the hospital for the status of the burn. R406 was returned to the facility with no new orders. In an interview on 7/12/2023 at 9:33 AM, Surveyor asked LPN D (Licensed Practical Nurse) if LPN D could recall the events on 5/13/2023 when R406 sustained a burn to the right upper thigh. LPN D did not know anything about the burn occurring, but did recall LPN D was working on the C Wing that day and worked both 1st and 2nd shift. (The C Wing was an alarmed unit. Anyone going through the door either on or off the unit would have to put in a code to disarm the alarm to prevent the alarm from sounding or put in a code to stop the alarm once it was activated.) LPN D stated the microwave was in the large conference room on C Wing and was accessible to anyone who wanted to use it. Surveyor asked LPN D if the alarmed door prevented anyone from accessing the unit. LPN D stated anyone could go through the door and if the alarm went off, any staff member could disarm the alarm. LPN D stated the unit was a very busy unit and people were constantly going through the door causing the alarm to go off. LPN D recalled hearing pounding (on a table) on that day while LPN D was passing medications to the residents on C Wing. LPN D stated R406 was in the conference room and was pounding on a table to get someone's attention because the electric wheelchair would not move. LPN D stated LPN D tried to help R406 but was unable to move the wheelchair. LPN D stated LPN D happened to notice a cup of noodles in the microwave, like the kind of product that has noodles in a cup and all you must do is add water before putting in the microwave. LPN D stated LPN D was not even sure why LPN D noticed the noodles in the microwave but did not think anything of the noodles in the microwave because there was nothing spilled anywhere. Surveyor asked LPN D if R406 said anything about the noodles in the microwave. LPN D stated R406 did not say anything about the noodles and R406 did not have anything spilled on R406. LPN D stated R406 was not a resident of the C Wing so LPN D went and got LPN R from the D Wing to assist getting R406 back to the D Wing. Surveyor notes LPN R confirmed they had worked both the 1st and 2nd shift on the D Wing on 5/13/23. In an interview on 7/12/2023 at 9:46 AM, Surveyor asked LPN R if LPN R could recall the events of 5/13/2023 when R406 sustained a burn to the right upper thigh. LPN R stated earlier in the shift, LPN D came and got LPN R because R406's electric wheelchair would not move. LPN R stated LPN R physically pushed R406's electric wheelchair with R406 in it back to D Wing and plugged in the wheelchair in R406's room. LPN D stated R406 stayed in the wheelchair while it was charging. Surveyor asked LPN R if R406 was carrying anything back to the unit from C Wing. LPN R stated R406 did not have anything with R406. Surveyor asked LPN R if R406 had wet clothing. LPN R stated R406 did not have anything spilled on R406. Surveyor asked LPN R if LPN R saw anything spilled in the conference room on C Wing. LPN R stated LPN R did not observe any spills or anything else out of place. LPN R stated later that day, sometime after supper, LPN R was at the nurses' station charting. LPN R heard R406 talking to a Certified Nursing Assistant (CNA) standing at the desk and asked for food. LPN R stated the CNA gave R406 a paper menu but did not order or give any food to R406. LPN R stated R406 was diabetic, and the staff know to tell LPN R if R406 had any food beyond mealtimes; none of the staff reported to LPN R that R406 had any food after supper. Surveyor asked LPN R if R406 was capable of heating up something in the microwave. LPN R stated R406 was extremely capable of heating up food in the microwave. Surveyor asked LPN R if R406 could have gone onto the C Wing independently without anyone knowing that was where R406 was. LPN R stated R406 could go anywhere they wanted in their electric wheelchair. Surveyor asked LPN R if the staff on C Wing would know R406 was on that unit. LPN R stated the alarm would go off when R406 went through the door and the staff would have to turn off the alarm, but they would not be monitoring where or what R406 was doing. LPN R stated between 9:00 PM and 10:00 PM, the CNA told LPN R that R406 had a bruise and a burn. LPN R stated the skin was a sheet of red with no blisters. LPN R stated she called the NP, the Director of Nursing (DON), and the POA. LPN R stated the POA was out of town and told LPN R that R406 must have done it again, stating R406 had burned themselves before. In an interview on 7/12/2023 at 2:32 PM, Surveyor asked R406 how R406 got a burn to the right upper thigh. R406 stated R406 was warming up soup in the microwave and when R406 was cleaning out the microwave, R406 bumped the cup and spilled the soup. R406 stated R406 must have been in shock when R406 got burned because R406 did not even scream or anything. R406 stated it happened in the evening after dinner and the nurse on that unit took R406 to the responsible nurse. Surveyor asked R406 if R406 still uses an electric wheelchair. R406 stated R406 has not had the electric wheelchair since the soup spilled, and the soup must have flooded the wheelchair because the special lock on the chair does not work. Surveyor noted R406 did not recall events the same way as the staff. Staff interviewed did not recall any spilled liquid in the conference room or on R406's clothing while R406 states the spilled soup caused her wheelchair not to work. In an interview on 7/12/2023 at 9:04 AM, Surveyor asked CNA S if there was a microwave on each unit. CNA S stated there were only two microwaves, one in a small, closed room and one in a larger conference room, both on C Wing. Surveyor asked CNA S if residents could use the microwave. CNA S stated no, residents do not heat up anything, the staff does it for them. In an interview on 7/12/2023 at 9:17 AM, Surveyor asked CNA U if there was a microwave on each unit. CNA U stated there were two microwaves on C Wing and nowhere else in the building. Surveyor looked in the small, closed room and the conference room on C Wing and no microwaves were observed in either place. On 7/11/2023 at 3:46 PM during the daily exit with the facility, Surveyor requested the facility investigation for R406's burn on 5/13/2023. On 7/12/2023 in the morning, the facility provided Surveyor with a synopsis of the facility investigation dated 5/23/2023 signed by ANHA A. The statement indicated R406 reported that the family had brought soup into the building for R406. R406 took the soup to the microwave outside of the conference room. R406 put the soup into a cup and put it in the microwave to heat it up. When the microwave was done, R406 reached into the microwave and R406's hand bumped the cup resulting in the soup spilling onto the right leg. R406 stated that when it happened, R406 thought R406 was OK. R406 reported a nurse came over and took R406 to R406's nurse. R406 denied pain to the area at the time. R406 stated later that night when the CNA took off the clothes, R406 had an injury to the leg. The NP was notified and R406 was sent to the hospital. R406 returned with treatment orders and will be seen by the wound physician. No staff statements were provided as part of the facility synopsis ANHA A provided to surveyor. Surveyor noted the size of the burn, 17 cm x 11 cm as measured in the emergency room , did not match the explanation of a spill from a cup of soup that was bumped. The only statement from the investigation was from R406 who was having delusions and hallucinations at that time. No other possible causes for the burn were investigated. On 7/12/2023 at 3:07 PM, Surveyor shared with ANHA A, DON B, and RCC C (Regional Corporate Consultant) the information Surveyor got from the staff interviews regarding R406's third-degree burn. Surveyor shared the concern R406 had been assessed to be at risk with hot liquids on 4/8/2023 and on 5/7/2023. On 5/13/23, R406 independently heated up soup in the microwave and sustained a burn when the liquid spilled on R406. On 7/13/2023 at 11:27 AM, Surveyor saw CNA N in R406's room providing incontinence care. R406 was insistent that R406 did not want to get out of bed. CNA N reassured R406 multiple times that R406 could stay in bed and CNA N was not going to get R406 up. Surveyor asked CNA N how mobile R406 was with bed mobility and moving the legs. CNA N stated R406 could move both legs independently and has sensation to both legs. CNA N stated R406 was complaining of pain from the burn and was going to go tell the nurse. On 7/13/2023 at 11:37 AM, Surveyor asked LPN D if R406 had pain caused from the burn to the right upper thigh. LPN D stated R406 has pain, but not all the time. LPN D was preparing to give R406 Tramadol at that time for current complaints of pain. On 7/13/23 Surveyor again reviewed R406's care plan. R406's Cognitive Impairment & Communication Impairment care plan initiated on 12/08/22 includes an intervention in part dated 12/08/2022- Assure patient is monitored during mealtime if needed. On 07/13/2023, the facility added the intervention of Supervision with hot liquids. (Set up assist with temperature check with all hot liquids.) Surveyor noted this intervention was added almost 2 months after R406 sustained a 3rd degree burn on her thigh on 5/13/23 from according to R406 hot liquid. 2. R406's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R406 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. R406's Smoking Care Plan was initiated on 12/8/2022 with the following interventions: -Assist to and from the designated smoking area. -Assure smoking material is extinguished prior to R406 leaving the smoking area. -Complete the smoking safety assessment per facility policy. -Observe R406 for unsafe smoking behaviors or attempts to obtain smoking material from outside sources; immediately inform facility management. -R406 is not to have cigarettes or smoking material on person. -Review smoking policy with R406 and/or family. -Storage of smoking materials per facility policy. On 3/29/2023 at 12:29 PM in the progress notes, nursing charted R406 was sent to the hospital for evaluation and treatment for altered mental status. R406 was admitted to the hospital. On 4/5/2023, while R406 was in the hospital, the facility did a Smoking and Safety assessment that determined R406 was a safe smoker. The Smoking Care Plan was not revised. On 4/5/2023 at 1:18 PM in the progress notes, while R406 was in the hospital, the facility did a quarterly review. The review stated R406 presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions yielding labile mood .R406 is a known smoker. On 4/22/2023 the facility did a Smoking and Safety assessment that determined R406 follows the facility's policy on location and time of smoking with no concerns. On 4/28/2023 at 12:43 PM in the progress notes, a quarterly review was done. The review stated R406 presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions yielding labile mood . R406 is a known smoker and following the assessment, R406 can safely participate in the facility smoking program. On 5/7/2023, a Smoking and Safety assessment was completed with no safety concerns identified. On 5/13/2023 at 10:22 PM in the progress notes, LPN R (Licensed Practical Nurse) charted LPN R was informed by a Certified Nursing Assistant (CNA) that R406 had an injury to the right thigh. LPN R assessed R406, and the injury appeared to be a burn. R406 stated they had spilled hot water or soup on themselves. R406 denied pain at that time. R406 had been having increased confusion. LPN R spoke to R406's POA who stated, OMG she burning [sic] herself again. The POA also stated R406 had spilt soup on R406 before and had also put cigarettes out on the leg thinking R406 was putting the cigarette out in an ashtray. On 5/25/2023 at 9:28 PM in the progress notes, nursing charted the nurse was alerted to R406's room by smoke odor and observed R406 in bed smoking. The nurse immediately removed the cigarette and lighter from R406 for resident safety. The Assistant Director of Nursing and R406's POA were notified of the incident. On 5/26/2023 a Smoking and Safety assessment was done. The assessment determined R406 displayed poor understanding of the facility protocols regarding smoking safety as evidenced by smoking indoors/in room. R406 was educated on safety measures surrounding smoking and verbalized understanding. R406's Smoking Care Plan was not revised. In an interview on 7/12/2023 at 9:46 AM, LPN R stated R406 was an independent smoker. On 7/12/2023 at 3:07 PM, Surveyor shared the concern R406 was found smoking in bed on 5/25/23 with ANHA A, DON B, and RCC C. 3. On 4/5/2023 at 1:18 PM in the progress notes, while R406 was in the hospital, the facility did a quarterly review. The review stated R406 presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions .R406 can self-propel using an electric wheelchair and does not present at an elevated risk for elopement at this time . On 4/28/2023 at 12:43 PM in the progress notes, a quarterly review was done. The review stated R406 presents with signs and symptoms of cognitive impairment as evidenced by poor reality orientation, perseveration, poor decision-making capabilities, poor frustration tolerance, and difficulty managing distressing emotions .R406 can self-propel using an electric wheelchair and does not present at an elevated risk for elopement at this time . On 5/7/2023 at 2:13 PM in the progress notes, nursing charted R406 was very confused and tried to leave the building. R406 was redirected and confusion remained. On 5/10/2023 at 10:56 AM in the progress notes, nursing charted R406 was alert and oriented times two with increased bouts of confusion. R406 used a motorized wheelchair for mobility and was seen attempting to go toward the street with the wheelchair. The nurse intervened and brought R406 inside. An elopement assessment was completed and a Wanderguard was placed on R406. On 5/10/2023 an Elopement Evaluation was completed that determined R406 had wandering behavior that was a pattern or goal-directed and was at risk for elopement with a score of 4. A score of 1 or higher places a resident to be at risk for elopement. An Elopement Risk Care Plan was initiated on 5/10/2023 due to R406 having a history of attempting to leave the facility without notifying staff and wears a Wanderguard for their safety. The following interventions were implemented at that time: -Assess for risk of elopement per facility policy. -Educate family/responsible party on talking positively about facility placement. -Evaluate effect of cognitive impairment upon R406's ability to understand changes in surroundings. -Involve R406 in preferred activities such as coloring and painting. -Involve R406 in preferred activities. -Involve R406 in decision making regarding daily choices. -Redirect R406 from doors. -Take picture of R406 upon admission for identification for updating elopement book. On 7/12/2023 at 3:07 PM, Surveyor shared with ANHA A, DON B, and RCC C the concern R406 eloped from the facility on 5/10/2023 after which a Wanderguard was placed. On 7/17/2023, the facility provided a statement by the nurse that was working on 5/10/2023 when R406 exited the building. The statement was dated 7/16/2023 and states on 5/10/2023 R406 was in the front lobby and chose to go outside. Staff witnessed R406 and had R406 in their viewpoint during that time. R406 was on facility premises in the front drive area. Staff assisted R406 back into the facility without incident. R406 did not elope from the building. Surveyor noted facility staff completed an elopement assessment at that time and determined R406 was at risk for eloping and placed a Wanderguard on R406 at that time. An Elopement Care Plan was developed on 5/10/2023. The nurse was not interviewed at the time of the elopement as part of the facility investigation; the nurse was interviewed after Surveyor brought forth the concern of R406's elopement. No further information was provided at that time. 21855 The facility's policy and procedure for Falls Management Process, undated, was reviewed by Surveyor. The Policy indicates: #11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. #12. The nurse will determine the most appropriate intervention, implement, and update care plan. The facility's policy and procedure for Baseline Care Plan, dated 3/1/19, was reviewed by Surveyor. The policy indicates: #2. The admitting nurse shall gather information from the hospital transfer information, physical assessment, physician orders, and discussion with the resident and resident representative. #2a. Once gathered , initial goals shall be established that reflect the resident's stated goals and objectives. #2b. interventions shall be initiated that address the resident's current needs including: any health and safety concerns to prevent decline or injury, such as elopement, fall or pressure injury risk. #2c. Once established, goals and interventions shall be documented in the designated format. 4. R201's medical record was reviewed by Surveyor. R201 was admitted on [DATE] from the hospital and was discharged to another skilled nursing facility on 6/23/23. R201 Hospital Discharge Summary dated 6/13/23 was reviewed. The Discharge Summary hospital course indicates R201 has generalized weakness with gait ataxia. A MRI (magnetic resonance imaging) of R201 brain showed acute ischemic stroke in multiple territories. R201 has a history of A-fib and previously taken off DOAC(direct oral anticoagulants) due to high fall risk., has been on aspirin and statin at home. The Discharge Summary Instructions for Medication Changes indicate to take plavix and aspirin for 30 days then continue with aspirin alone. This will help prevent strokes again. If risk of falls decrease (i.e. more supervised care) then discuss risks and benefits of resuming anticoagulation. R201 Progress Note on 6/13/23 at 7:05 PM indicates R201 had an unwitnessed fall in their room. R201 stated they were attempting to self toilet themselves. R201 was observed in a fetal position by their wheelchair in their room. R201 did not have an injury noted and indicated they wanted to use the bathroom. The progress note does not indicate if any interventions were implemented with this fall. R201 plan of care was reviewed. There is no baseline, or plan of care, that identify's the fall with risk interventions. The Facility provided Fall Investigation dated 6/13/23 7:04 PM that was reviewed by Surveyor. The report description indicates R201 was observed on the floor laying on their right side in a fetal position next to their wheelchair. R201 statement I was going to the bathroom. The investigation indicates no witnesses; however, there are no staff statements regarding toileting or activity prior to the fall. The report investigation conclusion is R201 was attempting to reach for an item on the floor and Therapy will provide a reacher. There is no supporting documentation to this conclusion. There is no fall risk interventions or a Fall plan of care. On 7/5/23 at 2:49 PM Surveyor spoke with RN F (Registered Nurse) who conducts the MDS assessments and care plans. R201 medical record was also reviewed at this time. There was no Fall plan of care. The admitting nurse typically does the Baseline Care Plans. There was not a Baseline plan of care. On 7/6/23 at 7:38 AM, Surveyor spoke with DON B. DON B indicated the admitting Nurse is an Agency who is also on a month long vacation. On 7/6/23 at 3:00 PM, R201 fall concerns were shared at the facility Exit Meeting. On 7/10/23, ANHA A and RCC C provided Surveyor with a Performance Improvement Plan (PIP) started 7/6/23. The facility started training on 7/7/23 for baseline care plans and comprehensive care plans. 5. R202's medical record was reviewed by Surveyor. R202 was admitted into the facility on [DATE] from the hospital. R202 has a diagnosis of Alzheimer's dementia with an activated Power of Attorney. The Progress Note on 3/30/23 indicates R202 fell off the gurney upon admission to the facility. R202 complained of left leg pain and an x-ray was obtained. The x-ray was negative. There was no documentation of fall risk interventions and circumstances surrounding the fall. R202 did not have a Baseli [TRUNCATED]

Uncorrected on revisit Event ID MT9J11 Based on interview and record review, the facility did not ensure that 2 (R31 and R64) of 3 sampled residents for falls were free of from accident hazards and provided supervision and assistive devices to prevent avoidable accidents. R31 was being transferred from a wheelchair to the Paramedics gurney for transport to dialysis with a Sit to Stand Lift on 4/8/23. R31 was feeling weak and verbalized this to the Certified Nursing Assistant (CNA) who was transferring her. The CNA continued to transfer her and she fell and fractured her right leg. The CNA was not following policy of 2 person transfer of resident. Documentation in the Care Plan and Kardex was inconsistent and documented resident should be a Hoyer Lift or Slide Board transfer. Physical Therapy documentation notes resident can be a Sit to Stand Lift but the lift was not appropriate to transfer R31 as she exceeded the manufacturers recommended weight limit. This example, regarding R31, is being cited at a scope and severity of a G (actual harm/isolated). R64 was a high fall risk and sustained a fall on 4/17/23. A Root Cause Analysis was completed but the intervention of a Reacher that was put in place was not effective and did not address the root cause of the fall. There was no immediate intervention put in place and reacher was not added to the care plan until 4/26/23. When staff was interviewed about the interventions, a Broda chair was the intervention they put in place after the fall. On 5/16/23, R64 had a fall out of bed with no immediate intervention put in place. On 5/16/23 after fall, R64 was observed in bed with call light out of reach and did not have a Reacher or a Broda chair. Findings include: Surveyor reviewed the facility Falls Management Process policy with no date that documents: 1. In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life threatening safety concerns are present (fire, highway, etc.). Remain with the resident while calling for assistance, if at all possible. 2. Quickly scan the resident surroundings for personal safety. Only move the resident in the event of a life-threatening safety situation such as a busy highway or fire. Observe for electrical safety concerns prior to touching the resident (down electrical wires, etc.). 3. When safe, go to resident and quickly scan for consciousness, breathing and pulse. If the resident is unconscious, has difficulty breathing or a stroke /severe head injury is suspected, immediately call 9-1-1 for transfer. 4. If the resident is conscious, provide reassurance and comfort; provide a cover for dignity and warmth if applicable and available. Resident is NOT to be moved until assessed for injury by a nurse unless life-threatening situation exists. 5. If able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later). 6. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. 7. Obtain vitals signs: Blood pressure, pulse, pulse oximetry, and respirations. 8. Obtain neurological checks (neuro-checks) per policy for any unwitnessed fall or any fall with evidence to head. 9. If no obvious injury or only minor injury move resident to a comfortable position. If significant injury, severe pain, or abnormal assessments observed, call 9-1-1. 10. Obtain finger-stick blood sugar if known diabetic. 11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. Contact physician and family and document in the medical record, including time and person spoken with. If transferred, document transferring agency/responders. 13. Resident fall will be noted on 24 hour Report for three days for post fall monitoring, assessing for injury, full vital signs every 8 hours, and pain assessment. 14. The Director of Nursing will be notified immediately of falls resulting in injury and/or transfer. Surveyor reviewed the facility Falls Review Process policy with no date that documents: Post Fall 1. Director of Nursing/Designee will assess the resident and review fall documentation, including witness statements, resident interview, environment review of area where fall occurred, and equipment inspection. 2. The event will be discussed and event documentation reviewed for completion in IDT meeting. Compare data from previous assessments. Discuss identified trends. 3. Therapy referral and Medication Review initiated. 4. Other referrals if applicable. Neurological, Vision, Hearing, Psych, etc. 5. Review Fall Risk Assessment for any potential new risk factors. 6. Review plan of care/interventions to ensure all prior interventions are in place and still appropriate. 7. Adjust/add interventions on the Plan of Care. Update and communicate interventions. Provide appropriate training for caregivers if appropriate. Educate resident/family if appropriate. 8. Discuss findings and interventions with the resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IPOC). 1.) R31 was admitted to the facility 12/6/22 with Type 2 Diabetes Mellitus, Acute and Chronic Respiratory Failure with Hypoxia, Morbid (Severe) Obesity Due to Excess Calories, Nephrotic Syndrome with Unspecified Morphologic Changes, End Stage Renal Disease and Dependence on Renal Dialysis. Surveyor reviewed R31's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/21/23. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. Documented under Functional Status for Bed Mobility was 3/3 which indicated Extensive assistance - resident involved in activity, staff provided weight-bearing support; Two+ persons physical assist. Documented under Transfer Status 3/3 which indicated Extensive assistance - resident involved in activity, staff provided weight-bearing support; Two+ persons physical assist. On 5/15/23 at 12:28 PM Surveyor interviewed R31. Surveyor asked about the fall on 4/8/23. R31 stated she was supposed to go to Dialysis. R31 stated when the driver was pushing her wheelchair to the transport van he broke her wheel going over a pothole. R31 said they brought her back inside but she could not go on the van because the other wheelchair she had was too big to fit on the van so an ambulance was called. R31 stated CNA-C was lifting her out of the Sit to Stand lift with Paramedics at her side but was not listening to her. R31 stated she told CNA-C that her legs were weak multiple times but she did not listen and she fell to the floor when her knees gave out. R31 stated she had right knee pain after the fall of 10 out of 10 that she expressed to RN-D and the Paramedics. R31 stated when she finally got off the floor with the assist of six Paramedics they took her to the hospital and she had fractured her right leg. Surveyor reviewed R31's Comprehensive Care Plan with an initiation date of 11/8/21. Documented was: Focus: At risk for falls related to: Use of medication, impaired mobility, etc. Goal: No Falls Interventions: o 11/30-fall-staff to be educated regarding following Kardex o Call light and personal items available and in easy reach o Clear and monitor environmental obstacles (tubing, cords, etc.) o Encourage participation in activities to improve strength or balance such as therapies, in room exercises, etc. o Encourage rest periods if feeling fatigued o Keep environment well lit and free of clutter o Therapy Referral as ordered and PRN R31's Care Plan was updated on 4/7/23 to include: o 04/07/22: Provide wheel chair is of appropriate size; and has footrests; is locked/unlocked for safety, has anti tippers, as needed. R31's Care Plan was updated on 4/11/23 to include: o Re-educate staff on lift use. Surveyor reviewed R31's CNA Visual/Bedside Kardex Report sheet for directed resident care. Documented under Mobility was Transfer with total assistance of (2) and Beazy Board bed to chair or assist of 2 and Hoyer type lift. Sit to Stand Lift was not documented. Surveyor reviewed Incident Report from 4/8/23 fall. Documented by Former Registered Nurse (RN)-D was: Incident Description: Nursing Description: At about 0750, writer was notified by [Former (CNA)-C] that resident was on the floor. Resident was seen laying on her back in front of sit to stand machine. Resident fell while being transferred from w/c to [name of ambulance company] ambulance [gurney] using sit to stand. It was a witnessed fall. Resident Description: Resident stated that her knees gave up while being lifted to the sit to stand. Immediate Action Taken: Description: Resident was transferred back to the [gurney] using a sliding board by 6 paramedics and taken to [hospital] for dialysis. Resident Taken to Hospital? [No] Injuries Observed at Time of Incident: Injury Type: No injuries observed at time of incident. Level of Pain: Numerical: 9 Level of Consciousness: Alert Mobility: Lift Transfer . RN-D was unable to be interviewed. Surveyor reviewed Progress Notes for R31 with a date of 4/8/23 at 8:54 AM. Documented was Note Text: At about 0750, writer was notified by [CNA-C] that resident was on the floor. Resident was seen laying on the floor in front of the sit to stand on her back. She fell while transferring from chair to [name of ambulance company] Ambulance [gurney]. She stated that her knees hurt, she verbalized pain at 9/10. She was transferred back to [gurney] using a sliding board by 6 paramedics and was taken to [hospital] for dialysis . On 5/15/23 Surveyor interviewed Former CNA-C. Surveyor asked what happened when R31 fell from the Sit to Stand lift. CNA-C stated it happened so fast and was not sure about all the details. CNA-C stated she was alone with the Paramedics and did not utilize a second aide to operate the lift per policy. CNA-C stated the leg straps were broken on the lift and she only had her arms strapped in. CNA-C stated R31 never verbalized she was weak, she just fell . Surveyor reviewed Emergency Medical Services report with a date of 4/8/23. Documented under NARRATIVE was: [Ambulance] DISPATCHED WITHOUT LIGHTS AND SIRENS FOR OTHER - SEE COMMENTS. UPON ARRIVAL, PATIENT FOUND IN WHEEL CHAIR. PATIENT STATES TO EMS THAT PATIENT WAS GETTING READY TO GO TO DIALYSIS THIS MORNING WHEN THE DRIVER OF THE VAN WAS PUSHING PATIENT IN A WHEEL CHAIR, THEN PATIENT'S FRONT WHEEL GOT STUCK IN A POT WHOLE, AND THEN THE VAN DRIVER FORCED PATIENT'S WHEEL CHAIR TO MOVE FORWARD WHERE IS CAUSED PATIENTS WHEEL ON HER WHEELCHAIR BROKE. PATIENT STATES THAT WHEN THE WHEEL OF THE WHEEL CHAIR BROKE, PATIENT STOPPED HERSELF FROM FALLING FORWARD WITH HER RIGHT LEG. PATIENT DENIES HAVING ANY PAIN FROM THE WHEEL OF THE WHEELCHAIR BREAKING WITH THE ALMOST FALL. PATIENT STATES SHE WAS COVID POSITIVE LAST WEEK AND MISSED HER REGULAR DIALYSIS TREATMENTS, PATIENT STATES HER DIALYSIS DAYS HAD TO BE ADJUSTED. PATIENT STATES HER FIRST REGULAR DIALYSIS DAY WOULD BE TODAY BUT BECAUSE OF THE WHEEL OF THE WHEELCHAIR BREAKING, PATIENT COULDN'T GO TO DIALYSIS ANYMORE, DUE TO THE PATIENT'S NEW WHEELCHAIR THAT DOES NOT FIT IN THE VAN. EMS ASKED HOW PATIENT GETS AROUND. FACILITY STAFF STATES THAT SOMETIMES PATIENT GETS UP USING THE [NAME] SIT TO STAND OR BY THE HOYER LIFT. FACILITY STAFF GRABBED THE MARRISA SIT TO STAND TO HELP PATIENT GET FROM PATIENT WHEELCHAIR TO EMS COT. AFTER THE PATIENT WAS CONNECTED TO THE [NAME] SIT TO STAND, FACILITY STAFF PROCEEDS TO GET THE PATIENT UP AND OUT OF HER WHEELCHAIR FACILITY STAFF ONLY CONNECTED PATIENT TO THE ARM STRAPS, FACILITY STAFF DID NOT MOVE THE BUTT SITTING PARTS THAT GO BEHIND THE PATIENT'S BUTT IN POSITION NOR DID FACILITY STAFF CONNECT THE LEG STRAPS ON TO THE PATIENT. FACILITY STAFF ONLY CONNECTED PATIENTS ARMS TO THE [NAME] SIT TO STAND AS FACILITY STAFF CONTROLLED THE MACHINE TO LIFT THE PATIENT OFF HER WHEELCHAIR, PATIENT TOLD FACILITY STAFF TO PUT HER BACK IN HER WHEELCHAIR EMS ASSISTED IN GETTING THE PATIENT BACK IN HER WHEELCHAIR AND WAS SUCCESSFUL THE FIRST TIME. AFTER PATIENT GOT INTO HER WHEELCHAIR WITH THE HELP OF EMS PUTTING THE WHEELCHAIR UNDERNEATH THE PATIENT, FACILITY STAFF TRIED TO LIFT THE PATIENT UP AGAIN USING THE [NAME] SIT TO STAND MACHINE THAT FACILITY STAFF WAS CONTROLLING PATIENT AGAIN TOLD FACILITY STAFF THAT PATIENT CANNOT HOLD HERSELF UP AND THAT SHE IS FEELING WEAK LIKE SHE IS GOING TO FALL FACILITY STAFF STILL TRIED TO PROCEED LIFTING THE PATIENT UP WITH THE [NAME] SIT TO STAND. PATIENT AGAIN TOLD FACILITY STAFF ONE MORE TIME THAT PATIENT IS GOING TO FALL IF FACILITY STAFF DOES NOT STOP LIFTING THE PATIENT UP. FACILITY STAFF THEN TRIES TO PUT PATIENT BACK INTO HER WHEELCHAIR. EMS IS AT THE SIDE OF PATIENT'S WHEEL CHAIR. EMS TRIED TO ASSIST THE PATIENT TO GET BACK INTO HER WHEEL CHAIR BY TRYING TO GET THE WHEELCHAIR UNDERNEATH THE PATIENT WHILE FACILITY STAFF HAD CONTROL OF THE [NAME] SIT TO STAND MACHINE PATIENT STATES TO EMS AND FACILITY STAFF THAT PATIENT CANNOT HOLD ON ANY LONGER. BY THE TIME EMS TRIED TO GET THE WHEELCHAIR UNDERNEATH THE PATIENT, THE PATIENT WAS LOWER TO THE GROUND. PATIENT THEN YELLED OUT I'M GOING TO FALL. EMS CREW TRIED TO CATCH THE PATIENT. ONE EMS CREW WAS AT THE HEAD OF THE PATIENT AND THE 2ND EMS CREW WAS AT THE SIDE OF THE PATIENT. PATIENT THEN SLOWLY STARTED TO FALL AND SLIDE TO THE GROUND. EMS AND FACILITY STAFF WITNESSED PATIENT SLIDING AND FALLING ONTO THE GROUND FROM BEING CONNECTED TO THE ARM STRAPS OF THE [NAME] SIT TO STAND AS SOON AS PATIENT GOT ONTO THE FLOOR, PATIENT WAS ASSESSED TO MAKE SURE PATIENT WAS OKAY. PATIENT DENIED HEAD, NECK OR BACK PAIN. PATIENT STATES THE ONLY PAIN SHE HAS IS FROM HER RIGHT KNEE THAT IS THROBBING. PATIENT STATES TO EMS THAT PATIENT HAS CHRONIC RIGHT KNEE PAIN THAT'S ALWAYS HURTING, BUT WITH THE INCIDENT, PATIENT IS STATING THAT HER RIGHT KNEE IS HURTING MORE THAN USUAL. EMS ASSESSED CMS, CMS IS INTACT. PATIENT STATES THAT PATIENT WAS ALWAYS NEVER ABLE TO MOVE HER TOES BUT CAN FEEL EMS CREW TOUCHING HER TOES AND HER FEET. EMS PUT A PILLOW UNDER PATIENT'S HEAD FOR COMFORT WHILE BEING ON THE FLOOR. EMS ALSO PUT A PILLOW UNDERNEATH THE PATIENT'S RIGHT KNEE FOR COMFORT AS WELL. AFTER PATIENT WAS ASSESSED BY EMS CREW AND COMFORTABLE, EMS CREW CALLED DISPATCH TO GET A LIFT ASSIST AND TO HAVE A SUPERVISOR COME TO THE SCENE AFTER LIFT ASSIST CREW AND SUPERVISOR ARRIVED, EMS CREW WITH LIFT ASSIST AND SUPERVISOR ASSISTED IN GETTING THE PATIENT ONTO THE SCOOP STRETCHER. AFTER PATIENT WAS PUT ON TO THE SCOOP STRETCHER, THE SPIDER STRAPS WERE USED TO SECURE THE PATIENT. EMS CREW LAYED (SIC) DOWN THE MEGA MOVER ON THE COT. AFTER PATIENT WAS SECURED, EMS CREW, LIFT ASSIST, AND SUPERVISOR HELPED GET THE PATIENT ONTO THE COT BY LIFTING THE PATIENT UP FROM THE FLOOR TO EMS COT. AFTER PATIENT IS SETTLED ONTO THE COT, EMS CREW, LIFT ASSIST AND SUPERVISOR REMOVED THE SCOOP STRETCHER FROM UNDERNEATH THE PATIENT. PATIENT IS NOW SECURED X5, RAILS UP X2 PATIENT WAS ASSESSED AGAIN AFTER BEING SECURED ONTO EMS COT. EMS LOADED PATIENT ONTO AMBULANCE VIA AMBULANCE POWER LIFT SYSTEM. VITALS AND HISTORY NOTED IN REPORT. PATIENT IS [alert and orientated times 4], [Glasgow Coma Scale: 15], ABCS INTACT BEFORE THE FALL AND AFTER THE FALL EMS TRANSPORTING PATIENT WITHOUT LIGHTS AND SIRENS TO [ER] PATIENT MONITORED AND REASSESSED DURING TRANSPORT. NO PHYSICAL CHANGES TO PATIENT DURING TRANSPORT. EMS CALLED REPORT TO [ER]. AT DESTINATION, PATIENT WAS LOWERED TO GROUND USING THE AMBULANCE POWER LIFT SYSTEM AND WHEELED INTO ER ROOM G20. EMS TRANSFERRED PATIENT FROM EMS COT TO ER VIA MEGAMOVER WITH ASSISTANCE OF ER STAFF. PATIENT STATES PATIENT HAS A HEADACHE AFTER THE STRESS OF EVERYTHING THAT HAPPENED AT THE ASSISTED NURSING HOME. REPORT GIVEN TO RN, SIGNATURES OBTAINED. Surveyor noted the Paramedics Report was consistent with R31's statement of verbalizing she was too weak to transfer and not with CNA-C's statement. Surveyor noted report reiterates CNA-C was not assisted with the transfer per policy of 2 persons to transfer resident. Surveyor reviewed hospital paperwork for R31 for admission from 4/8/23 through 4/13/23. Documented under diagnoses was Right Medial Femoral Condyle Fracture. Surveyor reviewed R31's Therapy to Restorative Nursing Communication - Resident Status Update with an assessment date of 10/3/22 completed by Occupational Therapist (OT)-G. Documented under Transfers was Beazy board transfer bed [to] [wheelchair (w/c)]. Sit to Stand Lift transfer w/c [to] bed. Hoyer lift if too fatigued post dialysis . Surveyor reviewed R31's Physical Therapy (PT) Discharge Summary with a date of 12/13/22 completed by PT-H. Documented under Transfers was Sit to stand = Substantial/maximal assistance. On 5/16/23 at 9:50 AM Surveyor interviewed CNA-E. Surveyor asked which Sit to Stand lift R31 used for transfers. CNA-E stated she now used a Hoyer lift but prior to her fall she used the Sit to Stand. CNA-E showed Surveyor the lift and sling R31 was using prior to her fall. Surveyor observed the Sit to Stand Lift was a [NAME] 3000 labeled #4 and had a light purple sling. Surveyor read the instruction tag on the sling which documented Max weight: 200 kg/440 lbs. Surveyor reviewed [NAME] 3000 Operating and Product Care Instructions. Documented under Safety Instructions was: Intended use: [NAME] 3000 is a mobile raising aid, with a Safe Working Load of 200 kg (440 lbs.), intended to be used for raising to a standing position and short transfer of residents (e.g. raising from bed and transit to wheelchair, or from wheelchair to toilet) in hospitals, nursing homes or other health care facilities where the resident has been clinically assessed to correspond to the following categories; Category C - Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on [caregiver] in most situations - Physically demanding for [caregiver] - Stimulation of remaining abilities is important. [NAME] 3000 shall always be handled by a trained caregiver, continuously attending to the resident, and in accordance with the instructions outlined in these Operating and Product Care Instructions. [NAME] 3000 is intended to be used with clip slings only -except for the 'Transfer Slings' which also have loops for attachment of the leg flaps to the central lug situated on the resident support arms . Surveyor reviewed R31's weights documented in the medical record. There was no current weight listed. Last weight taken prior to fall was 420.5 lbs. documented on 3/9/23. R31 had previous weights of 458.5 lbs. on 10/11/22 and 462.5 lbs. on 12/9/22 when PT transfer recommendations of Sit to Stand Lift were made. Surveyor reviewed hospital paperwork for R31. Documented under admission weight on 4/8/23 taken by bed scale was 473 lbs. These weights would exceed the recommended weight limit for the machine making it unsafe to transfer R31 with a Sit to Stand Lift. On 5/16/23 at 1:04 PM Surveyor interviewed PT Assistant (PTA)-F and OT-G. Surveyor asked what R31's transfer status was prior to the fall. PTA-F stated she was a Sit to Stand lift. Surveyor asked if anyone assessed her weights and her weighing more than the manufacturer's recommendations. PTA-F stated PT-H would have assessed that. Surveyor asked if the expectation of OT-G's recommendation of specific transfers from her 10/3/22 recommendations be specific and Kardex reading Transfer with total assistance of (2) and Beazy Board bed to chair or assist of 2 and Hoyer type lift be appropriate to list on the Kardex. OT-G stated no. Surveyor asked if CNA's were competent and able to determine or assess which transfer means to use. OT-G stated no. On 5/16/23 at 2:10 PM Surveyor interviewed PT-H. Surveyor asked about R31's transfer status prior to the fall on 4/8/23. PT-H stated she was a Sit to Stand lift. PT-H stated that was her choice except for when she was weak after dialysis then she should have been a Hoyer lift. Surveyor asked if CNA's were competent and able to determine or assess which transfer means to use. PT-H stated no. Surveyor asked if he assessed R31's weights and the manufacturers recommendations of 440 lbs. as the limit. PT-H stated no. PT-H stated that was not the working weight because the resident does some of the work in a Sit to Stand. Surveyor asked . Surveyor asked if he assessed R31's working weight and the manufacturers recommendations. PT-H stated no. On 5/16/23 at 1:04 PM Surveyor interviewed Regional Director of Operations (RDO)-J. Surveyor asked about the 3 different transfer statuses for R31. RDO-J stated there should have only been 1. RDO-J stated the CNA's do not have the authority to determine which transfer status to use. 2.) R64 was admitted to the facility 11/4/22 with diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetic Mellitus with Diabetic Polyneuropathy and Other Symptoms and Signs Involving Cognitive Functions Following Cerebral Infarction. Surveyor reviewed R64's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/20/23. Documented under Cognition was a BIMS (brief interview mental status) score of 00 which indicated severe impairment. Documented under Functional Status for Bed Mobility was 2/2 which indicated Limited Assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance; One person physical assist. Documented under Transfer Status 2/2 which indicated Limited Assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance; One person physical assist. Surveyor reviewed Fall Risk Evaluation with a date of 1/21/23. Documented under Score was 10 which meant At Risk for falls. Surveyor reviewed R64's Comprehensive Care Plan with an initiation date of 12/5/22. Documented was: Focus: At risk for falls related to: Use of medication, impaired mobility, unstable gait, impaired mobility, [history (hx)] falls, etc. Goals: [Resident] will have no falls with related injuries. Interventions: o Assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, anti tippers, etc. o Call light and personal items available and in easy reach o Clear and monitor environmental obstacles (tubing, cords, etc.) o Encourage participation in activities to improve strength or balance such as therapies, etc. o Encourage rest periods if feeling fatigued o Keep environment well lit and free of clutter R64's Care Plan was updated on 2/15/23 to include: o Monitor for restlessness and implement interventions o Observe for side effects of medications and update MD or NP if present o Therapy Referral as ordered and [as needed (prn)] Surveyor reviewed Incident Report from 4/17/23 fall. There was no documentation of what happened to R64. Documented was: .Other Info: Resident on Hospice care with increased weakness and fatigue. Sits forward in [wheelchair (w/c)] when up in chair. Broda chair ordered from Hospice . Notes: 4/18/23 IDT reviewed - Hospice is providing Broda chair. Surveyor reviewed Post Fall Evaluation for 4/17/23 fall with an effective date of 4/17/23. Documented was: .Fall Details Note: Resident found lying on the floor on his right side in his room in front of his w/c. Resident leans forward when up in w/c and yells at staff when asked to sit back in his chair. Has a 5cm red, dry scratch on his right lower arm above his wrist. [range of motion (ROM)] [within normal limits (WNL)] for resident. Able to move all extremities without [complaint of (c/o)] pain. No alteration in leg alignment. Assisted into bed. [NAME] check negative. B/P-150/83 P-72 R-18 T-97.9. On hospice care with increased weakness and fatigue. Broda chair to be delivered . Surveyor reviewed Root Cause Analysis findings for R64's 4/17/23 fall documented by Director of Nursing (DON)-B. Documented was offer a reacher. R64's Care Plan was updated on 4/26/23 to include: o Offer a reacher Surveyor noted that the reacher was not an effective intervention as the resident was not reaching to pick up anything. Surveyor noted the intervention was not put on the Care Plan until 9 days after the fall. Surveyor noted there was no immediate intervention. On 5/16/23 at 3:11 AM R64 had a fall out of bed. Progress Notes documented CNA reported resident lying on the floor. The resident was found lying on his left side on the floor near his bed, back towards the bed and head towards the door. Resident assessed, ROM performed and assisted with 2 assist to bed. No injury sustained. [DON-B] notified . There was no immediate intervention put in place for R64. Surveyor reviewed Root Cause Analysis findings for R64's 5/16/23 fall documented by Regional Director of Operations (RDO)-J. Documented was: Root Cause: Resident, disoriented and left sitting up in bed after refusing to lay down, with no supervision or diversional activity to attempt to divert resident from attempting to get up without assistance. Interventions - Increased monitoring, Diversional activities - refer to activities and [social services]. On 5/16/23 at 9:06 AM Surveyor observed R64 in bed with Hospice Social Worker (SW)-K at bedside. Surveyor observed R64's call light was out of reach near the foot of the bed. There was no reacher or Broda chair in room. Surveyor asked CNA-L if R64 had a reacher. CNA-L searched the room and stated no, not that she knew of. SW-K stated she was not aware R64 should have a reacher but Hospice would provide one if needed. CNA-L stated he would not know how to use it anyway. On 5/16/23 at 11:47 AM Surveyor interviewed DON-B. Surveyor asked what intervention was put in place for R64 after the 4/17/23 fall. DON-B stated a Broda chair. Surveyor asked why a reacher was noted on the Root Cause Analysis sheet and added to the care plan. DON-B was unsure why. Surveyor noted that R64 was observed with call light out of reach and no Broda chair or reacher. DON-B was unsure why. Surveyor asked what the immediate intervention was for the fall that day. DON-B stated he was still working on that. Surveyor noted the immediate intervention would be put in place right away. DON-B stated he was unsure. No additional documentation was provided. On 5/16/23 at 12:15 PM Surveyor interviewed RDO-J with DON-B in the room. Surveyor asked about the reacher intervention put in place for R64. RDO-J stated that does not make sense. RDO-J stated to DON-B that the Root Cause Analysis needs to address the why questions including why the resident fell and what you are going to do to prevent further falls. Surveyor asked about the immediate intervention for the fall earlier that day. RDO-J was unaware of a fall that day. RDO-J stated she is beginning retraining on falls, interventions and root cause analysis.

Based on observations, interviews and record review, the facility did not implement an effective infection control and prevention program during a COVID-19 outbreak in the facility. This deficient practice has the potential to affect all 100 residents in the facility. As of 3/16/23, the facility was having a COVID-19 outbreak with 5 staff members and 24 out of 100 residents had tested positive for COVID-19. The outbreak began on 2/9/23 when one resident (R77) tested positive while at the hospital. R77 was sent to the hospital on 2/9/23, where they were tested for COVID-19 and were positive. The facility was not aware of R77 testing positive for COVID-19 until 2/14/23. On 2/14/23, the facility began testing all staff and residents for COVID-19 and no other staff or resident tested positive. The facility continued testing staff and residents twice a week. On 2/20/23, two more residents (R51 and R3), who were roommates, tested positive for COVID-19. The facility did not implement measures to reduce the spread of COVID-19 such as identifying which residents or staff had been in contact with those residents who tested positive, limiting in person group activities, residents wearing face masks, and ensuring hand hygiene until 2/23/23, when 5 more residents tested positive for COVID-19. During the survey, staff were observed entering and exiting resident rooms who had COVID-19 without the proper personal protective equipment (PPE) and wearing PPE incorrectly. Staff were also observed entering resident rooms who did not have COVID-19 with the same PPE worn in resident's rooms with COVID-19. The facility also did not ensure residents who tested positive for COVID-19 were placed in the proper isolation precautions to prevent the spread of COVID-19 to other residents. The facility did not implement policies and procedures to ensure staff working the floor were fit tested for N95 masks, implement the proper precautions for residents who tested positive for COVID-19, and ensure effective education for staff in the proper use of PPE to reduce the spread of COVID-19. The facility's failure to implement an effective infection control and prevention program to prevent the transmission of COVID-19 resulted in a finding of immediate jeopardy which began on 2/20/23. Surveyor notified Nursing Home Administrator (NHA) A of the finding of immediate jeopardy on 3/16/23 at 3:00 PM. The immediate jeopardy was removed on 3/21/23. The deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement and monitor the effectiveness of their action plan. Findings Include: Surveyor reviewed the facility's policy and procedure entitled, Infection Outbreak and Response, dated 8/15/22. The policy indicates the facility will promptly respond to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of outbreak: 1. Changes in condition and/or signs and symptoms of infection will be reported according to procedures for infection reporting. 2. The following triggers shall prompt an investigation as to whether an outbreak exists: i. An increase over baseline infection rate (i.e. ten percent or more increase). u. A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases). ill. A single case of a rare or serious infection (i.e. invasive group A Strep, foodborne pathogens, active TB, acute hepatitis, Legionella, chicken pox, measles, COVID-19). 1. An outbreak will be defined according to the characteristics of a given organism. Current definitions used by local and state health departments will help guide the determination. 2. An outbreak will be reported to the local and/or state health department in accordance with the state's reportable diseases website. 2. Implementation of infection control measures: 1. Symptomatic residents will be considered potentially infected, assessed for immediate needs, and placed on empiric precautions while awaiting physician orders. 2. Symptomatic employees will be screened by the Infection Preventionist, or designee, and referred to appropriate medical provider. 1. Standard precautions will be emphasized. Transmission-based precautions will be implemented as indicated for the particular organism. 2. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines. c. Surveillance activities will increase to daily for the duration of the outbreak. 3. Outbreak investigation: 1. When the existence of an outbreak has been established, an investigation will begin. 2. The Infection Preventionist will be responsible for coordinating all investigation activities. Note: the health department may assume decision making and coordination activities. In this case, the Infection Preventionist will be the liaison between the health department and the facility. c. A case definition will be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include: i. Person - key characteristics the patients share in common ii. Place - the location associated with the outbreak iii. Time - period of time associated with illness onset for the cases under investigation iv. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough 1. A line list about each person affected by the outbreak will be maintained. 2. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved. 3. A summary of the investigation will be documented and reported to QAA committee and health department, if indicated. Surveyor was provided with an additional policy and procedure from the facility on 3/20/23. The facility policy, titled Novel Coronavirus Prevention and Response, reviewed 3/17/23, documents: .Restrict residents with fever or acute respiratory symptoms to their room. Have them wear a facemask (if tolerated) if they must leave the room for medically necessary procedures. In general, for care of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection .Implement heightened surveillance activities or consult public health authorities for additional guidance if there is transmission of COVID-19 in the community. 1. Support hand hygiene and respiratory/cough etiquette by residents, visitors, and employees by making sure tissues, soap, paper towels, and alcohol-based hand rubs are available. 2. Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection. 3. Promote easy and correct use of personal protective equipment (PPE) by: 4. Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE Make PPE, including facemask, eye protection, gowns, and gloves, available immediately outside of the resident's room. Position a trash can near the exit inside any resident room to make it easy to discard PPE. 6. Procedure when COVID-19 is suspected: 1. Notify physician, Director of Nursing, Infection Preventionist, and family. 2. Screen visitors of persons with known or suspected COVID-1g for symptoms of acute respiratory illness. 3. Notify local health department of suspected COVID-19. Follow any instructions for a coordinated, planned transfer. 4. Arrange for transfer to a facility with the appropriate capacity to manage the resident (i.e. designated treatment center). Inform ambulance personnel of suspicion of COVID-19 when arranging transportation. Inform staff at transfer location of suspicion of COVID-19. 5. Implement standard, contact, and droplet precautions. Wear gloves, gowns, goggles/face shields, and masks (respirators) upon entering room and when caring for the resident . On 3/13/23 at 8:30 AM, NHA A informed the survey team that staff in the facility are expected to wear an N95 mask and eye protection in areas of the facility where resident care is taking place. NHA A reported they had one resident (R74) who was positive for COVID-19 currently. On 3/13/23 at 10:40 AM, Surveyor observed R74's room door closed. Surveyor also observed R74 had a roommate (R59). Surveyor observed a sign on the door indicating R74 and R59 were in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor observed Certified Nursing Assistant (CNA) P enter R74's room wearing a white N95 mask with the bottom yellow strap hanging in front of face and not around CNA P's head and the top strap around CNA P's neck. Surveyor observed CNA P enter R74's room without wearing a gown or gloves. Surveyor then observed CNA P leave R74's room without changing their N95 mask. Surveyor observed CNA P enter R2's room wearing the same N95 mask that CNA P wore in R74's room. Surveyor did not observe signage on R2's door that indicated R2 is to be on isolation precautions. On 3/14/23 at 7:51 AM, Surveyor observed CNA Q enter R74's room. Surveyor observed a sign on the door indicating R74 was in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor observed CNA Q wearing a white N95 mask with the bottom yellow strap ripped off the N95 mask and that top yellow strap around the middle of their head. Surveyor observed that CNA Q did not put on a new N95 mask, gown, or gloves when they entered R74's room. Surveyor observed CNA Q leave R74's room wearing the same N95 mask with the bottom yellow strap ripped off. Surveyor then observed CNA Q entered R12's room wearing the same N95 mask that CNA Q wore in R74's room. Surveyor did not observe signage on R12's door that indicated R12 is to be on isolation precautions. On 3/14/23 at 9:46 AM, Surveyor observed R74's room. Surveyor observed a sign on the door indicating R74 was in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor also observed another sign on R74's door that indicates those entering R74's room need to see a nurse before entering and instructs staff to wear a gown, gloves, and N95 mask when entering R74's room. Surveyor noted the two signs on R74's door is inconsistent with each other and give two different directions to staff on what PPE is required when entering R74's room. The Enhanced Barrier Precautions sign indicates to wear a gown an gloves for high contact care activities while the See a nurse before entering sign instructs staff to wear a gown, gloves and an N95 mask when entering the room. According to the facility's COVID-19 outbreak infection line listing, R74 and R29 tested positive for COVID-19 on 3/11/23. Surveyor observed that the facility did not place R74 and R29 in the proper isolation precautions (contact and droplet) required for COVID-19, until 3/14/23, 3 days after R74 and R29 had tested positive for COVID-19. On 3/14/23 at 9:43 AM, Surveyor observed CNA R enter R74's room. Surveyor observed a sign on the door indicating R74 was in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor also observed another sign on R74's door that indicates those entering R74's room need to see a nurse before entering and instructs staff to wear a gown, gloves, and N95 mask when entering R74's room. Surveyor observed CNA R wearing an N95 mask pulled down below their chin and not covering CNA R's mouth and nose. Surveyor observed CNA R with their eye protection on top of their head and not covering their eyes. Surveyor observed CNA R leave R74's room carrying a bag of trash. Surveyor observed CNA R wearing the same N95 mask that was worn while in R74's room. Surveyor observed CNA R place the bag of trash on the floor in the hallway and enter R12's room. Surveyor observed CNA R enter R12's room wearing the same N95 mask that CNA R wore in R74's room. Surveyor did not observe signage on R12's door that indicated R12 is to be on isolation precautions. On 3/14/23 at 9:47 AM, Surveyor observed CNA Q enter R54's room. Surveyor observed CNA Q wearing an N95 mask with the bottom strap that is ripped off and the top strap around CNA Q's head. Surveyor observed signage on R54's door that indicates those entering R54's room need to see a nurse before entering and instructs staff to wear a gown, gloves, and N95 mask, and a surgical mask when entering R54's room. Surveyor observed CNA Q leave R54's room and enter R47 and R29's room, who are roommates. Surveyor observed CNA Q wearing the same N95 mask with the bottom strap ripped off which was also worn in R54's room. Surveyor did not observe signage on R47 and R29's door that indicated R47 and R29 is to be on isolation precautions. According to the facility's COVID-19 outbreak infection line listing, R54 tested positive for COVID-19 on 3/12/23. On 3/14/23 at 11:06 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C. ADON reported they are the infection preventionist for the building. ADON C reported that they have been the infection preventionist for the last two weeks, and that a different staff member was the infection preventionist before them. ADON C reported that they do not have a certificate of completion for an infection control program, but Director of Nursing (DON) B does. On 3/14/23 at approximately 12:00 PM, Surveyor was provided with documentation from DON B that they completed an infection control program training on 10/10/22. On 3/14/23 at 1:09 AM, Surveyor interviewed CNA JJ. CNA JJ reported that in the building they are supposed to wear an N95 mask. CNA JJ reported that they wear a surgical mask under their N95 mask because the N95 mask hurts their face. CNA JJ reported that if they go into a resident's room who has COVID-19, they should wear a gown, gloves and N95 mask and they need to wash their hands. Surveyor asked CNA JJ if they were provided education on putting on a new N95 mask when leaving a resident's room who has COVID-19. CNA JJ reported they were not given any instructions on when to put on a new N95 mask. On 3/14/23 at 1:14 PM, Surveyor interviewed CNA R. CNA R reported that when entering a resident's room who is positive for COVID-19, they should wear an N95 mask, gown, and gloves. Surveyor asked CNA R if they were given any education on when to put on a new N95 mask. CNA R reported they know they need to change their mask if it is sliding down their face or if it fits improperly. On 3/14/23 at 1:34 PM, Surveyor interviewed Registered Nurse (RN) S. RN S reported that the expectation is that staff are to wear an N95 mask and eye protection in the hallways of the facility. RN S reported that when going into a resident's room who is positive for COVID-19, staff should be wearing an N95, eye protection, gown, and gloves. Surveyor asked RN S what should be removed when leaving a resident's room who has COVID-19. RN S reported that when leaving a resident's room who has COVID-19, staff should remove their gown, gloves, eye protection, and N95 mask. RN S reported that when they go into a resident's room who has COVID-19, they wear a surgical mask over their N95 to protect their N95. RN S reported when they leave the room, they remove their surgical mask and leave on the N95 mask. On 3/15/23 at 1:31 PM, Surveyor interviewed DON B. DON B reported the expectation for staff is that they should be wearing an N95 mask and eye protection while in areas of the facility where resident care is taking place. On 3/15/23 at 3:25 PM, Surveyor shared concerns with NHA A, DON B, ADON C, Corporate Consultant E, and Corporate Consultant F. Surveyor asked what the expectation is for staff regarding what PPE should be worn in the building. Corporate Consultant E reported that staff only need to be wearing an N95 when entering a room of a resident who is positive for COVID-19. Corporate Consultant E reported that staff would also need to wear a gown, gloves, and eye protection when entering a resident's room who has COVID-19. Surveyor shared concerns regarding observations of staff not wearing proper PPE or wearing PPE improperly when entering resident's rooms who have COVID-19, staff observed not changing their N95 when leaving resident's rooms who have COVID-19, and that R74 was observed in enhanced barrier precautions until 3/14/23 when another sign was added to R74's door indicating R74 was in droplet precautions. Surveyor also shared that through interview, staff are not aware of what PPE they should be wearing and what PPE they should be removing when leaving a resident's room. NHA A reported that in their facility, the residents and staff are not compliant with COVID-19 guidelines and precautions in general. Corporate Consultant E reported they will continue to reeducate staff regarding Surveyor's concerns. On 3/16/23 at 8:16 AM, Surveyor observed CNA K passing out breakfast trays to residents on the D Unit. Surveyor observed CNA K enter R2's room wearing an N95 mask, gloves, gown, and eye protection. Surveyor observed signage on R2's door indicating that R2 is on droplet and contact precautions and that when entering the room staff should be wearing a gown, gloves, eye protection, and a surgical mask. Surveyor observed CNA K leave R2's room and remove their gown and gloves. Surveyor observed that CNA K did remove their N95 mask. Surveyor observed CNA K enter R81's room wearing the same N95 mask CNA K wore in R2's room. Surveyor did not observe signage on R81's door that indicated R81 is to be on isolation precautions. According to the facility's COVID-19 outbreak infection line listing, R2 tested positive for COVID-19 on 3/15/23. On 3/16/23 at 8:26 AM, Surveyor observed CNA K enter R47 and R29's room, who are roommates, wearing the same N95 mask worn in R2 and R81's room. Surveyor observed signage on R47 and R29's door indicating R47 and R29 are on droplet precautions and staff should wear an N95 mask, gown, gloves, and eye protection. Surveyor observed CNA K leave R47 and R29's room removing their gown and gloves. Surveyor observed CNA K leave on their N95 mask and continue passing breakfast trays to other residents on the unit. According to the facility's COVID-19 outbreak infection line listing, R47 and R29 tested positive for COVID-19 on 3/15/23. On 3/16/23 at 8:33 AM, Surveyor interviewed CNA T. CNA T reported that they were fit tested in the last year at a different facility. CNA T reported they were not fit tested for the N95 mask they are wearing at the facility when going into COVID-19 rooms. On 3/16/23 at 8:35 AM, Surveyor interviewed CNA K. CNA K reported that they were fit tested on Monday. CNA K reported that they were not fit tested for the N95 mask that they are wearing while at the facility. Surveyor observed CNA K wearing the same style N95 used when entering R2, R47, and R29's room. On 3/16/23 at 8:37 AM, Surveyor interviewed Medication Technician U. Medication Technician U reported they were not fit tested in the last year or fit tested for the N95 mask they are wearing. Surveyor observed Medication Technician U wearing an N95 mask with a surgical mask covering their N95. Medication Technician U reported that they wear the surgical mask over their N95 for extra protection. On 3/20/23 at 7:31 am, Surveyor observed RN OO wearing an N95 while in the A unit hallway. RN 00 had only 1 strap around her head while the second strap was hanging under her chin. Surveyor asked RN 00 if she was shown how to wear an N95, and RN 00 stated yes however was wearing it her own way. On 3/20/23 at 7:51 am, on unit B, Surveyor observed Med Tech U passing medication. Surveyor observed Med Tech U enter R49 and R250's room wearing an N95, gown and gloves. Med Tech U was not wearing eye protection. Surveyor observed Med Tech U interact with both R49 and R250 while in the room. R49 and R250's door to the room had signs indicated contact and droplet precautions as well as enhanced barrier precaution signs on the door to the room. Surveyor was informed R49 and R250 were in isolation for COVID-19. Surveyor also observed Med Tech U was not wearing both N95 straps around her head as she had one strap hanging below her chin. On 3/20/23, at 8:08 am on unit B, Surveyor observed Med Tech U gowning and entering R-7's room. The door to R7's room had a sign for contact and droplet precautions as well as enhanced barrier precautions. Med Tech U sanitized her hands, put on a gown, gloves, N95 with 1 strap below her chin and 1 strap around her head. At 8:11 am Assistant Administrator O told Med Tech U to put both N95 straps around her head. Med Tech U then entered R7's room without wearing eye protection. At 8:16 am, Surveyor observed Med Tech U entering R3 and R51's room. Neither R3 nor R51 were on any precautions. Surveyor noted Met Tech U went into 2 rooms that were noted to have R's who were positive for Covid-19 without wearing full eye protection and then entering R3 and R51's room. On 3/20/23 at 8:00 am, on unit B, Surveyor observed CNA PP wearing an N95. Surveyor interviewed C N A PP as to whether she was fit tested for the N95 she was wearing. CNA PP informed surveyor she had not yet been fit tested for the N95. CNA PP stated all the residents with signs on their door are residents who have Covid-19. On 3/20/22 at 8:21 am, CNA PP informed Surveyor she had just been fit tested for her N95. CAN PP had not been initially fit tested for her N95 prior to CNA PP going onto the unit where Residents were noted to be positive for Covid 19. On 3/21/23 at 7:55 am, on unit D, Surveyor observed CNA Q enter R62 and R20' room. The door to the room had 3 signs indicating contact precaution, droplet precaution and enhanced barrier precautions. Surveyor was informed residents who have the signs on the door have Covid19. CNA Q entered R62 and R20 room wearing a gown, gloves, N95, but no eye protection. On 3/21/23, Administrator A informed Surveyor he saw that and that CNA Q has been re-educated on wearing eye protection. On 3/16/23 at 9:00 AM, Surveyor interviewed ADON C. Surveyor asked ADON C if the facility has a specific COVID-19 outbreak policy and procedure. ADON C reported that they did not know. ADON C reported that Corporate Consultant E would know. ADON C reported that they offer antivirals for residents who test positive for COVID-19. Surveyor requested an updated line list for residents who have tested positive for COVID-19 from ADON C as there are several more isolation carts on different units of the building. On 3/16/23 at 9:02 AM, Surveyor requested a specific COVID-19 outbreak policy and procedure from Corporate Consultant E. On 3/16/23 at 9:37 AM, Surveyor reviewed the Facility Assessment Tool (not dated), which does not include the role of an Infection Preventionist and does not address the responsibilities or allocated hours for an Infection Preventionist. The facility assessment tool also did not address how the facility was going to evaluate the effectiveness of their systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals. The facility assessment tool documented See Policy. On 3/16/23 at 9:40 AM, Surveyor was provided the same copy of the facility's policy, titled Infection Outbreak and Response policy that was previously provided. Surveyor asked Corporate Consultant E if this is the only policy they have regarding a COVID-19 outbreak. Corporate Consultant E reported that the Infection Outbreak and Response policy addressed COVID-19 and they do not have a separate policy and procedure for COVID-19. Surveyor reviewed the facility's line listing that was provided to Surveyor by ADON C. ADON C reported that one resident (R103) who tested positive for COVID-19 was hospitalized on [DATE] related to lethargy. R103 was readmitted to the facility. The facility outbreak started on 2/9/23 when R77 tested positive for COVID-19 while at the hospital. R77 went to the hospital on 2/9/23 and was tested for COVID-19 once they arrived at the hospital. The facility was not aware R77 was positive until 2/14/23. R77 was fully vaccinated against COVID-19. R77 resided on Unit A. On 2/17/23, 1 staff member tested positive for COVID-19. On 2/19/23, 1 staff member tested positive for COVID-19. On 2/20/23, two more residents, who were roommates, tested positive for COVID-19 on the B Unit. The residents were both fully vaccinated against COVID-19 and were given an antiviral after they were positive for COVID-19. On 2/23/23, 5 residents on Unit A, B, and D and 1 staff member tested positive for COVID-19. On 2/28/23, 1 resident on Unit A tested positive for COVID-19. On 3/6/23, 1 staff member tested positive for COVID-19. On 3/11/23, 2 residents, who were roommates, on Unit D tested positive for COVID-19. On 3/12/23, 2 residents on Unit A and D tested positive for COVID-19. On 3/15/23, 11 residents on Unit B, C, and D tested positive for COVID-19. On 3/16/23, 1 staff member tested positive for COVID-19. Surveyor noted that since the outbreak started on 2/9/23, 5 staff members and 24 residents have tested positive for COVID-19. On 3/16/23 at 12:33 PM, Surveyor interviewed ADON C, DON B, and Corporate Consultant F. Surveyor asked how the role of the infection preventionist was being completed in the facility. Corporate Consultant F reported that ADON C is the infection preventionist and that DON B has an infection prevention program certification. Surveyor asked how DON B can complete the infection prevention and control tasks required and their other assigned duties. Corporate Consultant F reported that DON B delegates the infection prevention and control tasks to ADON C. Corporate Consultant stated Unit Manager Z also assists with Infection Control. Surveyor asked ADON C to walk Surveyor through the outbreak. ADON C reported that R77 was sent to the hospital on 2/9/23 and was positive on 2/9/23 in the hospital. ADON C reported the facility was not aware R77 was positive for COVID-19 until 2/14/23. ADON C reported that once they were aware R77 was positive, they started testing all staff and residents twice a week. Surveyor asked if the facility completed contract tracing or attempted to identify who R77 contracted COVID-19 from. Corporate Consultant F reported that they have many residents that are younger and leave the building frequently and spend time with family outside of the facility, so they started testing all staff and residents twice a week because they were not sure how R77 contracted COVID-19. ADON C reported that they contacted to local health department who gave no recommendations. ADON C and Corporate Consultant F reported that on 2/23/23, when 5 residents and 1 staff member tested positive for COVID-19, the facility was still testing all staff and residents twice per week, the facility stopped dining in the dining room and stopped group activities. ADON C reported that they contacted the local health department who recommended interventions the facility was already doing. ADON C reported that they were encouraging residents to stay in their rooms and wear masks while out of their rooms. ADON C they also increased their PPE audits and re-educating staff on PPE and how to reduce the spread of COVID-19. Surveyor asked what the expectation for PPE for staff when entering a room with a resident who has COVID-19. ADON C reported that the expectation is that staff are to be wearing an N95 mask, gown, gloves, and eye protection. Surveyor asked what the expectation is for staff regarding PPE when leaving a resident's room who has COVID-19. ADON C reported that the expectation for staff is that when leaving a resident's room who has COVID-19 is to take off their gown and gloves and perform hand hygiene. ADON C reported that staff should remove their N95 mask and put on a new N95 mask or surgical mask. Surveyor asked who is responsible for putting signage on the doors when a resident tests positive for COVID-19. ADON C reported that they are working on being notified by the lab when a resident tests positive for COVID-19, but the nurse is responsible for placing a sign on the resident's door that indicates the type of precautions needed. The nurse would also get an isolation cart with the required PPE supplies need. Surveyor asked what type of isolation is required for residents who are positive for COVID-19. ADON C reported that a resident who is positive for COVID-19 should be on contact and droplet precautions. Surveyor asked how the facility is ensuring that staff are educated and training in wearing the proper PPE and ensuring staff are following the protocols for preventing infections. ADON C reported that education for staff has been continuous during this COVID-19 outbreak. Corporate Consultant F reported that the facility works with an agency and that agency has done education and re-education with their staff as well. ADON C reported that they perform PPE audits of staff at least weekly. Corporate Consultant reported that they provide staff education on infection prevention and control practices at least quarterly and just provided re-educating to staff 3/15/23. ADON C reported that infection prevention and control is always included in the facility's Quality Assurance and Performance Improvement meetings. Surveyor asked ADON C, DON B, or Corporate Consultant F if any of them has reviewed the facility assessment. ADON C, DON B, and Corporate Consultant F reported that they have not reviewed the facility assessment and that NHA A and Corporate Consultant E are responsible for reviewing the facility assessment. Surveyor asked if the medical director is aware of the facility's current COVID-19 outbreak. Corporate Consultant F reported the facility updates the medical director on every new case of COVID-19. Surveyor asked ADON C why R74 and R59, who are roommates, were observed in enhanced barrier precautions on 3/13/23 and 3/14/23 and not placed in contact and droplet precautions when they were diagnosed with COVID-19 on 3/11/23. ADON C reported they were not sure and would have to look into it. Surveyor asked why isolation signs were observed with contradicting information and did not include clear direction for staff to follow regarding PPE when entering a resident room with COVID-19. Corporate Consultant F reported that the facility is auditing all the precautions signs in the building and had started to re-education the staff on the proper signage needed for a resident who is positive for COVID-19. Surveyor asked if the facility has dedicated staff to care of residents who are positive for COVID-19. ADON C reported that with the facility staff that they have, they are not able to have dedicated staff for res [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure the designated Infection Preventionist (IP), Assistant Director of Nursing C was qualified as an IP to assess, develop, monitor, and manage the Infection Prevention and Control Program. This deficient practice has the potential to affect all 100 residents in the facility. * Director of Nursing (DON) B completed a certification in an infection control program in October of 2022. Corporate Consultant F informed Surveyor, DON B delegates the IP duties to Assistant Director of Nursing (ADON) C. Assistant Director of Nursing (ADON) C and Corporate Consultant F informed Surveyor ADON C is designated as the facility's IP. ADON C has not yet completed a certification in an infection control program. Corporate Consultant F stated Unit Manager Z helps with infection control. Surveyor was provided with a training certificate for Unit Manager Z indicating Unit Manager Z has completed 0.5 training hours for a course, Creating Infection and Control Cases which does not meet the requirements for an IP. The DON, IP and Unit Manager Z did not implement, monitor, and manage the Infection Control Program's policy and procedure's related to the transmission of COVID-19. As of 3/16/23, the facility was experiencing a COVID-19 outbreak with 5 staff members and 24 out of 100 residents having tested positive for COVID-19. The outbreak began on 2/9/23 when one resident (R77) tested positive while at the hospital. R77 was sent to the hospital on 2/9/23, where they were tested for COVID-19 and were positive. The facility was not aware of R77 testing positive for COVID-19 until 2/14/23. On 2/14/23, the facility began testing all staff and residents for COVID-19 and no other staff or resident tested positive. The facility continued testing staff and residents twice a week. On 2/20/23, two more residents (R51 and R3), who were roommates, tested positive for COVID-19. The Infection Preventionist did not implement measures to prevent the spread of COVID-19 such as identifying which residents or staff had been in contact with those residents who tested positive, limiting in person group activities, residents wearing face masks, and ensuring hand hygiene until 2/23/23, when 5 more residents tested positive for COVID-19. During the survey, staff were observed entering and exiting resident rooms who had COVID-19 without the proper personal protective equipment (PPE) and wearing PPE incorrectly. Staff were also observed entering resident rooms who did not have COVID-19 with the same PPE worn in resident's rooms with COVID-19. DON B, Infection Preventionist (ADON C) and Unit Manager Z did not implement policies and procedures to ensure staff working residents with COVID-19 were fit tested for N95 masks. DON B, Infection Preventionist/ADON C and Unit Manager Z did not implement the proper precautions for residents who tested positive for COVID-19, and ensure effective staff education, and surveillance of staff to ensure proper use of PPE was worn to reduce the spread of COVID-19. DON B and the Infection Preventionist/ADON C and Unit Manager Z did not ensure residents who tested positive for COVID-19 were placed in the proper isolation precautions (contact & droplet precautions) to prevent the spread of COVID-19 to other residents. The lack of oversight from DON B with the delegation of the Infection Control responsibilities to ADON C and Unit Manager Z, the lack of qualifications of ADON C identified as the IP, and the lack of qualifications of Unit Manager Z to assist in the duties in infection control, resulted in the facility not implementing and managing an effective Infection Control and Prevention program to prevent the transmission of COVID-19 during a COVID outbreak. The failure of the facility to have an identified qualified Infection Preventionist (ADON C) resulted in a finding of immediate jeopardy which began on 2/20/23. Surveyor notified Nursing Home Administrator (NHA) A of the finding of immediate jeopardy on 3/16/23 at 3:00 PM. The immediate jeopardy was removed on 3/17/23. The deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement and monitor the effectiveness of their action plan. Findings Include: On 3/16/23 at 9:37 AM, Surveyor reviewed the Facility Assessment Tool (not dated), and noted the Facility Assessment Tool does not identify the role of an Infection Preventionist and does not address the responsibilities or allocated hours for an Infection Preventionist. The Facility Assessment Tool did not address how the facility was going to evaluate the effectiveness of their systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals. The Facility Assessment Tool documented See Policy. On 3/16/23 at 12:33 PM, Surveyor asked ADON C, DON B, or Corporate Consultant F if any of them has reviewed the facility assessment. ADON C, DON B, and Corporate Consultant F reported that they have not reviewed the Facility Assessment Tool and that NHA A and Corporate Consultant E are responsible for reviewing the Facility Assessment. Surveyor asked if the Medical Director is aware of the facility's current COVID-19 outbreak. Corporate Consultant F reported the facility updates the Medical Director on every new case of COVID-19. Surveyor reviewed the facility's policy and procedure entitled, Infection Preventionist, not dated. The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. .Policy Explanation and Compliance Guidelines: The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program. 1. The facility will ensure the Infection Preventionist is qualified by education, training, experience, or certification. 2. The IP must be professionally trained in nursing, medical technology, microbiology, epidemiology, or other related field. These may include: 1. A professionally trained nurse with a certificate/diploma or degree in nursing. 2. A professionally trained medical technologist (also known as a clinical laboratory scientist) that has earned at least an associate degree in medical technology or clinical laboratory science. 3. A professionally trained microbiologist that has earned at least a bachelor's degree in microbiology. 4. A professionally trained epidemiologist that has earned at least a bachelor's degree in epidemiology. 5. Other related fields of training such as physicians, pharmacists, and physician's assistants. 1. The IP will have the knowledge to perform the role and remain current with infection prevention and control issues and be aware of national organizations guidelines, as well as those from national/state/local public health authorities. 2. The facility will ensure that the individual selected as the IP has the background and ability to fully carry out the requirements of the IP based on the needs of the resident population, such as interpreting clinical and laboratory data. 3. The IP must be employed at least part-time, and the amount of time should be determined by the facility assessment, to determine the resources it needs for its IPCP. Designated IP hours per week may vary based on the facility and its resident population. 4. The facility, based upon the facility assessment, will determine if the individual functioning as the IP should be dedicated solely to the IPCP. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA. 1. The IP will physically work onsite in the facility. 2. The IP must be sufficiently trained in infection prevention and control. Specialized training in infection prevention and control may include care for residents with invasive medical devices, resident care equipment (e.g., ventilators), and treatment such as dialysis as well as high-acuity conditions. If the facility's resident population changes, the IP may need to obtain additional training for the change in the facility's scope of care, based upon reevaluation of the IP's knowledge and skills. 3. The IP must have obtained specialized IPC training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate(s) of completion or equivalent documentation. Specialized training should include the following topics: 4. Infection prevention and control program overview. 5. Infection preventionist's role. 6. Infection surveillance. 7. Outbreaks. 8. Principles of standard precautions (e.g., content on hand hygiene, personal protective equipment, injection safety, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing reusable resident care equipment). 9. Principles of transmission-based precautions; . 10. Preventing respiratory infections (e.g., influenza, pneumonia); . 11. The Infection Preventionist reports to the Director of Nursing. 12. Responsibilities of the Infection Preventionist include but are not limited to: 13. Develop and implement an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infections to provide a safe, sanitary and comfortable environment. 14. Establish facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. 15. Develop and implement written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevention and control. 16. Oversight of and ensuring the requirements are met for the facility's antibiotic stewardship program. 17. Oversight of resident care activities (i.e., use and care of urinary catheters, wound care, incontinence care, skin care, performing fingerstick, medication administration, etc.) 18. Review and/or revise the facility's infection prevention and control program, its standards, policies, and procedures annually and as needed for changes to the facility assessment to ensure they are effective and in accordance with current standards of practice for preventing and controlling infections. 19. Review/revise and approve infection prevention and control training topics and content and ensure facility staff are trained on IPCP. The infection preventionist is not necessarily required to perform the IPCP training if the facility has designated staff development personnel. Surveyor reviewed the position description, dated 10/15/2014, provided by the facility for the Director of Nursing which includes in part: Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality care that is consistent with company and regulatory standards. Assumes responsibilities of daily operations in the absence of Administrator. ESSENTIAL JOB DUTIES Oversees the nursing staff for the provision of quality and appropriate resident / patient care that meets or exceeds company and regulatory standards. 1. Assists in the preparation of annual budget for the living center. Monitors monthly performance of nursing services in relation to budget and intervenes as needed. Schedules and performs rounds to monitor and evaluate the quality and appropriateness of nursing care. 2. Maintains administrative authority, responsibility and accountability for the proper charting and documentation of care, medications, and treatments 3. Hires nursing staff, oversee the provision of orientation/training by a qualified Director of Education and retains qualified staff to carry out nursing programs and services. Reviews employee performance and conducts periodic performance appraisals timely 4. Develops and implements the written staffing plan and nursing schedule that reflects the needs of the resident and patient population. 5. Evaluates current and potential residents and patients to determine and maintain facilities ability to provide appropriate level of care. 6. Maintains regular and ongoing communication with the facilities Medical Director to identify educational needs for staff and provide quality care and services to meet the needs of residents. 7. Manages clinical aspects of state or federal government survey processes. 8. Conducts daily Clinical Start-up meeting with the interdisciplinary team to review resident and patient status. 9. Attends the weekly at risk meeting and reviews modifications to residents' and patient's plan of care 10. Oversees and monitors the Resident Assessment process for accuracy, attends care planning conferences periodically to determine compliance with care planning guidelines. 11. Collects, reviews, and analyzes clinical outcome data and determines trends. Brings identified concerns to the QA&A committee for development of appropriate plans of action . Surveyor noted the position description for the Director of Nursing does not include the role of the Infection Preventionist. Surveyor reviewed the facility's line listing that was provided to Surveyor by ADON C. Through interview with ADON C and review of the line listing, the facility outbreak started on 2/9/23 when R77 tested positive for COVID-19 while at the hospital. The facility was not aware R77 was positive until 2/14/23. The COVID-19 outbreak in the facility continued to spread as the facility's line listing continued to reflect both staff and residents testing positive for COVID-19. As of 3/16/23, the facility continued to experience a COVID-19 outbreak and since 2/9/23, 5 staff members and 24 out of 100 residents have tested positive for COVID-19. (Cross Reference F880) ADON C to reported to Surveyor that one resident (R103) who tested positive for COVID-19 was hospitalized on [DATE] related to lethargy. R103 was readmitted to the facility. On 3/13/23 at 8:30 AM, Nursing Home Administrator (NHA) A informed the survey team that staff in the facility are expected to wear an N95 mask and eye protection in areas of the facility where resident care is taking place. NHA A reported they had one resident (R74) who was positive for COVID-19 currently. Observations: On 3/13/23 at 10:40 AM, Surveyor observed R74's room door closed. Surveyor also observed R74 had a roommate (R59). Surveyor observed a sign on the door indicating R74 and R59 were in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor observed Certified Nursing Assistant (CNA) P enter R74's room wearing a white N95 mask with the bottom yellow strap hanging in front of face and not around CNA P's head and the top strap around CNA P's neck. Surveyor observed CNA P enter R74's room without wearing a gown or gloves. Surveyor then observed CNA P leave R74's room without changing their N95 mask. Surveyor observed CNA P enter R2's room wearing the same N95 mask that CNA P wore in R74's room. Surveyor did not observe signage on R2's door that indicated R2 is to be on isolation precautions. On 3/14/23 at 7:51 AM, Surveyor observed CNA Q enter R74's room. Surveyor observed a sign on the door indicating R74 was in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor observed CNA Q wearing a white N95 mask with the bottom yellow strap ripped off the N95 mask and that top yellow strap around the middle of their head. Surveyor observed that CNA Q did not put on a new N95 mask, gown, or gloves when they entered R74's room. Surveyor observed CNA Q leave R74's room wearing the same N95 mask with the bottom yellow strap ripped off. Surveyor then observed CNA Q entered R12's room wearing the same N95 mask that CNA Q wore in R74's room. Surveyor did not observe signage on R12's door that indicated R12 is to be on isolation precautions. On 3/14/23 at 9:46 AM, Surveyor observed R74's room. Surveyor observed a sign on the door indicating R74 was in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor also observed another sign on R74's door that indicates those entering R74's room need to see a nurse before entering and instructs staff to wear a gown, gloves, and N95 mask when entering R74's room. Surveyor noted the two signs on R74's door is inconsistent with each other and give two different directions to staff on what PPE is required when entering R74's room. According to the facility's COVID-19 outbreak infection line listing, R74 and R29 tested positive for COVID-19 on 3/11/23. Surveyor observed that the facility did not place R74 and R29 in the proper isolation precautions required for COVID-19, until 3/14/23, 3 days after R74 and R29 had tested positive for COVID-19. On 3/14/23 at 9:43 AM, Surveyor observed CNA R enter R74's room. Surveyor observed a sign on the door indicating R74 was in Enhanced Barrier Precautions and staff were required to wear a gown and gloves for high contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use, and wound care. Surveyor also observed another sign on R74's door that indicates those entering R74's room need to see a nurse before entering and instructs staff to wear a gown, gloves, and N95 mask when entering R74's room. Surveyor observed CNA R wearing an N95 mask pulled down below their chin and not covering CNA R's mouth and nose. Surveyor observed CNA R with their eye protection on top of their head and not covering their eyes. Surveyor observed CNA R leave R74's room carrying a bag of trash. Surveyor observed CNA R wearing the same N95 mask that was worn while in R74's room. Surveyor observed CNA R place the bag on trash on the floor in the hallway and enter R12's room. Surveyor observed CNA R enter R12's room wearing the same N95 mask that CNA R wore in R74's room. Surveyor did not observe signage on R12's door that indicated R12 is to be on isolation precautions. On 3/14/23 at 9:47 AM, Surveyor observed CNA Q enter R54's room. Surveyor observed CNA Q wearing an N95 mask with the bottom strap that is ripped off and the top strap around CNA Q's head. Surveyor observed signage on R54's door that indicates those entering R54's room need to see a nurse before entering and instructs staff to wear a gown, gloves, and N95 mask, and a surgical mask when entering R54's room. Surveyor observed CNA Q leave R54's room and enter R47 and R29's room, who are roommates. Surveyor observed CNA Q wearing the same N95 mask with the bottom strap ripped off worn in R54's room. Surveyor did not observe signage on R47 and R29's door that indicated R47 and R29 is to be on isolation precautions. According to the facility's COVID-19 outbreak infection line listing, R54 tested positive for COVID-19 on 3/12/23. On 3/14/23 at 1:09 AM, Surveyor interviewed CNA JJ. CNA JJ reported that in the building they are supposed to wear an N95 mask. CNA JJ reported that they wear a surgical mask under their N95 mask because the N95 mask hurts their face. CNA JJ reported that if they go into a resident's room who has COVID-19, they should wear a gown, gloves and N95 mask and they need to wash their hands. Surveyor asked CNA JJ if they were provided education on putting on a new N95 mask when leaving a resident's room who has COVID-19. CNA JJ reported they were not given any instructions on when to put on a new N95 mask. On 3/14/23 at 1:14 PM, Surveyor interviewed CNA R. CNA R reported that when entering a resident's room who is positive for COVID-19, they should wear an N95 mask, gown, and gloves. Surveyor asked CNA R if they were given any education on when to put on a new N95 mask. CNA R reported they know they need to change their mask if it is sliding down their face or if it fits improperly. On 3/14/23 at 1:34 PM, Surveyor interviewed Registered Nurse (RN) S. RN S reported that the expectation is that staff are to wear an N95 mask and eye protection in the hallways of the facility. RN S reported that when going into a resident's room who is positive for COVID-19, staff should be wearing an N95, eye protection, gown, and gloves. Surveyor asked RN S what should be removed when leaving a resident's room who has COVID-19. RN S reported that when leaving a resident's room who has COVID-19, staff should remove their gown, gloves, eye protection, and N95 mask. RN S reported that when they go into a resident's room who has COVID-19, they wear a surgical mask over their N95 to protect their N95. RN S reported when they leave the room, they remove their surgical mask and leave on the N95 mask. On 3/16/23 at 8:16 AM, Surveyor observed CNA K passing out breakfast trays to residents on the D Unit. Surveyor observed CNA K enter R2's room wearing an N95 mask, gloves, gown, and eye protection. Surveyor observed signage on R2's door indicating that R2 is on droplet and contact precautions and that when entering the room staff should be wearing a gown, gloves, eye protection, and a surgical mask. Surveyor observed CNA K leave R2's room and remove their gown and gloves. Surveyor observed that CNA K did remove their N95 mask. Surveyor observed CNA K enter R81's room wearing the same N95 mask CNA K wore in R2's room. Surveyor did not observe signage on R81's door that indicated R81 is to be on isolation precautions. According to the facility's COVID-19 outbreak infection line listing, R2 tested positive for COVID-19 on 3/15/23. On 3/16/23 at 8:26 AM, Surveyor observed CNA K enter R47 and R29's room, who are roommates, wearing the same N95 mask worn in R2 and R81's room. Surveyor observed signage on R47 and R29's door indicating R47 and R29 are on droplet precautions and staff should wear an N95 mask, gown, gloves, and eye protection. Surveyor observed CNA K leave R47 and R29's room removing their gown and gloves. Surveyor observed CNA K leave on their N95 mask and continue passing breakfast trays to other residents on the unit. According to the facility's COVID-19 outbreak infection line listing, R47 and R29 tested positive for COVID-19 on 3/15/23. On 3/16/23 at 8:33 AM, Surveyor interviewed CNA T. CNA T reported that they were fit tested in the last year at a different facility. CNA T reported they were not fit tested for the N95 mask they are wearing at the facility when going into COVID-19 rooms. On 3/16/23 at 8:35 AM, Surveyor interviewed CNA K. CNA K reported that they were fit tested on Monday. CNA K reported that they were not fit tested for the N95 mask that they are wearing while at the facility. Surveyor observed CNA K wearing the same style N95 used when entering R2, R47, and R29's room. On 3/16/23 at 8:37 AM, Surveyor interviewed Medication Technician U. Medication Technician U reported they were not fit tested in the last year or fit tested for the N95 mask they are wearing. Surveyor observed Medication Technician U wearing an N95 mask with a surgical mask covering their N95. Medication Technician U reported that they wear the surgical mask over their N95 for extra protection. On 3/16/23 at 8:26 AM, Surveyor observed CNA K enter R47 and R29's room, who are roommates, wearing the same N95 mask worn in R2 and R81's room. Surveyor observed signage on R47 and R29's door indicating R47 and R29 are on droplet precautions and staff should wear an N95 mask, gown, gloves, and eye protection. Surveyor observed CNA K leave R47 and R29's room removing their gown and gloves. Surveyor observed CNA K leave on their N95 mask and continue passing breakfast trays to other residents on the unit. According to the facility's COVID-19 outbreak infection line listing, R47 and R29 tested positive for COVID-19 on 3/15/23. On 3/16/23 at 8:33 AM, Surveyor interviewed CNA T. CNA T reported that they were fit tested in the last year at a different facility. CNA T reported they were not fit tested for the N95 mask they are wearing at the facility when going into COVID-19 rooms. On 3/16/23 at 8:35 AM, Surveyor interviewed CNA K. CNA K reported that they were fit tested on Monday. CNA K reported that they were not fit tested for the N95 mask that they are wearing while at the facility. Surveyor observed CNA K wearing the same style N95 used when entering R2, R47, and R29's room. On 3/16/23 at 8:37 AM, Surveyor interviewed Medication Technician U. Medication Technician U reported they were not fit tested in the last year or fit tested for the N95 mask they are wearing. Surveyor observed Medication Technician U wearing an N95 mask with a surgical mask covering their N95. Medication Technician U reported that they wear the surgical mask over their N95 for extra protection. On 3/15/23 at 1:31 PM, Surveyor interviewed DON B. DON B reported the expectation for staff is that they should be wearing an N95 mask and eye protection while in areas of the facility where resident care is taking place. On 3/14/23 at 11:06 AM, Surveyor interviewed ADON C who reported she is the infection preventionist for the building. ADON C reported she has been the infection preventionist for the last two weeks, and that a different staff member was the infection preventionist before her. ADON C reported she does not have a certificate of completion for an infection control program, but Director of Nursing (DON) B does. On 3/14/23 at approximately 12:00 PM, Surveyor was provided with documentation from DON B that he completed an infection control program training on 10/10/22. On 3/16/23 at 12:33 PM, Surveyor interviewed ADON C, DON B, and Corporate Consultant F. Surveyor asked how the role of the infection preventionist was being completed in the facility. Corporate Consultant F reported that ADON C is the infection preventionist and that DON B has an infection prevention program certification. Surveyor asked how DON B can complete the infection prevention and control tasks required and their other assigned duties. Corporate Consultant F reported DON B delegates the infection prevention and control tasks to ADON C. Corporate Consultant F also stated they try to have [NAME] than one staff member to help with the infection control task and that Unit Manager Z helps with infection control. Surveyor asked ADON C why R74 and R59, who are roommates, were observed in enhanced barrier precautions on 3/13/23 and 3/14/23 and not placed in contact and droplet precautions when they were diagnosed with COVID-19 on 3/11/23. ADON C reported they were not sure and would have to look into it. Surveyor asked why isolation signs were observed with contradicting information and did not include clear direction for staff to follow regarding PPE when entering a resident room with COVID-19. Corporate Consultant F reported that the facility is auditing all the precautions signs in the building and had started to re-education the staff on the proper signage needed for a resident who is positive for COVID-19. Surveyor asked if the facility has dedicated staff to care of residents who are positive for COVID-19. ADON C reported that with the facility staff that they have, they are not able to have dedicated staff for residents who are positive for COVID-19. ADON C reported that staff are educated to provide cares to those residents last. Surveyor asked ADON C how often they are fit testing staff. ADON C reported that they fit test staff yearly and upon hire. Surveyor shared concerns that CNA T, CNA K, and Medication Technician U indicated they were either not fit tested or were fit tested but not for the masks that they were wearing while caring for residents with COVID-19. On 3/16/23 at 1:49 PM, Corporate Consultant F and DON B reported to Surveyor that the facility has started re-education to staff regarding the proper PPE use, enhanced audits, and started fit testing all staff again. Surveyor shared concerns with continued observations of staff without the proper PPE and the effectiveness of the education that is being provided. ADON C reported that education for staff has been continuous during this COVID-19 outbreak. Corporate Consultant F reported that the facility works with an agency and that agency has done education and re-education with their staff as well. ADON C reported that they perform PPE audits of staff at least weekly. On 3/16/23 at approximately 3:45 pm, Administrator A provided Surveyor with a training certificate for Unit Manager Z. This training certificate reflects Unit Manager Z has completed 0.5 training hours for a course, Creating Infection and Control Cases which does not meet the requirements for an IP. Surveyor noted with the facility's education provided to staff on the use of PPE, with weekly PPE audits, along with the increase in COVD-19 resident cases, the facility's infection preventionist should have had the qualifications necessary to observe, and identify staff not adhering to infection control practices, and should have been able to put appropriate control measures in place to prevent the transmission of COVID 19. The failure of the facility to have an identified qualified Infection Preventionist (ADON C) resulted in a finding of immediate jeopardy which began on 2/20/23. The Immediate Jeopardy was removed on 3/17/23 when the facility implemented the following: * Regional Director of Clinical Operations educated DON, ADON, Unit Manager on Infection Preventionist Role and becoming Infection Preventionist, to include reviewing CDC Infection Preventionist modules on the role of the infection preventionist, transmissions-based precautions, PPE requirements, and outbreak implementation and management. * As of 3/17/23, the Regional Director of Clinical Operations (RDCO) is currently overseeing the Infection Prevention program with tasks being delegated to ADON who is currently in process of completing Infection Control Certification and will then be assuming the role with RDCO identified as back up in the case of ADON being unable to fulfill the duties. ADON will be certified within 7 days. * The facility conducted a root cause analysis (RCA) on 3/16/2023 with causation identified as non-compliance by residents and staff to adhere to infection control policies and procedures as educated. The current policy does meet the current standards of practice as set forth through CMS guidelines and as approved by facility medical director. * Facility Infection Preventionist will have completed the required CDC Infection Preventionist training, including the modules on outbreak identification, implementation, and management surveillance. The infection preventionist will further review all new guidance as released by the CMS and State of Wisconsin as it applies to infection control in nursing homes. * An infection prevention certified RDCO will review and provide oversight to facility IP regarding outbreak implementation, management, and surveillance of infections. RDCO will rev [TRUNCATED]

Based on observation, interview and record review the Facility did not ensure 1 (R2) of 1 resident reviewed for anticoagulation medications were free of significant medication errors. * On 11/25/22 the facility failed to discontinue R2's Enoxaparin/Lovenox (anticoagulant) once R2's INR (international normalized ratio) was therapeutic according to orders. R2 received four additional doses of Lovenox, was hospitalized and needed to have INR reversed with vitamin K while in the hospital. * R2's Warfarin orders stopped from 12/26/22 until 1/10/23 without a reason as to why the Warfarin was stopped. On 2/27/23 R2 did not have a active physician's order for Warfarin or a PT/INR lab draw until 3/7/23. The Nurse Practitioner (NP) reported R2 should have been receiving 4 mg of Coumadin between 2/24 and 3/7/23 with INRs being checked 2 times a week and with INRs to be between 2.5 and 3.5. (Cross Reference F757) Findings include: 1. R2 was admitted to the facility on [DATE] with diagnoses including presence of prosthetic heart valve, atrial fibrillation, schizophrenia, anxiety, depression, malignant neoplasm of prostate and chronic kidney disease stage four. R2's admission MDS (Minimum Data Set) Assessment with an Assessment Reference Date of 12/22/22 documented, R2 had a BIMS (Brief Interview for Mental Status) of 15, indicating R2 is cognitively intact and documented R2 used anticoagulation medication 7 out of the last 7 days. R2's care plan, initiated 10/09/2022, documented, At risk for complications related to anticoagulant or antiplatelet medication due to: Warfarin, ASA (Aspirin) with a goal documented, Maintain INR within a range of 2-3 had interventions including, Obtain and Monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. Surveyor reviewed R2's medical record and noted the following physician's progress note dated 1/12/2023 which documented, [Resident name] was recently hospitalized from November 27 until December 15. Patient was admitted with profound dizziness and found to have a blood pressure of 88/53 [sic] hemoglobin was 4.2 .INR (International normalized ratio) was reversed with vitamin K. Further review of R2's medical record showed R2 was hospitalized from 11/08/22 to 11/23/22 due to an infection to the left hip prosthesis. Surveyor reviewed the hospital discharge summary dated 11/23/2023 which documented, Patient needs to be on a Lovenox and Coumadin (Warfarin) bridge until INR is therapeutic . Medication instructions in the hospital discharge summary document, Enoxaparin (Lovenox) 100mg/ml (milligrams/milliliters) .inject 1ML into the skin every twelve hours. Stop when INR is greater than 2 and Warfarin 10mg tablet, Take 10mg by mouth once in the evening of 11/23/2023. Recheck INR on 11/24/2023 and continue to dose Warfarin for goal INR of 2-3. Stop Lovenox (Enoxaparin) when INR therapeutic. Surveyor noted the following nurses note in progress notes dated 11/23/2022, Patient transported back to facility via ambulance at 18:15 (6:15pm) .10MG Warfarin administered per ordered . Surveyor noted the following physician's orders upon re-admission to the facility on [DATE], Coumadin Tablet 10mg (Warfarin Sodium) Give 10mg by mouth in the evening for anticoagulants. This order was scheduled nightly starting on 11/23/22. Enoxaparin Sodium (Lovenox) Solution Inject 100ML (transcription error; Surveyor verified R2 received 1ML not 100ml) subcutaneously every 12 hours .STOP WHEN INR GREATER THEN TWO. This order was scheduled two times a day starting on 11/23/22. Recheck INR 11/24/2022 one time only . This order was scheduled for one time on 11/24/2022. Surveyor reviewed documentation on R2's PT/INR flow sheet which stated, 11/24/23; INR 1.9; Current dose of Warfarin 10mg; Next Ordered Lab date 11/25/23; [nurses initials]; new orders to recheck PT/INR in the AM (morning) of 11/25/2023. Surveyor noted there was no lab recorded for 11/25/2023 on R2's PT/INR flow sheet. The next recorded PT/INR on the flow sheet was from 12/18/2023. Surveyor reviewed R2's EMAR (Electronic Medical Record) for November 2022 and noted R2 received Warfarin 10mg on 11/23/22, 11/24/22 and 11/25/22. Surveyor also noted R2 received the Enoxaparin 1ml Injection (Lovenox) one time on 11/23/22, two times on 11/24/22, 11/25/22, and 11/26/22, and one additional time on 11/27/22. Surveyor noted the following nurses note dated 11/27/22, Resident call 911 by self stating [sic] was dizzy, all scheduled medications administered. Transferred to [name of hospital] medical center . On 03/16/2023 Surveyor was given R2's PT/INR results from 11/25/22. Per the lab report R2's INR on 11/25/22 was 2.6. Surveyor noted R2 continued to receive 10mg of Warfarin on 11/25/22. Surveyor cannot determine if R2 received the 10 mg of Warfarin on 11/26/22 due to lack of documentation. The Enoxaparin injection/Lovenox was not discontinued per orders and was given to R2 twice a day on 11/25/22, 11/26/22 and once a day on 11/27/22. On 03/16/23 at 10:26 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked DON-B about R2's Enoxaparin/Lovenox order and why it was not discontinued when R2's INR was 2.6 on 11/25/23, per physician's orders to discontinue when INR was greater than 2. DON-B informed Surveyor he was not sure, and he would have to look into it and get back to Surveyor. On 03/20/23 at 1:36 PM, DON-B informed Surveyor the Enoxaparin/Lovenox order should have been discontinued if the order read to discontinue after INR was greater than 2. DON-B did not have any additional information on this issue. 2. Surveyor continued to review R2's medical record and noted R2 was readmitted from the hospital on 12/15/22. On 12/23/22 R2's PT/INR log documented, 12/23/22; .Current Warfarin Dose 8mg; .New Orders: Alternate 7.5mg with 8mg. Surveyor reviewed R2's EMAR and noted R2 had physician's orders for Warfarin 7.5mg every Saturday and Monday and Warfarin 8mg every Sunday. R2 received 7.5mg of Warfarin on 12/24/22 (Saturday) and 12/26/22 (Monday). R2 received 8mg of Warfarin on 12/25/22 (Sunday). Both orders stop after 12/26/22 and Surveyor did not note any other Warfarin orders for the month of December. Between 12/26/22 and 01/10/23, Surveyor could not locate any Warfarin orders, nor any documentation as to why R2 was not receiving any Warfarin. On 03/21/23 at 11:45 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A and CC (Corporate Consultant)-F. Surveyor questioned the lack of Warfarin ordered between 12/26/22 and 01/10/23 At this time, CC-F began reviewing R2's medical record. Surveyor asked CC-F if she found any additional information on R2's Warfarin, to let Surveyor know. On 03/21/23 at 12:42 PM, NHA-A informed Surveyor the facility did not have any additional information on R2's Warfarin dosing between 12/26/22 and 01/16/23. Surveyor continued to review R2's medical record. Surveyor noted R2 was transferred to the hospital on 02/15/23 and readmitted to the facility on [DATE]. R2's Hospital Discharge Summary dated 02/24/23 documented, .is Coumadin (Warfarin) dose is 4mg a day. Coumadin medication changes needing followed up. Surveyor noted the following physician's order, Coumadin (Warfarin) 4mg, Give one tablet by mouth. This order was started on 02/24/23 and discontinued on 02/26/23. R2 received the 4mg of Warfarin on 02/25/23 and 02/26/23. Surveyor noted another physician's order which documented, Warfarin .4mg .give 1 tablet by mouth at bedtime until 02/27/23 23:59 (11:59) . This order had a start date of 02/26/23 and an end date of 02/27/23. After 02/27/23, R2 did not have an active physician's order for Warfarin. On 03/07/23 there is a PT/INR recorded on R2's PT/INR flow sheet which documented, . Dose: 10mg x 1 then start 7.5mg; .give one dose of 10mg and then restart 7.5mg. A Nurse Practitioner documents in a progress note on 03/09/2023, .7.5mg of Warfarin ordered, doubt [R2] was getting it due to INR .discussed this with Director of Nursing . On 03/20/23 at 11:40 AM, Surveyor interviewed Registered Nurse, UM (Unit Manager) Z. UM-Z stated the Warfarin dose should be documented in the progress notes and in the INR book. Surveyor asked UM-Z if she had any information on R2's Warfarin orders between 02/27/23 and 03/07/23. Surveyor relayed concerns Surveyor was unable to find a Warfarin order between 02/27/23 and 03/07/23. UM-Z reviewed R2's record and informed Surveyor she could see what Surveyor was talking about. UM-Z stated she could not locate a Warfarin order between 02/27/23 and 03/07/23. Surveyor asked UM-Z for additional information on what was going on during that time with R2's Warfari. UM-Z informed Surveyor she would look into it. On 03/20/23 at 1:15 PM, Surveyor interviewed PT (Pharmacy Technician)-TT via phone. Surveyor asked what Warfarin dose was dispensed for R2 between 02/24/23 and 03/07/23. PT-TT informed Surveyor on 02/24/23 4mg of Warfarin was dispensed from the facility's machine. Per PT-TT there was no Warfarin dispensed after 02/24/23 until 03/07/23 when 10mg was dispensed. PT-TT informed Surveyor R2 did not have a Warfarin order between 02/27/23 and 03/07/23. Per PT-TT she would be able to see the order and the dispensed amount and there was nothing ordered or dispensed during that time frame. On 03/20/23 at 1:36 PM, Surveyor interviewed DON-B. Surveyor relayed the above concerns with the lack of Warfarin ordered for R2 between 02/27/23 and 03/07/23 and ask for any additional information. On 03/20/23 at 3:00 PM, during the end of the day meeting with NHA-A, DON-B, ADON-C, CC-E and CC-F, Surveyor relayed the concern of not following physician's orders and discontinuing R2's Lovenox in November 2022. Surveyor also relayed the concern of a lack of Warfarin ordered for R2 in the end of February 2023 and beginning of March 2023. Surveyor asked for any additional information. On 03/21/2023 at 8:50 AM, Surveyor interviewed NP (Nurse Practitioner) SS. NP-SS informed Surveyor she and another NP alternate visits with the facility. Per NP-SS, she was not at the facility in November, but reviewed R2's documentation from that month with Surveyor. NP-SS informed Surveyor the facility should have discontinued the Lovenox when R2's INR was 2.6 on 11/25/23. Surveyor asked NP-SS if they were aware of any issues with R2's Warfarin dosing between 02/24/23-03/07/23. NP-SS reviewed R2's documentation and informed Surveyor they were wondering if R2 had received any coumadin during that time, from 02/24/23-03/07/23. NP-SS stated at that time R2 was supposed to be receiving 4mg of coumadin. NP-SS stated R2 returned from the hospital on 02/24/23 and R2 should have been receiving coumadin between 02/24/23 and 03/07/23. NP-SS informed Surveyor she was doubtful R2 was receiving any coumadin between 02/24/23 and 03/07/23 because of R2's INR result. NP-SS informed Surveyor she had spoken with DON-B and UM-Z regarding this issue. NP-SS did not have any additional information for Surveyor. On 03/21/23 at 11:45 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A and CC (Corporate Consultant)-F. Surveyor questioned the lack of Warfarin ordered between 02/27/23 and 03/07/23. At this time, CC-F began reviewing R2's medical record. Surveyor asked CC-F to assist in locating any additional information on R2's Warfarin. On 03/21/23 at 12:42 PM, NHA-A informed Surveyor the facility did not have any additional information on R2's Warfarin dosing between 02/27/23 and 03/07/23.

Based on observation, interviews and record review the facility did not ensure residents remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents for 4 of 5 (R301, R507, R2, R43,) residents reviewed for accidents. * On 12/2/22, R301 was transferred with 1 person assist and a gait belt, and without the assist of a Hoyer lift with 2 person assist as care planned on 10/12/22, which resulted in a fall with a broken femur. The facility filed a facility self report with the State Agency. * R507 had falls on 11/24/22, 1/26/23, 2/18/23 which were not thoroughly assessed for a root cause analysis. The facility did not implement interventions based off of a root cause analysis after the falls to update R507's care plan. On 2/22/23 R507 sustained fall (s) due to behaviors resulting in R507 being hospitalized with a traumatic intracranial hemorrhage. R507 returned back to the facility on [DATE] and was placed in a different room with fall mats and was measured for a helmet and with 1:1. On 3/4/23 the 1:1 was stopped as R507 seemed fine. On 3/4/23 R507 fell again and the facility initiated 1:1 and placed additional an additional fall mat in the room. On 3/6/23 R507 fell again while not receiving 1:1. R507 was noted to have a scalp laceration requiring stitches and was admitted to the hospital. The facility self-reported this incident to the State agency. * R2 had 5 falls while at the facility. The facility did not complete a root cause analysis and care plan revisions after each fall and X- ray results were delayed after 1 fall. * R43 was observed exit seeking through a door to outside 3 of 6 days while on survey. Staff were unaware of R43's unsafe wandering and exit seeking. Findings include: The facility Policy and Procedure titled Falls Management Process which is not dated, documents (in part) . 1. In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life threatening safety concerns are present (fire, highway, etc.). Remain with the resident while calling for assistance, if at all possible. 4. If the resident is conscious, provide reassurance and comfort; provide a cover for dignity and warmth if applicable and available. Resident is NOT to be moved until assessed for injury by a nurse unless life-threatening situation exists. 5. If able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later). 6. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. 7. Obtain vitals signs: Blood pressure, pulse, pulse oximetry, and respirations. 11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. Contact physician and family and document in the medical record, including time and person spoken with. If transferred, document transferring agency/responders. 14. The Director of Nursing will be notified immediately of falls resulting in injury and/or transfer. 1. R301 was admitted to the facility on [DATE] and had diagnoses that included Encephalopathy, hemiplegia and hemiparesis following Cerebral Infarction, demyelinating disease of central nervous system, Adult Failure to Thrive and Neuroleptic Induced Parkinsonism. R301's Fall risk evaluation dated 10/11/22 documented a score of 8 (10 or greater is high risk). R301's Admission Minimum Data Set (MDS) dated [DATE] documented: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture: Total Dependence/One Person Physical Assist. Transfer - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet): Total Dependence Two+ persons physical assist. R301's Care plan documented: I have a physical functioning deficit related to: Mobility impairment, Self care impairment, cognitive impairment, Parkinsonism, etc. (etcetera) - initiated 10/12/22. Transfer with total assistance of (2) and Hoyer type lift - initiated 10/12/22. At risk for falls related to: Use of medication, impaired cognition, impaired mobility, Parkinsonism, etc. - initiated 10/12/22. R301's Brief Interview for Mental Status dated 10/13/22 documented a score of 5, indicating severe cognitive impairment. Facility progress notes documented: 12/2/22 2:01 PM Resident remains in droplet isolation for Covid. Sitting up in the w/c (wheelchair) in her room at this time. Repositioned q (every) 2 hrs (hours). Lungs clear, no cough or congestion. In no respiratory distress, SpO2 (blood oxygen level) 95% RA (room air). Resident ate 100% of her meals and fluids offered. No s/s (signs/symptoms) fever, chills, cough, SOB (shortness of breath), fatigue, body aches, headache, new loss of taste or smell, sore throat, N & V (nausea and vomiting) rhinitis or diarrhea. Fluids encouraged and taken well. B/P (blood pressure) 128/82 P (pulse) 89 R (respirations) 18 T (temperature) 97.7. 12/2/22 9:59 PM Remains in isolation for positive COVID status. No s/s (signs or symptoms) of respiratory distress noted. Complained of having a broken hip, NP (Nurse Practitioner) ordered a 2 view X-ray of the right hip. Also being monitored for pain, mood and behaviors. 12/3/22 2:33 AM Resident c/o (complained of) rt (right) leg pain, prn (as needed) pain med given. 12/3/22 9:38 AM Unit manager stated resident leg was broke and wants her to be sent out to ER (emergency room ). POA (Power of Attorney) Son called, unable to leave message. NP called and updated. Bell ambulance called to transport resident to (hospital). 12/3/22 10:35 AM Res awake, alert and oriented, follows simple commands. Res c/o pain to RT (right) leg and RT hip, states pain is a 10 (on a 0-10 pain scale). Area tender to touch. Nurse gave Tylenol. ambulance called for res to be sent out to hospital for X-ray. POA, MD (Medical Doctor) and DON (Director of Nursing) aware. 12/3/22 12:45 PM call out to (hospital) spoke to Nurse who stated that residents' femur is fracture and she is admitted , NP updated, message left for POA to call the facility back. 12/15/22 3:32 PM Writer contacted hospital and spoke to nurse regarding resident. Currently in PT/OT (Physical/Occupational Therapy). Non ambulatory. Wearing a hinge brace. Does have some outbursts with hallucinations. Nurse provided social worker's name and number. Writer left voice message for SW (Social Worker) to call facility. The facility filed a self report investigation which documented: CNA (Certified Nursing Assistant)-RR attempted to transfer resident to bed using a gait belt, resident became combative during the transfer, began to slip from gait belt and fell to the floor striking her right leg on the floor. Resident sustained right femur fracture. Resident complained of pain, and was provided pain medication. Resident and staff interviews were completed. All staff re-educated on abuse. Nursing staff educated on safe transfers, following resident care plans and combative residents. Audit of all residents transfer status verifying that the care plan and kardex coordinate appropriately, and re-competency completed with all CNA's on safe transfers using Hoyer, sit to stand and gait belt. Random weekly audits x 4 weeks of resident transfers. Statement of Licensed Practical Nurse (LPN)-QQ (working at time of incident) dated 12/3/22 documented: On December 2nd, second shift, (resident) was screaming while CNA was doing cares. I peeped in and asked if everything was OK. Resident said she was in pain and the CNA was too rough. I instructed the CNA to stay out of the room for the remainder of the shift. Resident said she was OK. She later began screaming. CNA came to me asking that I speak with the resident because she was saying her leg was broken. I asked the resident what happened and she said she was pushed. She said she fell on to her mat and the CNA pulled her back into bed and pushed her leg hard. She said she believed it (her right leg) was broken. I told the CNA to write a statement and leave. I called the Director of Nursing (DON) and notified him. I called the Nurse Practitioner and got an order for an X-ray. I asked the resident if she wanted to go to the hospital, she said no. I gave her Tylenol and told her an X-ray would be done. Surveyor noted there was no evidence of a fall investigation and there was no statement written by the CNA at the time of the incident. R301, who had severe cognitive impairment, denied wanting to go to the hospital, but there was no documentation her family was consulted. The CNA statement (obtained by phone by DON-B) dated 12/4/22 documented: Writer received a call on Sunday, 12/4/22 from CNA (CNA RR-involved in incident). She reported that on Friday evening, she was originally on unit B and was relocated to unit C. She also reported there was another aid on unit C and that they split the unit for their assignments. She stated that she knew resident was sitting in her chair for awhile and wanted to help get her back in to bed. She stated the Hoyer didn't have a charged battery and she looked around for another Hoyer without finding one. She stated she got tired of seeing resident in the chair and not being able to get back into bed. She reported having resident wrap her arms around CNA and using a gait belt attempted to transfer to the bed. CNA stated the belt got stuck on the chair the resident started to slide to the floor and started swinging at her. CNA stated she picked the resident back off the floor and got her into bed. CNA-RR and LPN-QQ involved in R301's incident no longer work for facility. On 3/20/23 at 10:29 AM Surveyor spoke with Corporate Consultant/Regional (CCR)-F. CCR-F reported the facility did not know about R301's fall until after the resident complained of pain, an X-ray was ordered and showed the fracture. CCR-F stated Even then, we didn't know about the fall until a couple days into the investigation because the CNA changed her story, initially said she transferred with the Hoyer, then finally did admit she transferred her alone. So, when the facility became aware of the fracture, the investigation began. Surveyor advised CCR-F the LPN QQ's statement indicated she was aware of the fall on 12/2/22 and DON-B was notified. CCR-F offered no explanation. On 3/20/23 at 12:52 PM Surveyor spoke with DON-B. DON-B reported the nurse did call the evening of 12/2/22 and told him about the fall. DON-B stated I don't recall her having any details about the fall at that time, just that (R301) fell and was complaining of leg pain, so she got the X-ray ordered. Surveyor advised DON-B there was no statement that the LPN asked the CNA to write that night. DON-B reported the facility did not get the full story of exactly what happened until days later when the CNA admitted on the phone interview that she transferred the resident with the gait belt instead of the Hoyer. On 3/20/23 at 3:15 PM Surveyor advised Nursing Home Administrator (NHA)-A and DON-B of concern the facility was aware of R301's fall on 12/2/23 after the resident reported she fell and the CNA put her back to bed, and reported her leg was broken. The resident was transferred with a gait belt and 1 assist versus the Hoyer lift as care planned, which resulted in the fall. An immediate investigation was not initiated, there was no investigation or statement from the CNA at the time of the fall and there was no evidence the nurse reported all of the information to DON-B. No additional information was provided. 21855 2. R507 medical record was reviewed by Surveyor. R507 was admitted to the facility with diagnoses of Profound Intellectual Disabilities, non-verbal, Anxiety and Cyclothymic disorder. R507 was not currently in the facility during survey for observations. R507 was sent out to the hospital from a fall on 3/6/23 and as of 3/21/23 has not returned to the facility during survey. R507 was reviewed for falls. R507 plan of care for At risk for falls initiated 10/14/2022 with a Goal date of 5/7/23 included the following interventions: -10/14/22 call light and personal items in reach; clear and monitor environment obstacles; encourage participation in activity; encourage rest periods; keep environment well lit; do not leave unattended in bathroom; observe for medication side effects and therapy referral. -11/17/22 labs ordered for seizure medication levels; monitor airway with seizures; -2/14/23 monitor orthostatic blood pressure x 3 days. -2/21/23 Attempt/ demonstrate in reducing behavior by using the 4 R's of Reduce, Replace, Reinforce and Respond. -3/3/23 1:1 started -3/4/23 mat at side of the bed. -3/7/23 1:1 to continue until helmet received. Surveyor reviewed R507 Plan of Care. R507 has At risk for falls related to: History of falls, Use of medication, cognitive deficits, seizures, etc. initiated 10/14/22. There is no individualized plan of care for actual falls that R507 had in the facility. There is no revisions to the plan of care that correlate with the individual fall event for 11/24/22, 1/26/23, 2/18/23 and 2/22/23 x 2. R507's following fall assessments with progress notes were reviewed: -On 11/24/2022 at 7:26 AM there was a Progress Note that indicated a fall at 2:00 AM. Patient was seen sitting on the floor outside his room. Patient was unable to give description of how he got to the floor. Writer assessed patient, no injuries. Patient aided back to his room with assist of 1. Writer was redirected, and offered fluid, patient drink fluid with no difficulty. Patient mood was pleasant, stayed in bed. Neuro check started. The second fall at approximately at 4:45 CNA(Certified Nursing Assistant) heard a loud sound from patient's room, went in, and found patient on the floor. Writer assessed patient, a hematoma, and a slight cut was noted on the red side of his head. Laceration was also noted on patient's upper back. Patient was taken to the nursing station for close monitoring. Patient appeared restless, and constantly tries to get up from the wheelchair chair. On-call Nurse Practitioner notified, acknowledged sending out to the hospital for further evaluation. R507 medical record did not contain a comprehensive assessment of the 2 falls. There was not documentation related to preventative interventions in place, revised interventions upon return from the hospital, possible causative factors or any statements leading up to the fall. - On 1/26/2023 at 9:24 PM While resident was walking around in his room he lost his balance and rubbed his back against the wall and sustained an abrasion to his upper back. No bleeding noted, just redness. No complaint of pain noted. R507 medical record did not contain a comprehensive assessment of this fall. There was no documentation related to preventative interventions in place, revised interventions, possible causative factors or any statements leading up to the fall. -On 2/18/2023 at 9:47 PM Resident found by staff sitting on the floor. Prior to incident, resident was in his room resting in bed after tube feeding administration, later started wandering around unassisted. On assessment resident does not have any physical injury from this fall, no hitting of head. Resident helped up from the ground and taken to his room not very easy to redirect to lie back down, continues to walk around unassisted. R507's medical record did not contain a comprehensive assessment of this fall. There was no documentation related to preventative interventions in place, revised interventions, possible causative factors or any statements leading up to the fall. - On 2/22/2023 at 7:50 AM Progress Note Resident had a fall this morning, Nurse Practitioner aware and received new orders to not send the resident to the hospital, and keep monitoring. - On 2/22/23 at 12:01 AM Progress Note indicates a change in condition related to falls and behavior and R507 is sent out to the hospital. At 4:55 AM R507 returns to the facility and is being monitored for multiple falls and behavior. At 10:30 AM R507 has altered mental status and is sent out to the hospital. R507 medical record did not contain a comprehensive assessment of these falls on 2/22/23. There was not documentation related to preventative interventions in place, revised interventions, possible causative factors or any statements leading up to the fall. Hospital Admission Physician assessment dated [DATE] at 6:17 PM indicates R507 was admitted to the Intensive Care Unit with traumatic intracranial hemorrhage. R507 is critically ill with life-threatening traumatic intracranial hemorrhage requiring careful neurological monitoring, strict blood pressure control and complex decision making. R507 was hospitalized from 2/22/23 through 3/3/23 with a diagnosis of Traumatic Subdural Hematoma. A Progress Note dated 3/3/23 indicated R507 returned to the facility. According to a facility timeline provided to surveyor, R507 returned to a different room with interventions started for adjustment purposes. R507 was 1:1 with a mat was started upon return to the facility on [DATE]. The facility timeline also indicated on 3/4/23 the 1:1 was discontinued. A progress note on 3/4/23 at 10:30 AM (after the 1:1 was discontinued) R507 had a fall in their room. Surveyor noted there was no injury and was comprehensively assessed. The facility's timeline indicated the revised interventions included an additional mat next to the bed and 1:1 supervision. A progress note on 3/6/23 noted R507 had a fall in their room and hit their head and was sent out to the hospital. R507 was not being supervised as care planned. The facility did conduct a self-report investigation. This was submitted to the State Agency. The facility's investigation indicated in part, Resident had a fall with major injury before midnight on 3/6/23. CNA responded to fall, and nurse assessed resident. Noted to have laceration to scalp. Pressure applied and resident care given until paramedic arrived. Nurse called and updated MD on resident fall. Resident's POA and care management team updated on resident fall and hospital transfer. Nurse called hospital for update and was informed resident required stitches and is being admitted and evaluated. DON and Administrator notified. Investigation started and initial report sent to State .The facility did educate staff on 1:1 supervision duties after the 3/6/23 fall. R507 was also being measured for a fall Helmut that will be followed up on upon return from the hospital. On 3/20/23 at 8:08 AM Surveyor spoke with SW-D (Social Worker) and SW-Y. SW-D indicated that Nursing completes all the fall interventions. They are not part of that discussion and referred Surveyor to UM-Z (Unit Manager) and ADON-C (Assistant Director of Nurses). On 3/20/23 at 9:50 AM Surveyor requested fall information from Administrator-A and ADON-C. On 3/20/23 at 10:01 AM Surveyor spoke with UM-Z. They did not have detailed information related to fall assessments. UM-Z indicated any staff can update the plan of care. UM-Z indicated that R507 had behaviors and was 1:1 supervision. R507 changed very quickly in their health status. UM-Z did not have specific fall information. On 3/20/23 at 10:17 AM Surveyor spoke with MDS(Minimum data set) Staff-X. The revised fall interventions are reviewed with morning stand up. R507 was very impulsive. They did do 1:1 supervision for awhile. There has been a Falls helmet ordered. R507 has behavior of putting self on floor, however hasn't been seen doing it. MDS-X did not recall specific falls with their intervention. Surveyor received a Fall Report for R507 fall on 2/22/23 at 3:28 AM. There was no additional fall information for 2/22/23 fall at 12:01 AM. This Fall Report for 2/22/23 at 3:28 AM indicates R507 was acting out and was uncooperative. R507 was beginning self harm behaviors by falling to the floor deliberately and hitting the back of his head. The Action Taken was to place a pillow under R507 head. There is no additional assessment information. On 3/21/23 at 10:41 AM Surveyor spoke with SW-D and RDOBS-V (Regional Director of Behavioral Services). They were not aware of R507 behavior of throwing themselves on the floor. They indicated the Risk Management Team reviews the root cause analysis of falls. On 3/21/23 at 11:47 AM ADON-C, DON-B (Director of Nurses) and RCC-E (Regional Corporate Consultant). DON-B indicated every morning we review status of facility. We go through any incidents and changes in condition. Ensure fall assessments are completed. RCC-E indicated they are trying to find root cause of falls. R507 is non-verbal can be aggressive or grunts. Have not determined causes of falls. There is no personal history of R507 to pull from. We are had a AD-HOC QAPI(Quality Assurance Performance Improvement)on 3/7/23 and talked about different pieces of a plan of care. And having a more palliative plan of care. We talked about food and R507 throwing self around. Have action items, however R507 has been at the hospital frequently. Will have to look at advance training. They do use a third party company for resident reviews to get suggestions. They are utilized for challenging cases. The Care Plan is revised by the Team. No definitive care plan designee. Surveyor did share about care plan revisions and fall interventions related to an comprehensive assessment. R507's Fall Timeline provided by the facility was reviewed with this interview. R507 was 1:1 with a mat was started upon return to the facility on [DATE]. R507 returned to a different room and interventions were started for adjustment purposes. Then the 1:1 was discontinued on 3/4/23 before the fall on 3/4/23. After the fall on 3/4/23 an additional mat was placed, along with 1:1 supervision. Then on 3/6/23 R507 had a fall and 1:1 supervision was not being performed correctly and this was self-reported to the State Agency. 46517 3. R2 was admitted to the facility on [DATE] with diagnoses including presence of prosthetic heart valve, schizophrenia, anxiety, depression, malignant neoplasm of prostate and chronic kidney disease stage four. R2's admission MDS (Minimum Data Set) Assessment with an Assessment Reference Date of 12/22/22 documented, R2 had a BIMS (Brief Interview for Mental Status) of 15, indicating R2 is cognitively intact; R2 required two person physical assist for transfers; and R2 had no falls either the last month prior to admission nor the last 2-6 months prior to admission. R2's fall risk assessments document the following scores with a score of 10 or greater meaning the resident is at risk for falls: on 03/17/22 score of 7 (not at risk); 04/26/22 score of 7; 09/19/22 score of 7; 10/07/22 score of 3; 11/03/22 score of 12 (At risk); 12/16/22 score of 9; 03/07/23 score of 8; and on 03/16/23 score of 15 (At Risk). R2's care plan documented, At Risk for falls related to impaired mobility and new environment initiated on 03/18/22, and had interventions including: Call light and personal items available and in easy reach. Date Initiated: 03/18/2022 Encourage participation in activities to improve strength or balance such as therapies, in room exercises, etc. Date Initiated: 03/18/2022 Encourage rest periods if feeling fatigued. Date Initiated: 03/18/2022 Clear and monitor environmental obstacles (tubing, cords, etc.). Date Initiated: 06/30/2022 Observe for side effects of medications and update MD or NP if present. Date Initiated: 06/30/2022 Therapy Referral as ordered and prn. Date Initiated: 06/30/2022 Walker or other device kept in consistent location. Date Initiated: 06/30/2022 Assess that wheelchair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, anti tippers, etc. Date Initiated: 06/30/2022 New B/B assessment to be completed. Date Initiated: 03/08/2023 Call before fall reminder signs. Date Initiated: 03/08/2023 Surveyor noted between 06/30/22 and 03/08/23 there were no additional interventions added to R2's Fall Care Plan. Surveyor reviewed R2's medical record and noted the following documentation: On 9/19/2022 at 4:15 AM, a nurse documented, Res(resident)[sic]; calling out for help. Writer observed res[sic]; in sitting position at the side of the bed on his buttocks. I was getting up to get in my chair and the wheelchair [sic] rolled away from me I slide off the bed on my butt. Doctor was called ro (related to) up on fall w/o (without) injury . Surveyor reviewed R2's post fall assessment, dated 09/19/22, which documented, Remind Resident to make sure he wears non-slip/grip socks; make sure wheelchair is locked before transferring. Surveyor noted R2's care plan was not updated to reflect these interventions and Surveyor could not locate a root cause analysis. On 10/7/2022 at 8:50 PM, a nurse documented in progress notes, Res was found on the floor at (sex of resident) bedside lying on right side. Res stated . lost balance, denies pain or discomfort. Res was transferred back to bed. Res was also able to ambulate per usual after this fall and reposition self in bed while using walker. Surveyor reviewed R2's post fall assessment, dated 10/07/22, which documented the fall was unwitnessed and resident stated they lost balance, but uncertain of how/why they lost balance. There was no root cause analysis nor new interventions noted on the post fall assessment. Surveyor noted R2's Fall Care Plan was not updated after this fall. On 11/3/2022 at 3:40 AM, a nurse documents in progress notes, Res; calling out for help. Res; observed lying on the floor under the bed on stomach. Res; stated, I was going to empty my urinal. I fell down on the floor. c/o (complained of) left hip pain/ disc;[sic] call doctor/ NP(nurse practitioner) received order forstat [sic] X-ray .ROM/ WNL (Range of Motion/Within Normal Limits) of all extremities with pain of the left hip no redness or warmth at the site. Left leg shorten due to prior hip injury/ surgery. Surveyor reviewed R2's post fall assessment, dated 11/03/22, which documented resident lost balance and fell on hip and resident needs assist when transferring to/from the bed/wheel chair. Surveyor noted there was no root cause analysis, no interventions mentioned and R2's Fall Plan was not updated after this fall. Surveyor reviewed R2's medical record for the result of the X-ray and noted the following documented in progress notes: On 11/3/2022 at 11:43 AM, a nurse documents, (Name of Nurse Practitioner (NP) NP called writer and asked writer to get X-ray report clarified d/t (due to) two different results. Writer contacted [name of X-ray company] stated that a stat order was placed for results to be reread by radiologist. On 11/3/2022 at 1:49 PM a nurse documents, Awaiting updated X- ray result from [name of X-ray company]. No c/o pain or discomfort noted f/u (follow up) fall. Up and about via w/c (wheelchair). Will continue to monitor On 11/4/2022 at 3:26 PM, a nurse documents, Writer called [name of X-ray company] for X-ray result clarification. No staff available to discuss this matter will cont[sic] this attempts. On 11/8/2022 at 10:08 AM, a nurse documents, [name of X-ray company] called again for reread results of X-ray. Writer remained on hold for 30 minutes with no response from [name of X-ray company]. Surveyor noted there was no documentation between 11/4/22 and 11/8/22 regarding facility attempts to contact the X-ray company for clarification. Surveyor could not locate documentation on what the facility did during this time to keep R2 safe. On 11/8/2022 at 10:19 AM, a nurse documents in progress notes,(name of X-ray company) called again and tech reported to writer that addendum to X-ray results should be completed within the next two hours. On 11/8/2022 at 6:53 PM, a nurse documents in progress notes, Writer updated apNP(Advanced Practice Nurse Practitioner), (name of APNP) in regards to radiology report from 11/3, received order to send res. to ER (emergency room ) for further eval (evaluation). Res refused to go . On 11/8/2022 at 7:01 PM, a nurse documents in progress notes, New order received; res must be NON weight bearing to LLE (Left Lower Extremity) until he is able to see a orthopedic specialist. Surveyor noted the non-weight bearing order on 11/08/22 was the first documented intervention for the fall that occurred on 11/03/22, five days earlier. On 03/21/23 at 8:50 AM, Surveyor interviewed NP (Nurse Practitioner) SS. Surveyor asked about R2's fall on 11/03/22 and what the X-ray results were. NP SS reviewed R2's chart and stated R2's X-ray result showed a new acute subtrochanter fracture and R2 refused to go to the emergency room . NP SS stated at that time, on 11/08/23, they gave the facility new orders for R2 to be non-weight bearing until seen by an orthopedic specialist. NP SS was unsure of the delay in getting the X-ray results. Surveyor reviewed R2's X-ray results, dated 11/03/23 at 8:35 AM, provided to Surveyor by the facility. The results document, There is a prosthetic left femoral head in proper alignment with respect to the acetabulum. There is no acute fracture or acute dislocation. The prosthesis is properly situated without any loosening. This is the only result Surveyor was provided with. Surveyor noted the X-ray result showed no acute fracture. On 11/8/2022 at 8:22 PM, a nurse documents in progress notes, Res was screaming out for help, was found kneeling at bedside with upper body resting on bed. Res was unclear as to what happened. Denies hitting head .Res did agree to go to the ER for an evaluation. On call apnp, Administrator, both sons are aware of fall and hospital transfer. Bell ambulance transporting res. To (name of hospital) Surveyor reviewed R2's post fall documentation and noted there was no root cause analysis, no new interventions documented and R2's Fall Care Plan was not update after the 11/08/22 fall. On 3/7/2023 at 4:08 PM, a nurse documents in progress notes, Unwitnessed fall: writer was called to resident's room. Resident noted on floor laying on left hip, incontinent of bowel and bladder. Resident had fallen attempting to transfer self from chair to stand with walker. No injuries noted. alert and oriented to self, situation and place. Denied hitting head, neuro check negative. No injury noted. Denies pain, no non-verbal indicators of pain noted with ROM. Resident stated was trying to go to toilet. Surveyor noted after the 3/7/2023 fall, R2's Fall Care Plan was updated to include new bowel and bladder assessment and call before fall reminder signs. Surveyor noted R2's CNA (Certified Nursing Assistant) Kardex had been updated to include new bowel and bladder assessment, however Surveyor could not locate the results of the assessment. On 3/16/2023 at 5:31 PM, a nurse documented in progress notes, Resident was found laying[sic] on left side on the floor by CNA in room. The resident self transferred with walker trying to toilet self without using call light that was in reach for staff assist. Resident stated, I can walk by myself with my walker, but my socks was [sic] very slippery and I fell . C/o pain 10/10 to Left hip. NOR(new order received) send to E.R for Eval & TX (treatment). Surveyor noted the following physician's order in R2's medical record dated 03/16/2023, Check condition of res gripper socks/make sure res wear when up and transferring. Surveyor noted this was the first nursing prompt of the need f [TRUNCATED]

Based on observation, interview, and record review, the Facility did not provide necessary treatment and services to promote healing for 2 (R4 & R6) of 3 Residents with pressure injuries. * R4's hospital discharge paperwork dated 12/6/21 indicated Gluteal Cleft Mid pressure injury. The skin only evaluation, completed by an LPN (Licensed Practical Nurse), dated 12/6/21 documents redness in groin and inner buttocks. There was no RN (Registered Nurse) skin assessment until 12/13/21 when R4 was identified as having a DTI (Deep Tissue Injury) on left buttocks and Stage 3 pressure injury on the right buttocks. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/20/21 Wound MD-X assessed R4's left buttocks pressure injury as unstageable with 100% slough while the Facility assessed on this date the left pressure injury as DTI. R4's skin integrity care plan was not revised until 12/26/21, 6 days later and there were no further revisions after 12/26/21. A skin only evaluation dated 1/1/22 backstaged R4's right buttocks pressure injury from Stage 3 to Stage 2. This evaluation was completed by an LPN. * R6 returned from the hospital on 12/22/21 and a skin only evaluation was completed by an LPN which indicated no skin impairments. On 12/28/21 a skin only evaluation was completed by an LPN, which indicated a skin tear on R6's coccyx. There is no RN assessment. On 12/27/21 Wound MD-X identified an unstageable pressure injury to the right first toe. On 1/10/22 Wound MD-X identified an unstageable pressure injury to R6's left buttocks. There was no revision to R6's skin integrity care plan. During the week of 1/16/22 to 1/22/22 there were no assessments for R6's pressure injuries. On 2/7/22 and 2/8/22, R6 was observed multiple times with his heels not being offloaded and not wearing heel boots according to the plan of care. Findings include: The Pressure Injury Prevention and Management policy not dated documents under policy explanation and compliance guidelines documents The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions and modifying the interventions as appropriate. 1. R4 was admitted to the facility on [DATE] & discharged to the hospital on 1/7/22. R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's power of attorney was activated on 11/4/21. The hospital records dated 12/6/21 documents Left, lower wound 11/5/21 Pressure injury Gluteal Cleft mid. Surveyor noted there are no stage or measurements in the hospital record. The COMS Skin Only Evaluation dated 12/6/21 documents Skin Issue: Other Skin Issue. Other Skin Issue: redness in groin area and inner buttocks Skin Issue Location: groin and inner buttocks Resident has bruising on his abdomen and upper extremities. Resident has redness to the inner groin areas and inner buttocks area. Areas cleansed with soap and water, pat dry and barrier cream applied. This skin only evaluation was completed by an LPN (Licensed Practical Nurse). There is no RN (Registered Nurse assessment) of R4's skin. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. The potential for alteration in skin integrity care plan initiated 12/8/21 has the following interventions: * Complete Braden Scale per Living Center Policy initiated 12/8/21 * Do not massage over bony prominence initiated 12/8/21 * Monitor vital signs as needed initiated 12/8/21 * Nutritional and hydration support initiated 12/8/21 * Provide pressure reducing wheelchair cushion initiated 12/8/21 * Provide pressure reduction/relieving mattress initiated 12/8/21 * Provide thorough skin care after incontinent episodes and apply barrier cream initiated 12/8/21. This intervention was revised on 12/26/21 with the same verbiage. * Skin assessment to be completed per Living Center Policy initiated 12/8/21 * Turning and repositioning schedule per assessment initiated 12/8/21. This intervention was revised on 12/26/21 to Turing and repositioning q (every) 2-3 hours and prn (as needed) initiated 12/26/21. * Diabetic food monitoring nightly initiated & revised 12/26/21. * Heel boots initiated & revised 12/26/21. The nurses note dated 12/11/21 includes documentation of .Has redness to the inner groins and inner buttocks. [MEDICATION(S)] ointment applied. The weekly skin impairment and wound evaluation dated 12/13/21 for skin issue location documents right buttocks, for description of skin issue documents Stage 3 pressure ulcer, and date wound identified 12/13/21. For visible tissue granulation tissue present is checked & percentage is 100%. Wound measurements for length 1.5, width 3, and depth 0.1. This weekly skin impairment was completed by RN (Registered Nurse)-W who is no longer employed at the Facility. The weekly skin impairment and wound evaluation dated 12/13/21 for skin issue location documents left buttocks, for description of skin issue documents DTI (deep tissue injury) with intact skin, date wound identified 12/13/21 and skin impairment type is pressure ulcer. Wound measurements for length 9 and width 9. This weekly skin impairment was completed by RN (Registered Nurse)-W who is no longer employed at the Facility. Surveyor noted this is the first RN assessment of R4's skin when R4 is identified as having a Stage 3 and DTI pressure injuries. Wound MD (medical doctor)-X initial wound evaluation & management summary dated 12/13/21 under focused wound exam (site 1) documents Unstageable DTI of the left buttocks partial thickness, etiology is Pressure and wound size is 9 x (times) 9 x not measurable cm (centimeters). Under focused wound exam (site 2) documents Stage 3 Pressure Wound of the right buttocks full thickness, etiology pressure, wound size 1.5 x 3 x 0.1 cm, and granulation tissue is 100%. Under dressing treatment plan documents Primary dressing(s) Xeroform sterile gauze apply once daily for 30 days. Secondary dressing(s) Foam with border apply once daily for 30 days. Surveyor reviewed R4's December 2021 and noted this treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses note dated 12/13/21 .Resident seen by the wound MD (medical doctor), resident has open areas to buttocks and treatment completed. Treatments to be put in place. [MEDICATION(S)] applied to reddened areas. No c/o (complaint of) pain or discomfort. The admission MDS (minimum data set) with an assessment reference date of 12/13/21 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R4 is coded as having no behaviors including refusal of cares. R4 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfer and does not ambulate. R4 is coded as having an indwelling catheter and is always incontinent of bowel. Height is 73 inches (6 feet 1 inch) and weight 293 pounds. R4 is at risk for pressure injury development and is coded as having a pressure injury. R4 is coded as having one Stage 3 pressure ulcer which was present upon admission and one unstageable pressure injury present upon admission. The actual pressure ulcer care plan initiated 12/14/21 has the following interventions: * Air mattress initiated 12/14/21. * Complete Braden Scale per Living Center Policy initiated 12/14/21. * Conduct weekly skin inspection initiated 12/14/21. * Evaluate need for pain reliever prior to cleansing or dressing changes initiated 12/14/21. * Monitor vital signs as needed imitated 12/14/21. * Notify practitioner if symptoms worsen or do not resolve initiated 12/14/21. * Nutritional and hydration support initiated 12/14/21. * Provide pressure reducing wheelchair cushion initiated 12/14/21. * Provide thorough skin care after incontinent episodes and apply barrier cream initiated & revised 12/14/21. * Skin assessment to be completed per Living Center Policy initiated 12/14/21. * Treatments as ordered initiated 12/14/21. * Turning and repositioning schedule per assessment initiated 12/14/21. This intervention was revised on 12/26/21 to Turning and repositioning q 2-3 hours and prn. * Weekly wound assessment initiated 12/14/21. The nurses note dated 12/17/21 documents .Resident continues to be seen by the wound MD, Treatment completed to the right buttocks wound and [MEDICATION(S)] ointment applied to the buttocks and groin areas. Specialty air mattress in place and functioning. No c/o (complaint of) pain or discomfort. The pressure injury CAA (care area assessment) dated 12/19/21 under analysis of findings - nature of problem/condition is blank. Under care plan considerations documents Res (Resident) has pressure ulcers upon admission. The ulcers receive txs (treatments) as ordered and are monitored weekly on wound rounds. Res. is at risk for further skin breakdown d/t (due to) decreased mobility, B & B (bowel and bladder) incontinence, RLE (right lower extremity) cast, [CONDITION(S)], etc. Res is assisted to reposition self q (every) 2-3 hours & prn (as needed) but is resistive at times. Res is toileted per assessment and prn. Res receives pericare and barrier cream wit each incontinence episode. Skin is monitored daily with cares and weekly with showers/body assessments. Will proceed to care plan to monitor heal existing wounds; as well as prevent or minimize effects of any further skin breakdown. The skilled evaluation dated 12/19/21 documents for skin Skin warm & dry, skin color WNL (within normal limit) and tugor is normal. No skin issues. The weekly skin impairment and wound evaluation dated 12/20/21 for skin issue location documents right buttocks, for description of skin issue documents Stage 3 pressure ulcer, and date wound identified 12/13/21. For visible tissue granulation tissue present is checked & percentage is 100%. Wound measurements for length 2.5, width 2.5, and depth 0.1. Under wound/skin impairment worsening is checked. This weekly skin impairment was completed by RN (Registered Nurse)-W who is no longer employed at the Facility. The weekly skin impairment and wound evaluation dated 12/20/21 for skin issue location documents left buttocks, for description of skin issue documents DTI (deep tissue injury) with intact skin, date wound identified 12/13/21 and skin impairment type is pressure ulcer. Wound measurements for length 8 and width 8. Under wound/skin impairment improving is checked. This weekly skin impairment was completed by RN (Registered Nurse)-W who is no longer employed at the Facility. Wound MD (medical doctor)-X wound evaluation & management summary dated 12/20/21 under focused wound exam (site 1) documents Unstageable (due to necrosis) of the left buttocks full thickness, etiology is Pressure and wound size is 8 x (times) 8 x not measurable cm (centimeters) and slough is 100%. Under focused wound exam (site 2) documents Stage 3 Pressure Wound of the right buttocks full thickness, etiology pressure, wound size 2.5 x 2.5 x 0.1 cm, and granulation tissue is 100%. Surveyor noted on 12/20/21 the Facility assesses R4's left buttocks as a DTI while Wound MD-X assess the left buttocks as unstageable. There is no revision in R4's skin integrity care plan until 12/26/21 6 days after R4's pressure injury was identified as being unstageable. There were no further revisions of R4's skin integrity care plan after 12/26/21. The nurses note dated 12/20/21 documents Resident seen by the wound MD. New treatment order received to the left buttocks DTI (deep tissue injury). To cleanse the left buttocks DTI with NS, pat dry. Apply Xeroform gauze f/b (followed by) border foam dressings daily. To continue the same treatment to the right buttocks wound. [name of] POA (power of attorney) aware and thankful for the call. The skilled evaluation dated 12/22/21 documents for skin Skin warm & dry, skin color WNL (within normal limit) and tugor is normal. No skin issues. The nurses note dated 12/26/21 documents Resident alert and oriented x (times) 3, able to make needs known. Skin color normal, warm and dry. Lying in bed and repositioned q2hrs (every two hours) from side to side. Resident can be non compliant and will roll back on his back Surveyor noted this is the first note regarding R4 being non compliant. Surveyor was unable to locate a weekly skin impairment and wound evaluation during the week of 12/26/21 to 1/1/22. Wound MD (medical doctor)-X wound evaluation & management summary dated 12/27/21 under focused wound exam (site 1) documents Unstageable (due to necrosis) of the left buttocks full thickness, etiology is Pressure and wound size is 8 x (times) 6 x not measurable cm (centimeters) and slough is 100%. Under focused wound exam (site 2) documents Stage 3 Pressure Wound of the right buttocks full thickness, etiology pressure, wound size 2.5 x 2.5 x 0.1 cm, and granulation tissue is 100%. The nurses note dated 12/27/21 documents Resident seen by the wound MD (medical doctor). Left buttocks wound debrided. To continue with the current treatment ordered. Treatment completed and dressing clean, dry and in place. The skilled evaluation dated 12/28/21 documents for skin Skin warm & dry, skin color WNL (within normal limit) and tugor is normal. No skin issues. The skilled evaluation dated 12/30/21 documents for skin Skin warm & dry, skin color WNL (within normal limit) and tugor is normal. No skin issues. The COMS Skin Only Evaluation dated 1/1/22 documents Skin: Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin issue: Pressure Ulcer/Injury. Skin Issue Location: Left buttocks Pressure Ulcer/Injury Stage: Unstageable. Length: 8.0 Width (cm) (centimeters) 6.0 Wound Bed: Slough. Wound exudate: Serous. Peri Wound Condition: Fragile Dressing Saturation: Moderate (26-75%). No wound odor. No tunneling. No undermining. Skin Issue: Pressure Ulcer/Injury. Skin Issue Location: right buttocks Pressure Ulcer/Injury Stage: Stage II (2) 0 Partial thickness skin loss. Length: 2.5 Width: 2.5 Depth: 0.1 Wound Bed: Granulation. Wound Exudate: Serous. Peri Wound Condition: Fragile. Dressing Saturation: Moderate (26-75%). No wound odor. No tunneling. No undermining. Resident has open areas on his right and left buttocks. Left buttocks unstageable, area 8.0 cm x 6.0 cm. Wound bed 100% slough. Moderate amount of serous drainage. No foul odor. Right buttocks stage 2, area 2.5 cm x 2.5 cm x 0.1 cm. Wound bed 100% granulation. Moderate amount of serous drainage. No foul odor. Treatment completed to the right and left buttocks wound. Dressing clean, dry and in place. Repositioned q2hrs. This skin evaluation only was completed by a LPN and the right buttocks pressure injury was backstaged from a Stage 3 to Stage 2. The skilled evaluation dated 1/1/22 documents for skin Skin warm & dry, skin color WNL (within normal limit) and tugor is normal. No skin issues. Surveyor was unable to locate a weekly skin impairment and wound evaluation during the week of 1/2/22 to 1/7/22. Wound MD (medical doctor)-X wound evaluation & management summary dated 1/3/22 under focused wound exam (site 1) documents Unstageable (due to necrosis) of the left buttocks full thickness, etiology is Pressure and wound size is 8 x (times) 6 x not measurable cm (centimeters) and slough is 100%. Under focused wound exam (site 2) documents Stage 3 Pressure Wound of the right buttocks full thickness, etiology pressure, wound size 2.5 x 2.5 x 0.1 cm, and granulation tissue is 100%. The nurses note dated 1/3/22 documents Resident seen by the wound MD. Open area to the left buttocks debrided. New treatment orders received. To continue with Xeroform and border foam dressing to the right buttocks. To change the left buttocks treatment to cleanse area with 1/2 strength Dakins solution then pack wound loosely with wet/moist Dakins gauze then apply calcium alginate and border foam dressings daily. To apply antifungal cream to both feet BID (twice daily). Resident and [name of] POA aware. [name of] APNP (advanced practice nurse prescriber) for [name of physician] in to see resident and updated on the right and left buttocks wounds and the new treatments ordered. R4 was discharged to the hospital on 1/7/22 and has not returned to the Facility. On 2/8/22 at 8:44 a.m. Surveyor spoke with MDS-I to inquire how she determined R4 was admitted with the deep tissue injury and Stage 3 pressure injury. MDS-I informed Surveyor she reviewed the hospital papers which indicated a pressure injury on the gluteal cleft mid and she looked at Wound MD-X's notes. On 2/8/22 at 8:51 a.m. Surveyor asked LPN-Y if she knew how R4 developed the pressure injuries. LPN-Y informed Surveyor she didn't as R4 already had the pressure injury when he came to her unit. Surveyor inquired if she completes the admission assessments for Residents. LPN-Y informed Surveyor she does. Surveyor inquired if she completes skin assessments. LPN-Y informed Surveyor she does. Surveyor asked if a RN reviews the assessments she completes. LPN-Y informed Surveyor they go in the computer and let us know if we are missing anything. On 2/8/22 at 8:56 a.m. Surveyor asked LPN-F if she knew how R4 developed the pressure injuries. LPN-F replied no I don't and explained R4 had high anxiety, never complained of pain to her but anxiety was something R4 always talked about. On 2/8/22 at 9:05 a.m. Surveyor spoke with CNA (Certified Nursing Assistant)-Z regarding R4. Surveyor inquired what cares CNA-Z would provide to R4. CNA-Z informed Surveyor she would wash R4, turn him. Surveyor asked how often she would turn R4. CNA-Z informed Surveyor every couple of hours and R4 was scared he would tip off the bed. Surveyor inquired if R4 had a wide bed. CNA-Z informed Surveyor R4's bed was longer but not wider. Surveyor asked if R4 refused to turn. CNA-Z informed Surveyor R4 did refuse at times and R4 was always scared, thinks R4 had a fall at the hospital and really didn't like to be repositioned. Surveyor inquired if R4 stayed in bed. CNA-Z informed Surveyor R4 was always in bed unless he had an appointment. Surveyor asked CNA-Z if she reported to anyone R4 was scared he would fall out of bed. CNA-Z replied no and explained many nurses knew he was scared. CNA-Z informed Surveyor R4 probably would of needed a larger bed and R4 was scared to move. Surveyor asked CNA-Z if she knew how R4 developed the pressure injuries. CNA-Z replied I don't know. On 2/8/22 at 10:09 a.m. Surveyor met with DON (Director of Nursing)-B to inquire how Resident assessments are completed. DON-B informed Surveyor each shift has a section to do and the floor nurses complete the assessments. DON-B explained the admitting nurse is responsible for medications, vital signs, skin assessments and admission nursing assessment. The next shift has hot liquids, Braden scale, & fall risk. The next shift has what ever is left over and checks to make sure everything is done. DON-B informed Surveyor the whole admission is looked over the next day by the MDS nurse and herself. Surveyor asked what DON-B means by the whole admission is looked over. DON-B informed Surveyor they make sure everything is done. Surveyor inquired who reviews paperwork from the hospital. DON-B informed Surveyor the nurses are looking at paperwork from the hospital. Surveyor inquired if the nurses are reviewing just the medications. DON-B informed Surveyor the nurses are looking over the whole paperwork to know everything as they don't know the Resident at this time. Surveyor asked DON-B if a Resident is admitted with a pressure injury does the LPN measure the pressure injury. DON-B informed Surveyor the nurse would measure but not stage the pressure injury. Management or Wound MD-X would stage the pressure injury. Surveyor inquired who is responsible for revising Resident's care plans. DON-B replied management explaining herself or the MDS Coordinator. Surveyor informed DON-B R4's admission hospital information indicated a pressure injury on the gluteal cleft, admission skin evaluation was completed by a LPN and Surveyor did not note a RN assessment until the pressure injuries were DTI and Stage 3. Surveyor asked DON-B to look into this and get back to Surveyor. Surveyor also informed DON-B Surveyor was informed R4 was afraid to turn in bed as he was afraid he would fall out of bed and R4 was very anxious. Surveyor did not note any interventions to address R4's concerns and did not note any interventions to address his anxiety. DON-B informed Surveyor R4 was not afraid to turn and he turned over for her. DON-B informed Surveyor she did not see any anxiety with R4. On 2/8/22 at 3:23 p.m. Surveyor asked DON-B if she had any additional information regarding R4's pressure injuries. On 2/8/22 at 3:43 p.m. DON-B informed Surveyor she does not have any additional information. 2. R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 has a history of left hand pressure injury. R6 was hospitalized from 11/25/21 to 12/13/21 and 12/20/21 to 12/22/21. R6 was admitted to hospice on 12/22/21. The potential for alteration in skin integrity care plan initiated 2/16/18 includes the following interventions: * Assist res. (resident) to reposition q (every) 2-3 hours and prn. Initiated & revised 2/16/18. * Complete Braden Scale per Living Center Policy. Initiated 2/16/18. * Conduct weekly skin inspections. Initiated 2/16/18. * Diabetic foot monitoring. Initiated 2/16/18. * Do not massage over bony prominence. Initiated 2/16/18. * Heel boots. Initiated 2/16/18. * Nutritional and hydration support. Initiated 2/16/18. * Provide pressure reducing wheelchair cushion. Initiated 2/16/18. * Provide pressure reduction/relieving mattress. Initiated 2/16/18. * Provide thorough skin care after incontinent episodes and apply barrier cream. Initiated 2/16/18. * Skin assessment to be completed per Living Center Policy. Initiated 2/16/18. The skin only evaluation dated 12/13/21 documents Skin : Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Excoriation. Skin Issue Location: buttocks Tissue: Warm. Skin Issue: Deep Tissue Injury. Skin Issue Location: right great toe No wound odor. No tunneling. No undermining. Tissue: Firm. Skin Issue: Other Skin Issue. Other Skin Issue: scab Skin Issue Location: on top of right great toe No wound odor. No tunneling. No undermining. Tissue: Warm. This evaluation was completed by a LPN. Surveyor noted there is no RN assessment and no revision in R6's care plan until 12/29/21. The nurses note dated 12/13/21 documents Resident arrived to facility at approximately 1810 (6:10 p.m.) via ambulance. Resident alert x (times) 1 staff to meet his needs. Resident LCTA (lungs clear to auscultation) no sob (shortness of breath) noted no coughing noted. ABD (abdomen) soft non-tender active x 4 quads. (quadrants). Resident skin warm and dry. Resident buttocks red and excoriated and right great toe has a DTI noted with a scabbed area to top of right great toe noted. Resident has no s/sx (signs/symptoms) of pain noted. Supra pubic Foley catheter patent wit yellow colored urine flow. Orders faxed to pharmacy at this time. Resident in bed resting comfortably. VSS (vital signs stable). This nurses note was completed by a LPN. The nurses note dated 12/15/21 documents Skin prep applied to DTI to right great toe, no s/s of pain , no acute distress noted. The nurses note dated 12/17/21 documents TX (treatment) to DTI left great toe cont. (continued). Assisted with cares and made comfortable. No s/s of pain or discomfort noted. Will cont. to monitor. R6 was hospitalized from 12/20/21 to 12/22/21. The nurses note dated 12/22/21 documents Resident readmitted to the facility @ (at) 1pm, transported via [name of] ambulance by 2 ambulance personal, res. (resident) on stretcher. Resident alert, supra pubic foley in place draining yellow urine. Skin warm and dry, no open areas or abrasion noted. LCTA, bs (bowel sounds) x 4 quads, abdomen soft non tender, no distention. Resident discharge diagnosis [CONDITION(S)] (urinary tract infection), chronic parapelegia, dementia MS (multiple scrosis), [CONDITION(S)] associated with catheterization of urinary tract. Resident to resume previous diet . The COMS skin only evaluation dated 12/22/21 documents Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time. This skin evaluation was completed by a LPN. Wound MD-X Wound evaluation & management summary dated 12/27/21 for focused wound exam (site 2) documents Unstageable (due to necrosis) of the right, first toe full thickness, Etiology pressure Wound size 4 x 1 x not measurable, thick adherent black necrotic tissue (eschar) 80% and skin 20%. Under treatment plan for primary dressing(s) documents [MEDICATION(S)] apply once daily for 30 days. Surveyor noted there were no revision to R6's skin integrity care plan until 12/29/21. The nurses note dated 12/27/21 documents [Wound MD-X] in this am (morning) shift new orders for left hand between index and thumb open area. Orders to wash with soap and water pat dry apply calcium alginate daily and orders for [MEDICATION(S)] to unstageable right great toe daily. The nurses note dated 12/28/21 documents Open area to coccyx skin peeled back bright red bleeding noted. Measured at 1.0 cm (centimeters) x 1.0 cm. Resident denies pain. [MEDICATION(S)] applied with DermaLevin drsg (dressing) applied. Resident repositioned. T (temperature) 98.0, P (pulse) 88 R (respiration) 20 BP (blood pressure) 110/69 SPo2 97% RA (room air). This note was completed by a LPN. The COMS skin only evaluation dated 12/28/21 documents Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Skin Tear. Skin Issue Location: coccyx Length: 1.0 cm Width (cm): 1.0 cm Wound Exudate: Sanguineous, Peri Wound Condition: Fragile. Tissue Warm. This skin only evaluation was completed by a LPN and there is not a RN assessment of R6's skin. The actual pressure ulcer care plan initiated 12/29/21 includes the following interventions: * Air mattress - check function and settings q shift and prn. Initiated 12/29/21. * Complete Braden Scale per Living Center Policy. Initiated 12/29/21. * Conduct weekly skin inspection. Initiated 12/29/21. * Do not massage over bony prominence. Initiated 12/29/21. * Heel boots on at all times, may remove for cares and to assess skin. Initiated & revised 12/29/21. * Monitor skin under braces, prosthetics, splints, casts for breakdown. Initiated & revised 12/29/21. * Monitor vital signs as needed. Initiated 12/29/21. * Notify practitioner if symptoms worsen or do not resolve. Initiated 12/29/21. * Nutritional and hydration support. Initiated 12/29/21. * Podiatry consult. Initiated 12/29/21. * Provide pressure reducing wheelchair cushion. Initiated & revised 12/29/21. * Provide thorough skin care after incontinent episodes and apply barrier cream. Initiated & revised 12/29/21. * Skin assessment to be completed per Living Center Policy. Initiated 12/29/21. * Treatments as ordered. Initiated 12/29/21. * Turning and repositioning q 2-3 hours and prn. Initiated & revised 12/29/21. * Weekly wound assessment. Initiated 12/29/21. The significant change MDS (minimum data set) with an assessment reference date of 12/29/21 documents short term & long term memory problems and is severely impaired for cognitive skills for daily decision making. R6 is coded as not having any behaviors including refusal of care. R6 requires extensive assistance with two plus person physical assist for bed mobility, dependent with two plus person physical assist for transfers & toilet use and does not ambulate. R6 is coded as having an indwelling catheter and is always incontinent of bowel. R6 is at risk for pressure injuries and has a Stage 3 pressure injury. The nurses note dated 12/30/21 documents Resident treatment to coccyx. left hand and right great toe remains intact. Resident denies pain/discomfort at this time. Resident foley catheter intact and patent with yellow colored urine flow. Resident continues on [name of] Hospice care at this time. Wound MD-X Wound evaluation & management summary dated 1/3/22 for focused wound exam (site 2) documents Unstageable (due to necrosis) of the right, first toe full thickness, Etiology pressure Wound size 4 x 1 x not measurable, thick adherent black necrotic tissue (eschar) 80% and skin 20%. Under dressing treatment plan for primary dressing(s) documents Xeroform sterile gauze apply once daily for 30 days Secondary dressing(s) Bandage apply once daily for 30 days. There is no assessment for R6's coccyx during this assessment. Surveyor was unable to locate a weekly skin impairment and wound evaluation during the week of 1/2/22 to 1/8/22. The nurses note dated 1/6/22 documents Resident treatment to coccyx. left hand and right great toe remains in place. Resident denies pain/discomfort at this time. Resident foley catheter intact and patient with yellow colored urine flow. Resident continues on [name of]Hospice care at this time. Resident has nos/sx of pain/discomfort at this time. Wound MD-X Wound evaluation & management summary dated 1/10/22 for focused wound exam (site 2) documents Unstageable (due to necrosis) of the right, first toe full thickness, Etiology pressure Wound size 4 x 1 x not measurable, thick adherent black necrotic tissue (eschar) 80% and skin 20%. Under dressing treatment plan for primary dressing(s) documents [MEDICATION(S)] apply once daily for 30 days. Focused Wound Exam (site 4) documents Unstageable (due to necrosis) of the left buttock full thickness, Etiology Pressure, Wound size 2.5 x 1 x not measurable cm, slough 100%. Under dressing treatment plan for primary dressing(s) documents Xeroform sterile gauze apply once daily for 30 days Secondary dressing(s) Foam with border apply once daily for 30 days. Surveyor was unable to locate a weekly skin impairment and wound evaluation during the week of 1/9/22 to 1/15/22. Surveyor noted there is no revision in R6's skin integrity care plan. The pressure injury CAA (care area assessment) dated 1/12/22 under care plan considerations documents Res. (Resident) has a pressure ulcer present on admission. The ulcer receives txs (treatments) as ordered and are monitored weekly on wound rounds. Res. is at risk for further skin breakdown d/t (due to) decreased mobility, B & B (bowel and bladder) incontinence, etc. Res is assisted to reposition self q (every) 2-3 hours and prn (as needed) but is resistive at times. Res. is toileted per assessment and prn. Res. receives peri care and barrier cream with each incontinence episode. Skin is monitored daily with cares and weekly with showers/body assessments. Will proceed to care plan to monitor heal existing wounds; as well as prevent or minimize effects of any further skin breakdown. The nurses note dated 1/13/22 documents Resident in Isolation for positive Covid 19, no s/s of respiratory distress, no coughing or congestion noted. T 97.3 will cont. to observe. Dressing changed to sacru [TRUNCATED]

Based on record review and staff interview, the facility did not ensure a resident received CPR (cardiopulmonary resuscitation) per their advance directives. This was observed in 1 of 57 residents in the facility with a full code designation. R13 had signed advance directives that indicated they wanted CPR performed in a situation where R13 was found pulseless and not breathing. On [DATE] R13 was found in respiratory distress by facility Certified Nursing Assistant (CNA) staff. The CNAs called the Licensed Practical Nurse (LPN) (LPN-R) assigned to R13 who did not verify R13's code status or initiate CPR. The LPN transferred R13 to an activity room in the facility and walked to a different unit, (leaving R13 behind) and told the registered nurse (RN) (RN-S) she needed her to verify that R13 had expired. The RN assessed R13 for pulse and did not verify code status or initiate CPR. A code status was not called in the facility and 911 was not contacted. Staff failure to initiate CPR and carry out a code situation in accordance with the facility's policy and procedures denied R13 the only chance for survival. Additionally, through interview facility staff were not able to communicate steps needed to be taken in a code situation, particularly in a situation where a resident has COVID. The facility's failure to implement CPR in accordance with R13's expressed wishes created a situation of immediate jeopardy that began on [DATE]. Surveyor notified Administrator-A of the immediate jeopardy on [DATE] at 11:35 AM. The facility removed the immediacy on [DATE] with the implementation of their action plan. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their plan. Findings include: The facility's policy for CPR dated [DATE] was reviewed by Surveyor. The policy includes the following: If a resident experiences a [CONDITION(S)], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services; and in accordance with the resident's advance directive. The facility also provided a policy and procedure titled CPR During Covid, which was implemented [DATE]. This policy indicates: It is the policy of this facility to follow American Heart Association guidelines regarding CPR in order to provide effective basic life support while minimizing infection risks to staff members providing CPR. Surveyor noted this policy also included an algorithm to be referred to. Policy explanation and compliance guidelines: 1. If a resident experiences a [CONDITION(S)], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advanced directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). 2. CPR certified staff will be available at all times. 3. Staff will maintain current CPR certification for healthcare providers. For certification that expire beginning [DATE] until the COVID-19 public health emergency expires: a. efforts will be made to obtain recertification in a manner that adheres to social distancing mandates. b. If a recertification course cannot be provided, a remediation course will be provided as soon as practicable, no later than 120 days beyond the renewal date. 4. Staff will don appropriate PPE (personal protective equipment) prior to (with emphasis) initiation of CPR: eye protection, N95 respirators (preferred), gloves, and gowns. Four sets of PPE will be placed on each crash cart. 5. A clear, plastic barrier will be placed over the resident's face to limit aerosolization during chest compressions until appropriate bag-mask device with filter and tight seal is obtained for rescue breathing. a. A clear, plastic barrier will be placed on each crash cart. b. On COVID-19 designated units, a clear plastic barrier will be placed in a Ziploc bag and secured over the resident's bed for easy access. 6. The number of people in the room will be limited to essential personnel (i.e. those with active duties such as compressions, airway management, and AED management. Each person in the room must wear appropriate PPE. All other essential staff (i.e. runners, scribe) shall remain in the hall at the doorway. 7. The crash cart shall remain in the hall at the doorway. The AED (if applicable) shall be brought into the room and placed on the resident's bedside table facing the doorway so other essential staff can view. The algorithm attached to the policy provided steps for BLS Healthcare Provider Adult Cardiac Algorithm for suspected or confirmed COVID-19 patients. Review of the algorithm indicates to verify scene safety, don PPE, limit personnel. If victim is unresponsive shout for nearby help. Activate emergency response system via mobile device (if appropriate). Get AED and emergency equipment (or send someone to do so) Look for no breathing or only grasping and check pulse (simultaneously). Is pulse definitely felt within 10 seconds? If normal breathing, has pulse monitor until emergency responders arrive. If no normal breathing, has pulse provide rescue breathing using bag-mask device with filter and tight seal. 1 breath every ,d+[DATE] seconds, or about ,d+[DATE] breaths/min. Activate emergency response system (if not already done) after 2 minutes. Continue rescue breathing: check pulse about every 2 minutes. If no pulse, begin CPR (go to CPR box). If possible opioid overdose administer [MEDICATION(S)] if available per protocol. CPR: begin cycles of 30 compressions and 2 breaths using bag-mask device with filter and tight seal or continuous compressions with passive oxygenation using face mask. Use AED as soon as it is available. AED arrives. Check rhythm. Shockable rhythm? Yes, shockable give 1 shock. Resume CPR immediately for about 2 minutes (until prompted by AED to allow rhythm checks). Continue until ALS providers take over or victim starts to move. If shockable rhythm is no resume CPR immediately for about 2 minutes (until prompted by AED to allow rhythm check). Continue until ALS providers take over or victim starts to move. R13 was admitted to the facility on [DATE] with Advance Directives previously developed on [DATE]. R13's power of attorney for healthcare signed a facility DNR/CPR Instruction/Consent form on [DATE] indicating Full Code status for R13: Cardio-pulmonary resuscitative measures will be instituted in the event of cardiac and/or pulmonary arrest. Surveyor noted the form was signed by a facility representative on [DATE]. Review of the progress notes dated [DATE] at 8:30 PM indicated R13 had no pulse and was not breathing. There is no indication in the progress notes CPR was attempted or that emergency personal were contacted. Surveyor noted the next progress note entry is on [DATE] at 6:47 AM indicating R13's family was called and provided a funeral home. On [DATE] the state agency received a facility self report/investigation into the code situation regarding R13 after surveyors expressed concern to the facility regarding a lack of reporting and investigating for possible neglect to R13 (cross-reference F609/F610). Review of the summary indicates R13 is a 79 y/o (year old) female who was admitted to our home on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her daughter-in-law and activated power of attorney for healthcare (name of) signed CPR instructions for Full Code on [DATE] .At 8:30 pm on [DATE] (R13) was found unresponsive by (CNA-AA). Her assigned nurse (LPN-R) was notified of the findings and immediately responded to resident's room. She observed her resident pulseless/breathless and did not initiate CPR, did not call a code and did not notify emergency services. She casually obtained an assessment from (RN-S) to confirm the resident was deceased . This neglect was discovered the following morning by (DON-B) Director of Nursing . The facility timeline of the incident indicates: 1700: (CNA-AA) and (CNA-BB) enter resident's room to drop of (sic) her dinner tray. At this time the resident appears to be in normal condition. 1800: (CNA-AA and CNA-BB) enter resident's room to pick up her dinner tray. At this time the resident appeared in normal condition. (CNA-AA) asked resident if she was finished with her meal and she replied by nodding her head yes. 2030: (CNA-AA) enters resident's room to perform HS (at night) cares and discovers resident unresponsive with a deceased appearance. She calls out to (CNA-BB) who was in the hallway donning her PPE and tells her to get the nurse quickly. The resident's nurse (LPN-R) responded immediately. Upon entering the resident's room, she was seen placing her stethoscope over her ears and listened to the resident's chest. (LPN-R) then wheels the resident out of her room into the activity room at the end of the hall. 2040: (LPN-R) goes to A wing and asks (RN-S) to verify that her resident is expired. Both nurses walk back over to C-wing and (RN-S) listens to the resident's chest for 1 minute without hearing any heartbeat. She then listens to her back for 1 minute and does not hear any lung sounds. She notes that there are no subjective or objective signs of life. The summary indicates times are approximate based upon witness statements provided by (CNA-AA, CNA-BB and RN-S). The summary indicates LPN-R has not returned call to facility for follow up . An undated statement by LPN-R indicates the aids (sic) had been in her room about 6:30 to remove her dinner tray. She ate 100% of her meal. At about 8:00 pm, LPN-R was notified the resident was not breathing. LPN-R went to the room to assess the resident and found her to be without breath sounds or a heartbeat. LPN-R indicated she called the charge nurse (RN-S) to the room to verify that the resident had expired. LPN-R indicated she called the DON on call to let her know that she could not get in touch with either the POA or 2nd emergency contact. LPN-R indicates she contacted the physician at 8:35 pm. The statement includes when asked by the DON why (R13's) [NAME] status wasn't checked and CPR was not started (LPN-R) replied she was already dead. Surveyor noted upon review of LPN-R's statement it does not include the detail that LPN-R wheeled R13 to an activity room or walked to a different unit, leaving R13 unattended to get RN-S. On [DATE] at 3:15 PM Surveyor spoke with LPN-R. LPN-R indicated the Aides told me to look at R13. LPN-R indicated she looked at R13 and checked all their pulses and did not feel any. LPN-R indicated they notified the Supervisor, RN-S, and told them R13 had no pulse. LPN-R indicated the RN should do the assessment and direct what happens next. LPN-R did not know R13's code status and felt the RN would do that. LPN-R verified she is CPR certified and continued to express that the RN needed to assess first before she started CPR. A statement dated [DATE] at 10:17 am from RN-S indicates: (LPN-R) came to get me on A-wing where I was working around 8:40 pm on [DATE] and asked me to verify that her resident was expired. RN-s indicated they walked over to C-wing where RN-S found her resident (R13) sitting in a wheelchair at the end of a hallway in the activity room. She had no signs of life whatsoever, but RN-S listened to her heart sounds for a minute and did not hear any. I then listened to her lung sounds for 1 minute and did not hear any. RN-S indicates she did not ask about code status because no code was called and the nurse casually walked over to get me simply to verify that the resident had passed. On [DATE] at 2:24 PM Surveyor spoke with RN-S (Registered Nurse) who assessed R13 on [DATE]. RN-S indicated LPN-R (Licensed Practical Nurse) called her and indicated R13 did not have a pulse. LPN-R did not mention R13's code status and RN-S assumed R13's code status was checked already. RN-S did not verify R13's code status and assessed R13 10 minutes after LPN-R notified her of R13 having no pulse. RN-S assessed R13 and verified there was no pulse or breath. RN-S did not perform CPR or call emergency personal and was unaware of R13's code status. RN-S indicated the resident's code status is in the medical records and assumed LPN-R already checked it and would have performed CPR if indicated. The facility statement from CNA-AA dated [DATE] at 9:07 am indicates: .(CNA-AA) went into her (R13's) room again around 8:30 to perform HS cares and (R13) did not appear normal. (CNA-AA) indicated they called to (CNA-BB) who was putting on PPE outside the door to get the nurse right away because (R13) appeared to be deceased . (LPN-R) came to the room within 30 seconds and listened to (R13's) chest with her stethoscope and confirmed the resident had passed away. On [DATE] at 3:27 PM Surveyor spoke with Administrator-A and DON-B (Director of Nurses) regarding the CPR concerns for R13. Administrator-A was not in the facility during this time and DON-B did not conduct an investigation surrounding this event as of this date. On [DATE] at 7:44 AM Surveyor observed the crash cart on the C-Wing and B-Wing nurses station. The Crash cart did not contain supplies to provide CPR to a resident with suspected or positive COVID-19 as indicated in the facility policy. At this time LPN-T was interviewed by Surveyor. LPN-T was not aware of any procedures for CPR or facility policy for providing CPR to a resident suspected for or positive with COVID-19. On [DATE] at 7:49 AM Surveyor observed the crash cart on the D-Wing. The crash cart did not contain supplies to provide CPR for a resident with suspected or positive COVID-19 per facility policy and procedure. At this time LPN-U was interviewed by Surveyor. LPN-U was not aware of any procedures or facility policy for providing CPR for a resident with suspected or positive COVID-19. On [DATE] at 7:53 AM Surveyor spoke with DON-B (Director of Nurses) and reviewed the CPR COVID-19 policy and procedures. Surveyor shared observation made with staff that the supplies identified in the procedures were not on the crash carts and the staff interviewed were not aware of the CPR policy and procedures for a resident with suspected or positive COVID-19. On [DATE] at 3:50 PM Surveyor shared the concerns with the process for CPR with suspected or positive COVID-19 residents. On [DATE] at 10:350a.m., Surveyor interviewed LPN- Z regarding educated to the facility's policy and procedures for providing CPR during the Covid pandemic. LPN- Z stated she is working the 1st shift on the B- wing and that she has also worked [DATE] and [DATE] and was not provided any education about providing CPR during Covid. LPN- Z stated that education would not happen over the weekend as the front office staff are not in the facility. On [DATE] at 10:50 a.m., Surveyor interviewed LPN-I regarding being educated to the facility's policy and procedures for providing CPR during the Covid pandemic. LPN-I stated that she is working 1st shift for the C-wing on this date and also worked [DATE] and [DATE]. LPN-I stated that she was not provided any formal education about the policy and procedure for CPR during Covid but a nurse did mention to her the need to use a barrier if providing CPR to a full-code resident who is Covid positive. Surveyor asked LPN-I who had provided her with that information and LPN-I stated she could not recall, maybe someone from the night shift. At this time Surveyor asked LPN-I to make an observation of the crash cart that is stored in the nurses' station. This crash cart is used for the C and D wings. LPN-I went through the items on the cart, which included the suction machine, oxygen and tubing, first-aid supplies, blood pressure cuff and stethoscope, face shields, gowns, apron, CPR mask and spill kit. Surveyor asked LPN-I what barrier would need to be used if providing CPR to a Covid- positive resident. LPN-I was not sure what the barrier would be and then took out a purple apron and stated that she believed that this would be the barrier that needs to be used in that situation. LPN-I was able to confirm that the unit she was assigned to- Unit C, currently had 3 Covid positive residents that have requested to be a full- code status. On [DATE] at 11:00 a.m., Surveyor made observations of R25's room. It was noted through record review and staff interview with LPN-I that R25 is a full code status and is currently Covid positive. Observations made showed that there was no Ziploc bag or any other type of container that help provide the barrier that was to be supplied above each resident's bed who was a full-code and Covid positive. On [DATE] at 11:40 a.m., Surveyor made observations along with DON- B of the crash cart located at the nurse's station for wings C and D and the cart located in the hallway for wings A and B. DON- B was able to show Surveyor that each cart contained 2 CPR masks otherwise known as an ambu bag that was to be used as the barrier when providing CPR during the Covid pandemic. DON- B was able to confirm that those residents who were a full-code and currently Covid positive did not have a clear plastic barrier placed in a Ziploc bad and secured over the resident's bed for easy access per the facility's policy for CPR during Covid. The facility's failure to ensure R13 received CPR in accordance with her expressed wishes and based upon current facility policy and standard of practices created a situation of immediate jeopardy. The facility removed the immediacy on [DATE] when the implemented the following steps: ~ Code status audit was completed by the Director of Social Services to determine which residents are Full Code and are potentially affected by this practice. ~ The RN and LPN involved with this situation were re-educated on the facility's CPR expectations for implementation. ~ The DON or designee will re-educate all licensed nurses on the facility's policy including updates made to the company policy in regards to the definition of respiratory barrier for initiating CPR for COVID positive residents, location of code status for each resident in the resident's chart, and activation of emergency medical personnel by dialing 911. Licensed nurses will not be permitted to work a shift until education is completed. Nurses on leave will receive education prior to their next scheduled shift. ~ The charge nurse is given the responsibility of assigning roles during a code. ~ A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted 2 times weekly for three months. Findings will be reported at monthly QAA Committee meeting. ~ DON or designee will audit new admissions to compare the resident's advance directives to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings will be reviewed at the monthly QAA Committee meeting. ~ A mock code drill and crash cart equipment check including COVID barriers will be performed with licensed nursing staff on all shift's weekly for one month and then on each shift monthly until it is determined by the IDT that substantial compliance exists. Mock codes will be conducted on each shift quarterly and as needed thereafter. Findings will be reviewed at the monthly QAA Committee meeting. ~ The DON will be immediately re-educated on the expectations and her responsibilities in relation to this removal plan. Education will be verified daily by the Administrator or Regional Nurse Consultant by checking signatures against working schedules until all licensed nursing staff have received education.

Based on observation, record review, and interview, the facility did not ensure adequate supervision was provided to prevent falls for 2 (R5 and R4) of 3 residents reviewed for falls. *R5 had eleven falls from 6/2020 to 10/2020. The fall on 6/15/2020 resulted in a fracture of the right humerus. R5's care plan was not followed at the time of the fall. The falls were not assessed and analyzed to determine the cause of the falls and the care plan was not revised with interventions to prevent future falls. *R4 fell from a mechanical lift that was operated by one Certified Nursing Assistant (CNA) and sustained a laceration to the scalp. The CNA did not follow the facility policy that states two staff members are required when operating a mechanical lift. Findings include: The facility policy and procedure entitled Accidents and Supervision dated 10/1/2009 states: Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: i. quality assessment and assurance (QAA) activities ii. environmental rounds iii. MDS/CAA data iv. medical history v. physical exam vi. facility assessment vii. individual observation e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully h. Facility-based interventions may include, but are not limited to: i. educating staff ii. repairing the device/equipment iii. Developing or revising policies and procedures i. Resident-directed approaches may include: i. implementing specific interventions as part of the plan of care ii. supervising staff and residents, etc. iii. Facility records document the implementation of these interventions 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment Example 1 R5 was admitted to the facility on [DATE] with diagnoses of dementia, [CONDITION(S)], low back pain, [CONDITION(S)], hypertension, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. R5's Cognitive Care Plan had the following intervention initiated on 5/29/2019: When I go where I probably shouldn't, please help me by taking me by the hand and leading me into another part of my living space that offers me activities that may engage me. The following interventions were added on 6/18/2019: -I understand the word 'STOP'. Placing a stop sign on doors that are not safe for me to use will help me to know to go somewhere else. -If I'm pacing/wandering throughout my living space, I may be looking for a bathroom. Quietly ask me if you could help me get to my bathroom. R5's Physical Functioning Deficit Care Plan had transfer assistance of supervision initiated on 5/29/2019 and revised to transfer assistance of one on 6/18/2019. Interventions initiated on 6/14/2019 included assistive device of wheelchair and walker and locomotion assistance of supervision. R5's Wandering/Elopement Care Plan was initiated on 1/24/2020. R5 had a pattern of wandering on the secured unit. An intervention initiated on 1/24/2020 was to redirect R5 from doors. F5's Falls Care Plan was initiated on 5/29/2019 with the following interventions: -assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, and anti-tippers. -have call light and personal items available and in easy reach. -clear and monitor environmental obstacles. -encourage participation in activities to improve strength or balance. -encourage rest periods if feeling fatigued. -footwear to prevent slipping. -keep environment well lit and free of clutter. F5's Falls Care Plan was revised on 6/18/2019 with the following interventions: observe for side effects of medication and update physician, and therapy referral as ordered and as needed. F5's Falls Care Plan was revised on 9/12/2019 with the following intervention: stand-by assist when R5 is ambulating. R5 ambulates behind the wheelchair and is not easily redirected related to dementia. R5 is unaware of safety needs. On 5/30/2020 at 8:34 PM in the progress notes, nursing charted R5 was walking behind the wheelchair up and down the hallways and was alert and oriented. On 5/31/2020 at 10:37 AM in the progress notes, nursing charted R5 was sitting up in the wheelchair and was repositioned every two hours. A decrease in weakness and fatigue was noted. R5 ambulated throughout the unit holding onto the wheelchair with a slow but steady gait. On 6/6/2020 at 7:53 PM in the progress notes, nursing charted R5 was found sitting on the floor next to the recliner near the nurses' station with the back against the recliner and the head on the recliner. R5 had gripper socks on and was assessed with no injuries. R5 was assisted to the recliner and was observed pushing off the recliner to a standing position and used the wheelchair for stability to walk down the hallway unassisted with a slow, steady, even gait. R5's care plan indicated R5 should have had stand-by assist when ambulating. No documentation was found of an interdisciplinary team (IDT) meeting to review the fall on 6/6/2020. R5's care plan was not revised. On 6/8/2020 at 7:35 PM in the progress notes, nursing charted R5 was walking in the hallways. On 6/9/2020 at 10:45 AM in the progress notes, nursing charted R5 was ambulating throughout the unit holding onto the wheelchair with safety cues and reminders given. On 6/15/2020 at 11:57 PM in the progress notes, nursing charted R5 was found on the floor in another resident's room. R5 sustained an injury to the right elbow area where the lateral side had a hard area sticking out a little further than the left side. R5 guarded the area as it was painful. The physician was notified and R5 was sent to the emergency room for evaluation and treatment. On 6/16/2020 at 3:33 AM in the progress notes, nursing charted R5 was admitted to the hospital for a right arm fracture. An investigation of the fall was conducted by the facility at that time. The facility investigation summary dated 6/16/2020 stated R5 had a history of wandering throughout the secured wing of the facility and has impaired safety awareness related the advanced dementia. The summary stated R5 experienced falls on 4 occasions since admission, but none since 11/25/2019. (R5 had fallen on 6/6/2020.) The summary stated: Staff had last seen (R5) walking in the halls prior to (R5's) fall, which is normal activity for (R5). (R5's) nurse was at the nurses' station and (R5's) CNA (Certified Nursing Assistant) was coming out of another resident's room when she found (R5) on the floor. No other staff were on the unit at the time of the incident. (R5) appears to have been taken care of according to (R5's) plan of care. (R5's care plan indicated R5 should have had stand-by assist when ambulating.) The facility fall investigation form indicated an IDT met on 6/16/2020. R5 had a history of wandering around on the unit and uses a wheelchair as a walker for support during ambulation. R5 ambulated independently and steadily with support of the wheelchair. Therapy had worked with R5 in the past to attempt to get R5 compliant with the use of a walker or cane, but R5 refused. No direct cause of fall was discussed or interventions were documented on the facility fall investigation form to prevent future falls. R5's care plan was not revised. On 6/19/2020, R5 was readmitted to the facility with a splint to the right arm. On 6/22/2020 at 11:44 AM in the progress notes, nursing charted R5 was impulsive and would get up from bed or wheelchair without asking for help. On 6/23/2020 at 1:27 PM in the progress notes, nursing charted R5 was assist of one with activities of daily living including stand and pivot transfers from the bed to the wheelchair. On 6/27/2020 at 11:42 AM in the progress notes, nursing charted R5 was assist of one with activities of daily living including stand and pivot transfers from the bed to the wheelchair. R5 was redirected back to the wheelchair when R5 got up and started to walk. On 6/27/2020 at 6:51 PM in the progress notes, nursing charted R5 was observed walking in the hallway holding onto rails and was redirected by staff. On 6/27/2020 at 9:40 PM in the progress notes, nursing charted R5 was found on the floor in the hallway. No documentation was found in R5's medical record that an IDT met to review the fall on 6/27/2020. R5's care plan was not revised. On 7/2/2020 at 7:34 AM in the progress notes, the weekly management meeting documented R5's therapy status. R5 was receiving therapy and indicated R5's functional status for ambulation and transfers was moderate assistance. On 7/5/2020 at 12:17 AM in the progress notes, nursing charted R5 was found on the floor in R5's room and sustained a skin tear to the left elbow. No documentation was found in R5's medical record that an IDT met to review the fall on 7/5/2020. R5's care plan was not revised. On 7/9/2020 at 7:34 AM in the progress notes, the weekly management meeting documented R5's therapy status. R5 was receiving therapy and indicated R5's functional status for ambulation and transfers was minimal assistance. On 7/19/2020 at 7:41 PM in the progress notes, nursing charted R5 was observed by the nurse to fall back into a sitting position to the floor near R5's room. R5 was ambulating without assistance or without using wall handrail to walk and lost balance. No injuries were sustained with the fall. On 7/21/2020 at 12:17 PM in the progress notes, nursing charted R5's fall on 7/19/2020 was reviewed by the IDT and R5's care plan was updated. (The progress note did not document what was updated in the care plan.) R5's care plan was not revised. On 9/12/2020 at 4:47 PM in the progress notes, nursing charted R5 was found lying on the floor. No injuries were noted. The Fall Investigation form indicated an IDT met on 9/15/2020 to review the fall on 9/12/2020. A new intervention was for staff to re-approach R5 as needed to assist with cares. R5's care plan was not revised. On 9/24/2020 at 8:04 PM in the progress notes, nursing charted R5 fell in the hallway while ambulating. No injuries were noted. The Fall Investigation form indicated R5 had been observed standing behind the wheelchair holding onto the back while talking to another resident. R5 had an unwitnessed fall and was found lying on R5's back with wheelchair on top of R5. The IDT met on 9/30/2020, six days after the fall, and determined anti-tippers were needed for R5's wheelchair. F5's Falls Care Plan was revised on 10/14/2020 with the following intervention: rear anti-tippers to wheelchair. (This intervention was added three weeks after the fall and two weeks after the IDT determined this was an appropriate intervention to prevent future falls.) On 10/1/2020 at 8:02 PM in the progress notes, nursing charted R5 fell unwitnessed in the hallway. R5 was not walking with the wheelchair as an assistive device. No injuries were noted at that time. The Fall Investigation form indicated the IDT met on 10/2/2020 to review the fall on 10/1/2020. The IDT determined R5 was walking with no assistive devices and usually ambulates while holding onto the wheelchair. The IDT documented no further interventions were indicated as the current care plan had been followed. R5's care plan was not revised. On 10/4/2020 at 10:09 PM in the progress notes, nursing charted R5 was found on the floor in another resident's room. No injuries were noted at that time. The Fall Investigation form indicated the IDT met on 10/5/2020 to review the fall on 10/4/2020. The IDT recommended staff were to monitor R5 for signs of fatigue and assist to lay down in bed. F5's Falls Care Plan was revised on 10/5/2020 with the following intervention: Staff to monitor R5 for fatigue and assist to lay in bed. (This intervention had been in R5's Falls Care Plan on 5/29/2019 and assisting R5 to lay in bed was added to the intervention.) On 10/15/2020 at 10:21 PM in the progress notes, nursing charted R5 was observed lying on the right side next to the bed. R5 had been ambulating without assistance and lost balance. No injuries were noted at that time. The Fall Investigation form indicated the IDT met on 10/16/2020 to review the fall on 10/15/2020. The IDT determined no new interventions were needed at that time. F5's Falls Care Plan was revised on 10/16/2020 by removing stand-by assist when R5 is ambulating from the care plan. No new interventions were added to R5's care plan. R5 had conflicting documentation on 10/27/2020 and 10/28/2020 regarding a fall or falls that occurred on those dates: On 10/27/2020 at 8:09 PM in the progress notes, a late entry documented R5 had a fall on 10/27/2020 at 10:00 PM that occurred while R5 was attempting to self-toilet. The fall was unwitnessed. On 10/27/2020 at 9:09 PM in the progress notes, a late entry documented R5 had a fall on 10/27/2020 at 8:09 PM that occurred while R5 was attempting to self-toilet. The fall was unwitnessed. On 10/28/2020 at 7:44 AM in the progress notes, nursing charted R5 was found lying on the floor on the back in R5's room. R5's brief was wet with urine. The Post Fall Evaluation Form stated the effective date and time of the fall was 10/27/2020 at 8:09 PM while the details section of the form states the date and time of the fall was 10/27/2020 at 10:00 PM. In an interview on 12/9/2020 at 1:45 PM, Surveyor shared with Director of Nursing (DON)-B the charting on 10/27/2020 and 10/28/2020 with conflicting times and dates. DON-B agreed it was very confusing and was unable to clarify when the fall or falls actually occurred. The Fall Investigation form indicated the IDT met on 10/28/2020 to review R5's fall on 10/27/2020. No recommendations were made to revise the care plan. R5's care plan was not revised. F5's Falls Care Plan was revised on 11/17/2020 with the following intervention: bed in low position with mat on the floor when R5 is in bed. In an interview on 12/9/2020 at 1:35 PM, Surveyor asked Registered Nurse (RN)-F who updated the care plan on 11/17/2020 with the intervention of a low bed and fall mat. RN-F stated she had updated the care plan after doing a quarterly assessment and reviewing R5's falls and interventions from the previous quarter. On 12/8/2020 at 12:00 Noon, Surveyor observed lunch being brought to R5 in R5's room. R5 was sitting on the edge of the bed. Certified Nursing Assistant (CNA)-C assisted R5 by cutting up the food on the plate. CNA-C stated R5 walks with the wheelchair and only needs supervision because R5 doesn't need any help. CNA-C stated R5 gets up independently. CNA-C was not aware R5 has had any falls. CNA-C was observed to help R5 transfer from the bed to the wheelchair with directed assistance. In an interview on 12/8/2020 at 2:30 PM, CNA-D stated she was taking care of R5 on 6/15/2020 when R5 fell in another resident's room and sustained a broken arm. CNA-D stated CNA-D had put R5 to bed at about 8:30 PM and around 9:15 PM, CNA-D came out of another resident's room, walked past R5's room and saw R5 was not in the room. CNA-D noticed another resident's door was halfway closed and found R5 on the floor just behind the door. CNA-D went and got the nurse to assess R5. CNA-D stated R5 pushes the wheelchair when walking, but sometimes walks without anything. R5 did not have the wheelchair at the time of the fall. In an interview on 12/9/2020 at 10:00 AM, Nursing Home Administrator (NHA)-A stated staff were following R5's care plan on 6/15/2020. NHA-A stated R5 walks around the unit and it would decrease R5's quality of life if R5 was told to sit down all the time. NHA-A stated R5's care plan has that R5 doesn't listen to directions. On 12/9/2020 at 1:00 PM, Surveyor observed R5 sitting on the edge of the bed in R5's room with the wheelchair in front of R5. The wheelchair had anti-tippers on the back of the chair. In an interview on 12/9/2020 at 1:05 PM, Licensed Practical Nurse (LPN)-E stated when a resident falls, the floor nurse completes the fall assessments in the computer. Surveyor asked who comprised the IDT for falls. LPN-E didn't know if there was an IDT. Surveyor asked who updates care plans with new fall interventions. LPN-E stated Registered Nurses (RNs) update the care plans, maybe, but wasn't really sure. LPN-E stated she doesn't do anything with care plans. LPN-E stated the Unit Manager probably updates the care plans, but the Unit Manager was not in the building. LPN-E stated the MDS (minimum data set) nurse may update the care plans, but wasn't sure. In an interview on 12/9/2020 at 1:35 PM, RN-F stated she does MDS assessments. RN-F stated falls are reviewed at morning meetings with the NHA, the DON, Assistant DON (ADON), Unit Manager, therapy, MDS, and dietary. Surveyor asked who documents the IDT meeting in the resident's record. RN-F stated the Unit Manager does, but right now it would be the DON or ADON because the unit manager is out of the building. Surveyor asked who updates the care plan after a fall. RN-F stated the Unit Manager does, but right now it would be the DON or ADON. RN-F stated care plan interventions are on the care cards at the nurses' station and are printed daily if not more often with updates. RN-F stated the nurses and CNAs are responsible for looking at the care cards when they start their shift. RN-F stated MDS reviews care plans quarterly, annually, and with significant changes. Surveyor discussed the multiple falls R5 had sustained with the care plan not being updated. RN-F did not know why they were not revised after a fall, but said the DON would know the answer to the question. In an interview on 12/9/2020 at 1:45 PM, DON-B stated when there is a fall, the nurses on the floor do the assessments and the fall is reviewed the next day. The unit manager will put the IDT note in the resident's record and update the care plan. Surveyor reviewed the eleven falls R5 has had since 6/2020. DON-B stated they have tried everything and can't come up with any other interventions. DON-B stated the facility has new management and so doesn't know who would have put IDT notes in the record. DON-B agreed the care plan should have been revised, especially after the fall on 6/15/2020 where R5 sustained a fracture. Surveyor showed DON-B the fall that happened on 9/24/2020, the IDT met on 9/30/2020, and the anti-tippers weren't on the care plan until 10/14/2020. DON-B agreed that was a lot of time between the fall and the intervention was in place, and R5 had two more falls after that before the anti-tippers were put on. DON-B stated R5's fall on 9/24/2020 was what prompted them to get anti-tippers on the wheelchair, but there weren't any in the building and had to be ordered. On 12/9/2020 at 3:14 PM, Surveyor shared concerns with NHA-A and DON-B regarding R5's eleven falls with no analysis of each fall and care plan revisions to prevent future falls. The fall R5 sustained on 6/15/2020 resulted in a humerus fracture and hospitalization . R5's fall on 9/24/2020 was reviewed by the IDT on 9/30/2020, six days after the fall with the recommendation of installing anti-tippers on the wheelchair. The anti-tippers were not implemented until 10/14/2020, twenty days after the fall. No further information was provided at that time. On 12/11/2020, NHA-A provided information regarding each fall as described above. Therapy recommendations include maximum assistance for transfers and ambulation on 5/19/2020, stand-by assistance or supervision with transfers and ambulation on 6/10/2020, would benefit from close supervision on 7/20/2020, R5 required physical and cognitive assistance due to significant cognitive impairment on 8/13/2020, R5 is unsafe to transfer and amb (ambulate), but continues to complete due to (decreased) safety awareness and dementia. Recommend nursing to cue/redirect on 9/25/2020, and recommended occupational therapy on 10/30/2020. These recommendations of increased supervision were not implemented in R5's care plan. Example 2 *The policy and procedure entitled Mechanical Lift Transfer dated 10/1/2019 provides step by step instruction on how to apply the sling and mechanical lift to transfer a resident from a bed to a chair. The policy states: 19. The other nursing assistant should hold the sling back in the hip area and help lower the resident slowly into position in the chair while you slowly release the hydraulic and lower the lift. 23. Reverse the procedure to return the resident to bed. The policy indicates two staff members are needed to transfer a resident. R4 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)] after suffering a stroke, and dysphagia. R4 required a mechanical lift for transfers from the bed to a wheelchair and back. R4's care plan initiated 2/15/2020 indicated R4 transferred with assist of two and a Hoyer lift. R4 was discharged from the facility on 11/18/2020 and is not currently a resident at the facility. On 4/6/2020 at 7:44 PM in the progress notes, nursing charted R4 had a fall after being transferred to bed. R4 was sitting at the side of the bed and tipped forward hitting the forehead on the wall causing a 3 cm laceration and hematoma to the left forehead. The fall was witnessed by staff. The laceration was cleaned and a pressure dressing was applied. R4 was sent to the emergency room for evaluation and treatment. R4 did not require any medical treatment at the hospital. The facility investigated the fall and determined R4 was transferred using a mechanical lift by a Certified Nursing Assistant (CNA) without the assistance of another staff member as R4's care plan and facility policy required. The statement made by the CNA who transferred R4 stated the CNA was in the process of laying R4 down, and when the CNA moved R4's bedside table to make room, R4 was falling face first on the side wall by the bed. The CNA was no longer employed by the facility and was not available for interview. The nurse that responded to R4's fall is no longer employed by the facility and was not available for interview. In an interview on 12/8/2020 at 1:45 PM, Director of Nursing (DON)-B stated the CNA was not following R4's care plan on 4/6/2020; R4 was transferred by one CNA instead of two staff members when using a mechanical lift. No further information was provided at that time.

Based on interviews and record review, the facility did not ensure that 1 (R3) of 1 residents reviewed received food that accommodated the resident's allergies. * R3, who is allergic to fish, received fish to eat causing her to have an allergic reaction requiring the administration of [MEDICATION NAME] and [MEDICATION NAME]. The dietary manager, who cooked and plated the food did not remember that R3 was allergic to fish. The dietary aide who checks meals at the end of the tray line did not know R3 was allergic to fish. The certified nursing assistant (CNA) who served the meal to R3 was not aware R3 was allergic to fish because there was no tray card on the tray. As a result, the facility served food to which R3 has a severe allergy. R3 was sent to the emergency room as a result of the allergic reaction that caused her mouth to swell, potentially causing a harmful and or life threatening condition for R3. The facility failure to provide food that accommodated the resident's fish allergy created a finding of immediate jeopardy that began on 9/17/19. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on 10/28/19 at 2:22 p.m. The immediate jeopardy was removed on 10/21/19. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its plan of correction. Findings include: 1.) R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Quarterly MDS (Minimum Data Set) dated 8/23/19 documents short and long term memory problems for Resident and states that Resident has severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that Resident requires limited assistance and one person physical assist for her eating needs. R3's Hospital Discharge documentation dated 5/24/19 documents, Allergies to Fish- Reaction Swelling, Nuts and Wheat with unknown reactions. R3's Allergy Report dated 5/24/19 and completed by MDS RN (Registered Nurse)-J documents, Allergen: Fish; Reaction Type: [MEDICATION NAME]- Laryngeal [MEDICAL CONDITION]; Reaction Note: Serious allergy to fish; Severity: Severe; Date: 5/24/19. R3's Nutritional CAA (Care Area Assessment) dated 5/31/19 documents under the Care Plan Considerations section, [DEVICE] (Gastrointestinal Tube)/enteral feeding; Food allergies-Fish, wheat, nuts, gluten, Plan-RD (Registered Dietician) will continue to monitor tolerance to tube feeding weekly. Surveyor noted that when R3 was admitted to the facility, R3 originally received enteral feeding for her nutritional needs. R3's diet changed on 7/1/19 when a physician order dated 7/1/19 documented, Regular diet; Regular texture; Regular (thin) consistency, No wheat, barley, rye or foods containing gluten, nuts, fish. A review of R3's physician orders did not include an order for [REDACTED]. R3's nursing note dated 9/17/19 documents, Resident ate fish had allergic reaction, mouth started swelling. NP (Nurse Practitioner) updated, new order received for [MEDICATION NAME] 25 mg (milligrams) 2 tab (tablets) stat (immediately) and [MEDICATION NAME] 1 mg/ml (milliliter) stat and to send resident to hospital for evaluation. All Meds (medications) given as ordered at 2000 (8 PM) resident was sent to Aurora hospital for evaluation. Brother emergency contact updated. ADON (Assistant Director of Nursing) aware. R3's SBAR (Situation, Background, Assessment, Recommendation) dated 9/17/19 documents, Situation: Allergy reactions which started on 9/17/19; Background: Medication changes made in past week: none; Assessment: BP (Blood Pressure) 118/75; P (pulse) 68; R (respirations) 16; T (temperature) 96.6 (degrees Fahrenheit); O2 (oxygen) 98%; Respiratory changes: Other respiratory changes observed (no description given); Recommendation: Send to hospital for Evaluation. R3's Hospital Discharge Summary dated 9/17/19 documents, ED (Emergency Department) Notes: 47 F (female) Possible allergic reaction 1mg subcutaneous Epi ([MEDICATION NAME]) given and [MEDICATION NAME]; P (pulse) 90, BP (blood pressure) 133/95, R (respiratory) 18, 98% SPO2 (Peripheral Capillary Oxygen Saturation) Medication Administration: [MEDICATION NAME] tablet 60 mg (milligrams), [MEDICATION NAME] Tablet 40 mg; Final Diagnosis: [REDACTED].>Per R3's nursing notes, R3 returned to the facility from the emergency roiagnom on [DATE] and did not require further treatment and or hospitalization . On 10/28/19 at 10:11 a.m., Surveyor interviewed Dietary Manager-G regarding the above incident involving R3. Surveyor asked Dietary Manager-G to describe what led to R3 receiving fish, a known allergy for R3, for the dinner meal on 9/17/19. Dietary Manager-G informed and confirmed to Surveyor that for dinner on 9/17/19, he (Dietary Manager-G) was forced to cook and serve the meal service due to short staffing. Dietary Manager-G informed Surveyor that on that day he asked Dietary Aide-I to let him know when R3's plate was to be served so he could serve R3 non-breaded tilapia as he was aware R3 had allergies to gluten. Dietary Manager-G informed Surveyor that although he remember R3's gluten allergy, he still served R3 tilapia (fish) because he simply forgot that R3 was also allergic to fish. Dietary Manager-G informed Surveyor that his mistake of serving fish to R3 should have been caught by Dietary Aide-I whom was reviewing and checking meal trays at the end of the tray line, however due to Dietary Aide-I being new to the position, Dietary Aide-I did not catch the fact that R3 was not to be served fish due to R3's allergy before sending R3's tray out for R3 to eat. On 10/28/19 at 12:58 p.m., Surveyor asked DON (Director of Nursing)-B if was the facility's expectation for CNA (Certified Nursing Assistant) staff to check resident's trays for food preferences, allergies and accuracy before delivering food plates and trays to residents. DON-B informed Surveyor that CNAs are expected to check resident's trays for food preferences, allergies and accuracy before delivering food plates and trays to residents. DON-B informed Surveyor that while she was working at the facility on 9/18/19, she could provide no additional information to Surveyor regarding R3's incident on 9/17/19. On 10/28/19 at 1:49 p.m., Surveyor interviewed CNA-H, whom passed out R3's meal tray on 9/17/19 during the meal dinner meal service. Surveyor asked CNA-H if she had reviewed R3's meal tray card to ensure that R3 was served a meal that accommodated R3's allergies. CNA-H informed Surveyor that she did not review R3's meal tray card before serving R3 fish to eat, as per CNA-H, there was no meal tray card on R3's tray when she served R3 fish on 9/17/19. CNA-H informed Surveyor that she fed R3 a piece of fish but that R3 spit it out of her mouth. CNA-H informed Surveyor that she usually does not pass out meal trays as she usually works the night shift. The facility's failure to provide food that accommodated the resident's fish allergy created a finding of Immediate Jeopardy. The Food Allergy Research & Education (FARE) notes, Finned fish can cause severe and potentially life-threatening allergic reactions (such as [MEDICATION NAME]). Allergic reactions can be unpredictable, and even very small amounts of fish can cause one. https://www.foodallergy.org/common-allergens/fish-allergy The facility removed the jeopardy on 10/21/19, when it had completed the following, which it had indicated it would do when the facility submitted a self-report concerning this incident to the state agency on 9/18/19: 1. The facility ensured that allergies are highlighted in red on the diet tickets, tickers always will be printed in color. 2. All trays will be double checked before leaving the kitchen. 3. The Dietary Manager will communicate staffing issues to NHA to provide adequate coverage 4. Allergies are to be called out to server before plating. 5. The dietician printed a report on all in-house residents with food allergies. 6. A review of nutritional data assessment identified that food allergies are not asked about but will be included in future assessments. 7. All residents in-house or their responsible party were asked about food allergies. 8. R3's allergy listing was updated to reflect the severity of her reactions to these allergens. 9. Contingency medications of [MEDICATION NAME] and [MEDICATION NAME] were replenished. 1O. A PRN (as needed) order was obtained for R3 for the [MEDICATION NAME] and [MEDICATION NAME]. 11. Dietary and nursing staff educated on the importance of the reading the tickets and using extreme caution to avoid any foods listed as an allergy. 12. NHA spoke with residents brother who is her POA to review the event and to let him know all the of the faucets of our plan to prevent such an occurrence in the future 13. Audits were completed to ensure compliance. On 10/28/19 at 12:37 p.m., Surveyor interviewed Dietician-K regarding the completion of audits as documented in the facility's self-report dated 9/18/19. Surveyor asked Dietician-K when she (Dietician-K) began to complete dietary audits and compile a list of resident allergies as documented in the facility's self-report dated 9/18/19. Dietician-K informed Surveyor that she began to complete dietary audits and compile a list of resident allergies as documented in the facility's self-report on 10/21/19. On 10/28/19 at 12:47 p.m., Surveyor informed Administrator-A of the above findings. Administrator-A informed Surveyor that he had just recently arrived at the facility and that he had become aware of the above incident on 10/21/19. Administrator-A informed Surveyor that after he became aware on 10/21/19, facility staff begun to take the steps as documented in the facility's self-report dated 9/18/19 to ensure the facility was back in compliance. Administrator-A informed Surveyor that since he was not working at the facility on 9/18/19, he could provide no additional information regarding R3's incident on 9/17/19.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 1(R1) of 2 sampled Residents. R1 was identified with a Stage 4 pressure injury on her left ischium on 5/23/18 and a Stage 2 on 6/29/18 on her coccyx which Wound Physician-N documented was a Stage 3 on 7/10/18. The facility failed to do ongoing assessments and documentation of the areas where treatments and preventative dressings were applied, failed to remove the dressing and observe the skin condition on 5/18/18, and failed to update and revise the care plan when changes occurred in the size or staging of R1's pressure injuries. The Facility's failure to provide the necessary care and services to R1 created a finding of Immediate Jeopardy beginning on 5/23/18. Interim Administrator-A and Interim DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 9/27/17 at 1:49 p.m. The Immediate Jeopardy was removed on 10/8/18 when the Facility implemented an action plan related to proper pressure injury care. The deficient practice continues at scope/severity of D (potential for harm/isolated) as the facility continues to implement its removal plan. Findings include: The Skin Integrity policy and procedure with a creation date of 2/13/18 and an effective date of 3/1/18 under policy statement documents, Residents will have their skin integrity evaluated upon admission and weekly. Risk assessments will be performed and care plans developed to reduce risk or address skin integrity or wound concerns using an interdisciplinary approach. Under process documents; 1. Residents will have skin integrity review completed upon admission, weekly, before a transfer or discharge to another setting (unless emergent nature of the transfer does not allow) and as necessitated by a change in condition. 2. CNAs (Certified Nursing Assistant) will monitor the resident's skin integrity during daily care and report changes to the licensed nurse. 3. A standardized pressure ulcer/injury risk assessment will be performed upon admission, weekly for 4 weeks, monthly and additionally as needed. 4. If a resident is identified as being at risk for skin breakdown or has a skin integrity/wound issue, a care plan will be developed that is individualized for the resident. The interdisciplinary team will review the care plan, interventions and make additions/revise as indicated. 5. The physician/practitioner will be kept informed of skin or wound issues. 6. Licensed nurses will implement any physician/practitioner orders related to skin or wound care. R1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The pressure ulcer actual or at risk care plan not dated under focus documents, Refuses to wear heel boots. Refuses to lay down at times and has the following interventions; Complete Braden Scale per Living Center Policy initiated 8/11/16 Do not massage over bony prominence initiated 8/11/16 Float heel initiated 8/11/16 Monitor skin daily with cares and weekly with showers and body assessments. Report any new open areas or areas of redness, rashes, blisters, bruises, abrasions, skin tears, etc. initiated 8/11/16 Nutritional and hydration support as needed initiated 8/11/16 Provide pressure reducing wheelchair cushion initiated 8/11/16 Provide pressure relieving mattress initiated 8/11/16 Provide thorough skin care after incontinent episodes and apply barrier cream initiated 8/11/16 Treatments as ordered initiated 8/11/16 Turning and repositioning every 2-3 hrs (hours) initiated 8/11/16 Weekly wound assessment initiated 8/11/16 Discuss risk vs benefits of heel boots and laying down initiated 11/2/17 Encourage resident to lay down after meals initiated 11/2/17 Bed rest until wound is healed enough initiated 5/23/18 & revised on 6/15/18 and Provide Supper (super) absorbent briefs initiated 5/28/18. Surveyor noted multiple other care plans addressing other issues but noted there was no care plan that identified refusal of care as a problem or how to approach refusal of care. The Braden assessment dated [DATE] has a score of 14, which indicates moderate risk. Review of the (MONTH) (YEAR) TAR (Treatment Administration Record) & (MONTH) (YEAR) TAR until the Stage 4 pressure injury is discovered indicates, Left buttocks open area cleanse with normal saline, skin prep periwound apply Allevyn life every Monday & Friday & prn (as needed) in evening and apply Allevyn life to coccyx for protection and change every Monday and Friday. Surveyor noted the TAR is initialed indicating the treatment was completed but does not document the status of the area where the treatment is being applied. The weekly skin review dated 4/3/18 under site documents, left buttocks and under description documents treatment area. There is a physician progress notes [REDACTED]. This note does not address a pressure injury. Surveyor did not locate evidence R1 had a pressure injury on this date. The weekly skin review dated 4/6/18 under site documents, left gluteal fold and is blank for description. The weekly skin review dated 4/10/18 under site documents, left gluteal fold and is blank for description. The weekly skin review dated 4/17/18 has skin intact checked. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/24/18 documents R1 is at risk for developing pressure injuries and is coded as not having any pressure injuries. Under the section skin & ulcer treatments pressure reducing device for chair, pressure reducing device for bed, application of non surgical dressings (with or without topical medications) other than to feet, and applications of ointments/medications other than to feet are checked. The weekly skin review dated 5/1/18 under site documents coccyx & left gluteal fold and under description documents treatment area. The weekly skin review dated 5/4/18 has skin intact checked. The weekly skin review dated 5/8/18 has skin intact checked. The nurses note dated 5/9/18 documents, Resident noted with a desirable significant weight gain in 90 days Eats 50-75% of all meals and 75-100% of supplements. Call placed to NP (Nurse Practitioner)-K updated on weighty (weight) gain, continue to work with dietician. Call placed to daughter-L, updated on desirable weight gain, daughter was happy about weight gain. The weekly skin review dated 5/15/18 documents under site coccyx and under description documents, treatment area. The weekly skin review dated 5/18/18 has skin intact checked. The nurses note dated 5/20/18 documents, Daughter here and wanted resident laid down. Prior to her coming resident had called her several times crying and telling her she was in pain. 3 attempts were made to give her medication, she said no I took them already. She did take her meds when daughter came. Daughter concerned about her positioning in the wc (wheelchair). Resident was comfortable when in bed. The SBAR (situation, background, assessment, response) note dated 5/23/18 documents, Situation: The change in condition, symptoms or signs Skin wound or ulcer. Which started on 5/23/18 in the morning. Skin evaluation: Pressure ulcer Left gluteal fold - open area 3.0 x 3.3 cm (centimeter) and 0.8 cm in depth 95% slough, Pain Evaluation: Resident has pain. Cognitively impaired pain assessment: Breathing normal. No negative vocalization. Facial expression: Sad, frightened, frown. Body language: Relaxed. Consolability: No need to console. Acute pain. Left buttock, Unable to determine if symptoms or changes have changed. Things that make the condition or symptom worse are: Not kept reposition, dry and clean. Things that make the condition or symptom worse are: Reposition, dry and clean. This condition, symptom or sign has occurred before: Yes treatment covering dressing Resident refuse to be reposition or poor nutrition resident eat mostly junk food and prefer to stay up in w/c at all time. Resident noted new open area to left gluteal fold. The eMAR (electronic Medication Administration Record) -Medication Administration Note dated 5/23/18 documents, buttock pain. The nurses note dated 5/23/18 documents, Call placed to Physician-M to inform of Stage 4 to left ischium and current pain assessment. New order received for CBC (complete blood count), BMP (basic metabolic panel), PAB ([MEDICATION NAME] test) in AM (morning). Call placed to POA (power of attorney)-L, awaiting call back. The nutrition note dated 5/23/18 documents, DTR (daughter) informed re (regarding) new stage 4 o/a (open area) to L (left) ischium. Requested PAB and to add prostat 30 ml (milliliters) BID (twice a day) for added 30g (grams) of protein/day. Will monitor for healing progress and initiate further nutrition assessment as needed. The Braden assessment dated [DATE] has a score of 11 which indicates high risk. R1 went from having intact skin on 5/18/18 to a stage 4 pressure injury on 5/23/18. The nurses note dated 5/24/18 documents, Dressing to left ischium changed. Dressing soiled with moderate amt (amount) of serous drainage. Wound base with 100% slough. Periwound dark with 10% induration. Call placed to Physician-M. New order received for bed rest and change dressing to BID (twice a day) due to location of wound. MD (Medical Doctor) will be in tomorrow to see resident. Call placed to daughter-L, aware of new orders. The physician progress notes [REDACTED]. She was refusing to get out of the chair and will sit in the chair all day long. During the care about a week ago she was noticed to have wound which has now opened up. She has significant dead tissue and some purulent drainage. She is currently getting wound care. patient has been afebrile. Under PE for skin documents, left ischial stage IV (4) wound with necrotic dead tissue and some drainage noted. Under A/P documents a [DIAGNOSES REDACTED]. Pressure offloading q.2 (every two) hours turning. Will check nutritional status and supplement. Patient is not allowed to sit in chair anymore. Will plan sharp debridement once scalpel available. discussed with nursing staff. The eMAR- Medication Administration note dated 5/27/18 documents, resident grimacing and crying, med given for L (left) ischium pain. The physician progress notes [REDACTED]. Under PE for skin documents, left ischial stage IV (4) wound with necrotic dead tissue and some drainage noted. Under A/P documents # Pressure ulcer of left buttock (L89.324) Bedside debridement was done under local anesthesia with informed consent approximately 5 centimeter of necrotic base which included fascia skin muscle was removed. Hemostasis was obtained with direct pressure patient tolerated procedure well there were no immediate complications. She was placed on antibiotic for 10 days along with some pain medications. The nurses note dated 5/28/18 documents, Physician-M in to see Res. (resident) and performed selective debridement to Left ischial wound at bedside. Wound was debrided down to bleeding tissue. Writer and unit nurse present to assist. Res. tolerated well with unit nurse providing encouragement and comfort. Physician-M wrote new orders for ABT (antibiotic) post procedure, did note purulent drng (drainage) when previous drsng removed. Verbal order rec'd (received) for change to Tx (treatment) order. See MAR. Review of R1's (MONTH) (YEAR) & (MONTH) (YEAR) MAR (Medication Administration Record) reveals the following: Starting on the evening shift on 5/28/18 with the last dose during the morning shift on 6/7/18 R1 received twice a [MEDICATION NAME] mg and [MEDICATION NAME] 100 mg for purlulent drainage of left gluteal fold. Starting on 5/28/18 with the last dose during the morning shift on 6/7/18 R1 received [MEDICATION NAME] 600 mg three times a day for purulent drainage of the left gluteal fold. Surveyor noted there are weekly skin impairment and wound evaluations completed by RN (Registered Nurse)/Wound Nurse-O which document the left ischial as a Stage 4 with an effective date of 5/30/18, 6/6/18, 6/13/18, 6/21/18, and 6/26/18. The significant change MDS with an assessment reference date of 5/30/18 documents a BIMS score of 9 which indicates moderately impaired. Rejection of care is not coded as occurring. R1 requires extensive assistance with one person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, does not ambulate, and is always incontinent of bowel and bladder. R1 is at risk for developing pressure injuries and is coded as having one Stage 4 pressure ulcer. The pressure ulcer CAA (Care Area Assessment) dated 6/13/18 under care plan considerations documents, Res. (Resident) has a pressure ulcer at this time. res. receives tx (treatment) as ordered to the ulcer and it is monitored weekly on wound rounds. Res. is at risk for pressure ulcers d/t (due to) impaired mobility, bowel and bladder incontinence, cognitive deficits etc. Res. is repositioned q (every) shift and prn (as needed). Res. receives peri care with each incontinence episode and barrier cream prn. Skin is monitored daily with cares and weekly with showers and body assessments. Will proceed to care plan to monitor and heal existing wound without complications; and prevent or minimize effects of any further skin breakdown. The nurses note dated 5/31/18 documents, Alert and verbally responsive, dressings was done, deep area with drainage and some tissue noted, dressing done, cleaned and covered with dressing. The nurses note dated 5/31/18 documents, Writer and NM (Nurse Manager) in to perform dressing change/assessment of Left ischial wound this morning. Large amt (amount) of serosang drng (drainage) noted on dressing removed. Note Tx order change to cover with Bordered foam dressing to better manage exudate. Drng was without odor. No s/s (signs/symptoms) of infection noted. The nurses note dated 6/3/18 documents, Resident is alert and oriented. Tx to open area left ischium was done on this shift. also protective dressing to coccyx is intact. Resident was assisted with cares and repositioned q 2 hrs. Took medication without any problems. No new problems noted. The nurses note dated 6/14/18 documents, Res. seen per Physician-N of Vohra wound care. Left ischial wound was assessed, selective debridement was performed at bedside to remove slough from wound base. New order recommendations were rec'd (received). Progress note per MD. The SBAR Change of Condition note dated 6/29/18 documents a second pressure injury, this one on the coccyx. Situation: The change in condition, symptoms or signs Skin wound or ulcer. Which started on 6/29/18 in the morning., Skin Evaluation Pressure ulcer new onset Grade 2 or high pressure ulcer OR progression of pressure ulcer despite interventions. Coccyx - 1 cm x 0.5 cm x 0.1 cm, superficial with scant amt (amount) of blood, periwound with usual scare tissue., Since the change in condition occurred have the symptoms or signs have stayed the same. Things that make the condition or symptom worse are: no change. Things that make the condition or symptom worse are: no change. This condition, symptom or sign has occurred before: Yes Allevyn Life Superficial stage 2 noted on coccyx Response: Reported to primary care clinical Physician-M 06/29/2018 12:00 AM Recommendations: D/C (discontinue) Protective dressing of allevyn and change to [MEDICATION NAME] Thin. The nurses note dated 6/30/18 documents, Dressing changed to left ischium. Coccyx dressing in place. Remains on bedrest. Check/changed/turned q2-3 hrs. POA (power of attorney) here and concerned about resident pain. Medicated x 2 for pain before tx. Eff. (effective). Resident sleeping comfortably. Wound Physician-N wound evaluation & management summary note dated 7/3/18 documents, R1's left ischial pressure injury as Stage 4. During this visit Wound Physician-N debrided the pressure injury and indicates the pressure injury is improved as evidenced by decreased depth and surface area. Wound Physician-N's note does not address R1's coccyx pressure injury. There is a weekly skin impairment and wound evaluation completed by RN/Wound Nurse-O with an effective date of 7/3/18 for the Stage 4 left ischial pressure injury but there is no assessment of the coccyx pressure injury on this date or during the week of 7/1/18. The nurses note dated 7/6/18 documents, Dressing to coccyx wound changed, Measures 1.0 cm x 0.5 cm x 0.1 cm, scant amt. of serous drainage, wound base red, periwound with pink scar tissue, No s/s of infection, denies pain, continue with current treatment. Wound Physician-N wound evaluation & management summary note dated 7/10/18 documents R1's left ischial pressure injury as Stage 4. During this visit Wound Physician-N debrided R1's left ischial pressure injury. Wound Physician-N documents (Site 2) Stage 3 pressure wound coccyx - initial evaluation. Under recommendations documents off-load wound; low air loss mattress. R1 was already on a low air loss mattress. The weekly skin impairment and wound evaluation with an effective date of 7/10/18 completed by RN/Wound Nurse-O for the Stage 4 left ischial pressure injury and another weekly skin impairment and wound evaluation with an effective date of 7/10/18 completed by RN/Wound Nurse-O for the Coccyx which under the original pressure ulcer stage documents, Stage III (3). Surveyor noted this pressure injury started as a Stage 2 and declined to a Stage 3. Under evaluation for comments documents, Initial visit per wound team/Wound Physician-N of Vohra (name of wound care company). Progress note written. New order rec'd (received). Wound without s/s (signs/symptoms) of infection. Periwound intact. Surveyor noted there are weekly skin impairments and wound evaluations for R1's left ischial and coccyx pressure injuries until she was hosptalized on [DATE]. There was no revision in R1's pressure ulcer care plan after R1's coccyx pressure injury declined to a Stage 3. The nurses note dated 7/18/18 documents, 2 cm x 2 cm DTI (deep tissue injury) noted on Left lateral Heel, Denies pain or discomfort. Skin prep applied, continue with prevalon boots and offload. NP-K and POA-L aware. The nurses note dated 7/18/18 documents, Correction: right heel. The nurses note dated 7/23/18 documents, F/U o/a coccyx foul smell noted and left ischium red in color scanty amount blood noted treatment in place resident alert no c/o pain or discomfort ate 24% meals fluid intake well updated daughter of meal intake resident was given extra cal drink 480 cc intake resident continues bed rest fort (for) wound healing. The nurses note dated 7/23/18 documents, Call placed to Physician-M, informed of foul odor noted to left ischium wound. New order received to cleanse with NS (normal saline) with dressing change. Call placed to daughter-L informed of new order received and rational. The nurses note dated 7/29/18 documents, Dressings in to lt ischium and coccyx. Prevalon boots in place to feet. Res. with no s/s or c/o pain. Rt. (right) heel with dark area intact. R1 was hospitalized from [DATE] and readmitted [DATE]. Hospital information documents left ischium pressure ulcer is healed as well as the weekly skin impairment and wound evaluation with an effective date of 8/14/18 documents date healed as 8/13/18. Under wound eval for comments documents, readmitted from hospital with 100% intact remodeled tissue in place. 100% silver scar. The weekly skin impairment and wound evaluation with an effective date of 8/14/18 for the Coccyx documents Stage 3. Under the evaluation section documents under comments, Initial assessment after readmit from hospital on [DATE]. Seen per Wound Physician-N of Vohra. Progress note written. No s/s of infection. Tx (treatment) with Santyl ongoing. Measurements nearly same as prior to hospitalization . Left ischial wound did heal while Hospital. Tx and interventions appropriate and ongoing. On 9/26/18 at 2:58 p.m., Surveyor met with RN/Wound Nurse-O regard her role and R1's pressure injury. RN/Wound Nurse-O explained to Surveyor she was hired three days a week to help take the documentation off of the unit managers. Surveyor inquired if there is a unit manager on R1's unit. RN/Wound Nurse-O informed Surveyor there was a unit manager until about two and a half weeks ago. Surveyor inquired if there is a wound team. RN/Wound Nurse-O informed Surveyor the wound team used to consist of the nurse managers, Director of Nursing, and nutrition at times. RN/Wound Nurse-O informed Surveyor right now she is the wound team but they have Wound Physician-N who sees Residents with pressure ulcers on Tuesdays unless the resident is seen at a wound clinic. Surveyor asked RN/Wound Nurse-O what is the weekly skin review. RN/Wound Nurse-O explained this is completed by the nurses and it used to be a shower check sheet. Surveyor ask if this skin review is done on bath days. RN/Wound Nurse-O informed Surveyor she assumed so. Surveyor asked what happens when a pressure injury is discovered. RN/Wound Nurse-O informed Surveyor it is reported to the Supervisor. Surveyor asked what happens when a CNA discovers the pressure injury. RN/Wound Nurse-O explained the CNA should report this to the nurse who would assess, measure it, complete a SBAR, update the doctor, obtain an order and update the family. Surveyor inquired if the nurse stages the pressure injury. RN/Wound Nurse-O informed Surveyor sometimes they stage it and sometimes the nurse practitioner will stage it if the nurse feels uncomfortable. Surveyor inquired where the weekly assessments and measurements would be. RN/Wound Nurse-O explained when a Resident has a pressure ulcer she completes the assessments on the weekly skin impairment and wound evaluation form until they are resolved and then for an additional two weeks. Surveyor asked RN/Wound Nurse-O how she becomes aware of a pressure injury. RN/Wound Nurse-O informed Surveyor she wouldn't unless someone tells her or she gets a list from the Director of Nursing with new areas. Surveyor inquired when RN/Wound Nurse-O started assessing R1's left ischial pressure injury. RN/Wound Nurse-O explained the first weekly skin impairment and wound evaluation form she did was on (MONTH) 30th because former DON-W was here at the time and RN/Prior Unit Manager-P saw the pressure injury and staged it as a Stage 4. RN/Wound Nurse-O informed Surveyor RN/Prior Unit Manger-P is wound certified and documented on the pressure injury so there was no need for her to document also. Surveyor asked RN/Wound Nurse-O if she knew why there was no skin impairment and then there was a pressure injury that was staged as a Stage 4. RN/Wound Nurse-O informed Surveyor she wondered that her self and she doesn't know why. RN/Wound Nurse-O informed Surveyor everything was resolved and there was a protective dressing in place. RN/Wound Nurse-O indicated R1 liked the head of her bed up and didn't want to be in bed. RN/Wound Nurse-O informed Surveyor R1 didn't have any meat and could see the depth going very fast. On 9/26/18 at 3:46 p.m., Surveyor spoke with LPN (Licensed Practical Nurse)-Q who initialed R1's left buttock treatment being completed on 5/4/18. Surveyor inquired if LPN-Q remembered how the area looked. LPN-Q informed Surveyor she doesn't recall the area being open when she did the treatment. Surveyor asked LPN-Q if she knew why the pressure injury wasn't identified until it was a Stage 4. LPN-Q informed Surveyor she usually works on the A unit but when the aides found it, it was already big. Surveyor asked LPN-Q if she knew which CNA (Certified Nursing Assistant) found the area. LPN-Q replied, no. On 9/26/18 at 4:02 p.m., Surveyor spoke with LPN-R who completed the weekly skin check on 5/18/18 and checked skin intact. LPN-R informed Surveyor on this day R1 refused her bath so she checked her skin in bed. Surveyor asked LPN-R if she removed the dressing. LPN-R informed Surveyor she did not because the dressing was not wet. LPN-R explained if R1 was in the shower room and the dressing became wet she would remove the dressing. On 9/27/18 at 7:30 a.m., Surveyor attempted to contact RN-T via the telephone to inquire about the treatment she initialed as being completed on 5/11/18 & 5/18/18. RN-T did not call Surveyor back. On 9/27/18 at 7:45 a.m., Surveyor asked Interim DON (Director of Nursing)-B if RN-S who initialed the treatment being completed on R1's left buttock on 5/21/18 is employed at the Facility. Interim DON-B informed Surveyor RN-S no longer works at the Facility. On 9/27/18 at 9:44 a.m., Surveyor asked LPN-C who initialed the treatment as being completed on 5/14/18 if she could recall what the area under the dressing looked like. LPN-C stated, wow it's (MONTH) now, She had a wound wasn't so bad. Can't remember. I can't remember how it looked. LPN-C explained to Surveyor she usually works night shift and once in a while works evening shift but mostly works on the A unit. LPN-C stated, can't really remember. On 9/27/18 at 9:59 a.m., Surveyor spoke with Physician-M on the telephone. Surveyor asked Physician-M about his 5/25/18 progress note which he documented, During the care about a week ago she was noticed to have wound which has now opened up. and asked what he was referring to. Physician-M informed Surveyor he got a call from a nurse but couldn't recall who the nurse was. Physician-M stated, someone called me from the nursing home and informed Surveyor when ever they call him they are suppose to write a note. Surveyor informed Physician-M Surveyor was unable to locate anything in R1's medical record regarding any skin impairment a week before R1 developed the Stage 4 pressure injury. Surveyor asked Physician-M how he thought R1 developed the pressure injury. Physician-M informed Surveyor R1 had a stroke and was also contracted. Physician-M indicated he was pretty sure R1 was refusing care and was also malnourished. Surveyor informed Physician-M in the beginning of (MONTH) R1 was noted to have weight gain. Physician-M informed Surveyor R1 was underweight. Surveyor asked Physician-M if there was anything else he thought the Surveyor should know. Physician-M replied, no not really and then informed Surveyor staff probably found the pressure ulcer when they moved R1 from the chair they noticed something on the chair and found the pressure ulcer. On 9/27/18 at 10:21 a.m., Surveyor asked CNA (Certified Nursing Assistant)-U if she provided cares to R1. CNA-U replied, yes. Surveyor asked CNA-U if she knew how R1 developed the pressure injury. CNA-U informed Surveyor when she came back they told her R1 had a sore but she doesn't know how R1 got it. CNA-U explained after she had the pressure ulcer they put her on bed rest and they turned her side to side. CNA-U informed Surveyor before she was up in a chair and was a Hoyer lift. CNA-U informed Surveyor one of R1's legs was bad and it was hard for her to sit in the chair. CNA-U indicated R 1 right leg was bad so she would lean on her left side. CNA-U informed Surveyor R1 was quiet, was to herself but would come out of her room for meals. CNA-U informed Surveyor they would ask R1 if she wanted to lay down but she would say no. On 9/27/18 at 10:08 a.m., Surveyor asked Interim DON-B if the Facility did an investigation as to how R1 developed a Stage 4 pressure injury. Interim DON-B informed Surveyor they usually do a risk management. At 10:27 a.m., Interim DON-B provided Surveyor with risk form dated 5/23/18 and shortly after education and staff statements. Surveyor reviewed the risk form dated 5/23/18 & revised on 5/24/18. Surveyor noted incident location is documented as Activity Room. Under nursing description documents, Resident noted open area 3.0 x 3.3 cm and 0.8 cm depth 95% slough moderate serous drainage. Wound assessed at Stage IV (4). Immediate action taken documents Resident was assess open area wash, clean and measurement taken treatment in place with Santyl ointment and dressing covering. MD updated. POA updated. POA came in and viewed with unit manager at bedside. Surveyor noted along with the risk form is education dated 5/23/18 which includes bed rest, ensure air mattress functioning properly, turn/reposition q 2-3 hours/prn, treatment is required to be changed daily/prn by floor nurse, alert nurse if dressing soiled, nurse to change as soon as possible, and ensure w/c cushion is in place when up. Surveyor noted there are three staff statements. LPN-X's statement dated 5/23/18 documents, R1, last weekly skin check I completed was on 5/15/18. No open areas noted. LPN-R's statement dated 5/23/18 documents, 5-18-18 Body check on R1 observed without open area skin noted intact covering dressing in place. and 5-22-18 Resident received bed bath refuse bath (shower) dressing intact not soiled. CNA-H's statement not dated documents, On Monday (MONTH) 21, (YEAR) I noticed a soiled dressing on R1 left hip and reported it to my nurse. On 9/27/18 at 10:27 a.m., Surveyor spoke with CNA-V if she noticed any open areas on R1. CNA-V replied, no. Surveyor asked CNA-V what R1's typical day like. CNA-V informed Surveyor when she had the open area R1 was on bed rest. Surveyor asked what about before the pressure ulcer. CNA-V informed Surveyor she was ok. CNA-V explained R1 would usually be up, sometimes for breakfast but if not for lunch and R1 liked to eat sweets. Surveyor asked CNA-V if R1 had to be repositioned in her wheelchair. CNA-V replied no, not really. CNA-V informed Surveyor R1 looked uncomfortable in her chair and refused to wear the boots. CNA-V indicated R1 was kind of fussy when taking her medication. On 9/27/18, Interim DON-B informed Surveyor she found in Former DON-W's office a statement from RN-S which Interim DON-B provided to Surveyor. This statement is typewritten dated 5/23/18 and not signed by either RN-S or Former DON-W. The statement documents, I changed R1's treatment on Monday evening 5/21/18 around 7:30-8:00pm. There was only scar tissue noted to coccyx and left buttock and I applied dressings. Patient had complained of pain and prn (as needed) [MEDICATION NAME] given. On 9/30/18, Corporate RN-Y e mailed to the Southeastern Regional office additional information which was forward to Surveyor. Surveyor noted this information included a nutritional assessment dated [DATE], document from Corporate RN-Y which included a statement the nurse would have charted by exception meaning that if a skin condition was observed, it would have been measured, documented and notifications made. The Facility did not provide to the Surveyor any current standard of practice or facility policy and procedure that allows charting by exception. Also included was an assessment history dated 7/3/18 to 8/28/18. This information does not have R1's name on the document and the time frame is after R1 developed the Stage 4 pressure injury A care plan history, pressure ulcer care plan and wound eval dated 8/21/18, 8/14/18, 7/31/18, 7/24/18, 7/17/18, 7/10/18, 7/3/18, 6/26/18, 6/21/18, 6/13/18, 6/6/18, & 5/30/18. This information does not have R1's name on the document and the time frame is after R1 developed the Stage 4 pressure injury. SBAR change of condition dated 5/23/18 and progress notes to 6/29/18. Although R1's name is not on

Based on record review and interview the facility did not provide necessary treatment and services to promote healing and prevent infection to pressure injuries for 4 (Resident #1,#3, #5, and #2) of 6 residents reviewed with pressure injuries. Resident #1 was admitted to the facility with a pressure injury to his coccyx area. The facility failed to consult with a physician to obtain guidance for care and treatment when the pressure injury was noted to have a strong odor and the dressing was noted to be saturated with greenish drainage on 7/22/16. There was no change in treatment. On 7/24/16 Resident #1 was sent to the hospital and was admitted in serious condition [MEDICAL CONDITION]. Resident #1 was found to [MEDICAL CONDITION] and septic shock, and [DIAGNOSES REDACTED] from the sacral pressure injury. On 7/25/16 Resident #1 had to have surgery which included the removal of his coccyx and wide debridement of skin, subcutaneous tissue, muscle fascia, and muscle. On 7/30/16 Resident #1 had to have surgery to have a diverting [MEDICAL CONDITION] placed. The facility's failure to provide necessary treatment and care when Resident #1's pressure injury showed signs of infection, such as the dressing noted to be saturated with greenish drainage and a strong odor noted on the wound, created a finding of Immediate Jeopardy for Resident #1 beginning on 7/22/16. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy and substandard quality of care on 9/28/16 at 1:40p.m. The Immediate Jeopardy was removed on 9/30/16 when the facility implemented their action plan; however, the deficient practice continues at a scope and severity level of G (actual harm that is not immediate jeopardy/isolated) for example #3a (Resident #3) and the Facility has not fully implemented all components of their removal plan. * Resident #2 had no documented pressure injury evaluation, including measurements, for 2 weeks. * Resident #3 was readmitted into the facility on [DATE] with a stage 2 pressure injury to the coccyx. Resident was assessed as high risk for the development of pressure injury. On 4/6/16, Resident was assessed as having two Deep Tissue Injuries (DTI) to his left lateral foot and heel. There is no evidence of the facility providing pressure injury preventitive measures (off-loading of heels/prevalon boots) in regards to Resident #3's heels from the time of readmission on 4/2/16 until 4/6/16 when Resident #2 was assessed to have two DTI on his left foot. On 9/24/16, 9/25/16 and on 9/26/16, green drainage was identified to Resident #3's left and right heel. There is no evidence in Resident #3's that either the primary physician or the Wound Physician-E was updated when the green drainage observed, in order to obtain guidance for care and treatment. As a result, no treatment changes were made until 4 days later. On 9/28/16, Wound Physician-E assessed the pressure injuries and treatment was then changed. * On 8/9/16, Resident #5 was admitted into the facility with no pressure injuries. Resident #5 was identified as being high risk for the development of pressure injuries. On 8/25/16, Resident #5 was observed to have a stage 2 pressure ulcer (blister wound) on the left heel and a stage 1 pressure injury on the right heal (developed into a Deep Tissue Injury). On 8/31/16 both pressure injuries were noted to increase in size with physician ordered treatment and orders to off-load heels at all times. There is no evidence of the facility off-loading resident's heels from admission on 8/9/16 to 8/25/16, prior to the development of these 2 pressure injuries, even though resident was at risk for the development of pressure injuries. Findings include: Cross-Reference F157 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Clinical Health Status document with an admission date of [DATE] also documents under the section SKIN CONDITIONS a skin concern first observed 6/3/16 a 2.5cmx1.0cm wound to the coccyx with a description of wound 100% slough. The Wound Evaluation Week 1 signed 6/7/16, documents the pressure injury measurements as 3cm (L) x1.8cm (W) x0.1cm (D) and 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.) Exudate is documented as serous, thin, watery, and with a small/minimal amount. Odor is documented as not present. Wound bed is documented as 100% slough. Wound Evaluation Week 2 signed 6/8/16 documents the pressure injury measurements as 2.6cm (L) x2cm (W) x0.1cm (D) and unstageable. Exudate is documented as serous, thin, watery, and with a scant amount. Odor is documented as not present. Wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Under Current Wound Status/additional comments: is documented Wound does not show any signs of infection. Wound Physician-E's progress note dated 6/8/16 documents, Wound #1 coccyx is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.6cm length x 2cm width x 0.1cm depth, with an area of 5.2 sq cm and a volume of 0.52 cubic cm. There is a small amount of serous drainage noted. Wound bed is 76-100% adherent, yellow slough. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Wound Evaluation Week 3 signed 6/15/16 documents the pressure injury measurements as 2.6cm (L) x 1.6cm (W) with no documented depth. It is documented as a stage III pressure injury. Exudate is documented as serous, thin, watery and with a small/minimal amount. Odor is documented as not present. Wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented, No signs of infection noted to site at this time. Wound Evaluation Week 4 signed 6/23/16 documents the pressure injury measurements as 2.2 cm (L) x 4.1 cm (W) x 0.1cm (D) and as a stage III pressure injury. Exudate is documented as serosanguineous, thin, watery, and with a small/minimal amount. Odor is documented as not present. Wound bed is documented as 25% slough, and 25% skin; odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented, No signs of infection noted to site at this time. Wound Physician-E's progress note dated 6/22/16 documents, Wound #1 coccyx is an Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.2cm length x 4.1 cm width x 0.1cm depth, with an area of 9.02 sq cm and a volume of 0.902 cubic cm. There is a small amount of serous drainage noted. Would bed is 1-25% [MEDICATION NAME], 1-25% adherent, yellow slough, 26-50% non-granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. General Notes: 50% Non granulation: area shows features of a DTI (deep tissue injury) Wound Evaluation Week 5 signed 6/29/16 documents the pressure injury measurements as 4.4cm length x4cm width X 0.1cm Depth and as unstageable. Exudate is documented as serous, thin, watery, and a small/minimal amount. Odor is documented as not present. The wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented Wound is 100% slough so it is unstageable. The features of a DT (deep tissue injury( noted previously have decreased. Wound Physician-E's progress note dated 6/29/16 documents, Wound #1 Coccyx is Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 4.4cm length x4cm width x0.1cm depth, with an area of 17.6 sq cm and a volume of 1.76 cubic cm. There is a small amount of serous drainage noted. Wound bed is 51-75% adherent, yellow slough, 1-25% non-granulation. The periwound skin texture is normal. The preiwound skin moisture is normal. The periwound skin color is normal. General notes: Features of DTI noted previously decreased. Wound Evaluation Week 6 signed 7/6/16 by RN (registered nurse)-D documents the pressure injury measurements as 8.1cm length x 4.7cm width x0.1cm depth and as unstageable. Exudate is documented as serous, thin, watery, and a moderate amount. Odor is documented as not present. The wound bed is documented as 25% granulation and 75% slough, odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented, No signs of infection noted to site at this time. On 9/28/16, Surveyor # interviewed RN-D. Surveyor # asked if RN-D recalled notifying a physician when Resident #1's wound increased in size from 4.4cm length x4cm width x0.1cm depth on 6/29/16 to 8.1cm length x 4.7cm width x0.1cm depth on 7/6/16. RN-D stated that he does wound rounds with Wound Physician-E on Wednesdays, and although he did not document notifying Wound Physician-E he believes that they discussed Resident #1's wound on 7/6/16. Wound Evaluation Week 7 signed 7/13/16 documents the pressure injury measurements as 6.5cm length x 4cm width x0.1cm depth and as unstageable. Exudate is documented as serous, thin, watery, and a moderate amount. Odor is documented as not present. The wound bed is documented as 100% slough, odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented, Wound was debrided today per (Wound Physician-E). Resident tolerated well. Wound Physician-E's progress notes dated 7/13/16 documents, Wound #1 (Pressure Ulcer) is located on the coccyx. Medical Necessity: The ulcer base is slough/necrotic. A skin/subcutaneous tissue level excisional debridement was performed by (Wound Physician-E), MD. Adipose, Dermis, Epidermis, and Subcutaneous were removed along with devitalized tissue: exudate and slough .Total area debrided was 26sq cm . Post debridement Measurements: 6.5cm length x 4cm width x0.2 cm depth with a Percentage Debrided at 100% and a volume of 5.2 cubic cm; post debridement stage notes as a Stage 3 Pressure Injury. On 7/19/16 at 1:55 p.m. and 9:29 p.m., LPN (licensed practical nurse)-F documented, Drsg (dressing) changed to coccyx this am shift. Odor noted slough noted. Resident in bed at this time with no complaints call light within reach. There is no documentation of physician notification regarding the presence of an odor to the wound or of a treatment change. Surveyor # noted that this was the first time the presence of an odor was documented. On 9/27/16 at 8:11 a.m., Surveyor # interviewed RN Manager-C. Surveyor # asked if RN Manager-C, had been notified of an odor to Resident #1's wound. RN Manager-C informed Surveyor # that she could not recall if she had been notified of an odor, but she would have documented on the Wound Evaluation Week 8 signed 7/20/16 if she had noted an odor to the wound at that time. On 9/27/16 at 3:25 p.m., Surveyor # interviewed LPN-F. Surveyor # asked LPN-F if she had notified a physician regarding the presence of an odor to the coccyx. LPN-F informed Surveyor # that she could not recall for sure, but believes that because 7/19/16 was a Tuesday she would have left a sticky note for the wound team, which includes Wound Physician-E and RN Manager-C, to evaluate on Wednesday; as the wound team rounds on Wednesday. The Wound Evaluation Week 8 signed 7/20/16 by RN Manager-C documents the pressure injury measurements as 6.2cm length x 5cm width x0.1cm depth and as unstageable. Exudate is documented as serous, thin, watery, and a small/minimal amount. Odor is documented as not present. The wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Physician-R's progress note dated 7/20/16 documents vitals stable, afebrile, and that patient to be closely monitored. The progress note does not document any information regarding Resident #1's pressure injury. On 7/21/15 at 6:38 p.m., LPN-G documented Drsg (dressing) to coccyx was changed this pm shift. Resident had no discomfort this pm shift. Foley patent and draining yellow urine. Resident in bed at this time repositioned with cares. Call light within reach. Will continue to monitor. LPN-G did not document the presence of drainage or an odor. On 7/22/16 at 7:14 p.m., LPN-G documented Drsg (dressing) to coccyx was changed this pm shift. Dressing saturated with greenish drainage. Strong odor noted on the wound. Resident had no discomfort this pm shift. Foley patent and draining yellow urine. Resident in bed at this time repositioned with cares. Call light within reach. Will continue to monitor. There is no documentation of physician notification, or of an RN assessment completed following the presence of the dressing being saturated with greenish drainage and a strong odor. Surveyor # noted that this was the first time greenish drainage is documented. No vital signs are documented on 7/22/16. There was no change in treatment. On 9/26/16 at 4:55 p.m., Surveyor # interviewed LPN-G. Surveyor # asked LPN-G if she recalled notifying an RN or physician on (Friday) 7/22/16 regarding Resident #1's wound having greenish drainage and a strong order. LPN-G informed Surveyor # that 7/22/16 was a Friday, and that the wound team would have seen the wound on Wednesday (7/20/16). LPN-G stated that she did not think that this was a change for that wound. LPN-G stated that she would have documented notifying the physician. LPN-G confirmed that she did not believe that she contacted the physician on 7/22/16 regarding Resident #1's dressing being saturated with greenish drainage and a strong odor noted on the wound. On 9/27/16 at 1p.m., Surveyor # interviewed Wound Physician-E over the phone. Surveyor # asked Wound Physician-E if he recalled Resident #1's wound having odor or green drainage. Wound Physician-E informed Surveyor # that he did not recall being notified of an odor or green drainage. Wound Physician-E state that with a change of status to the wound (such as odor/green drainage) he would either see the patient or change the treatment. Surveyor # asked Wound Physician-E if he would expect to be notified of green drainage and a strong odor. Wound Physician-E stated yes and that he is always available by multiple routes for the facility to contact him. On 9/26/16 at 5:21 p.m., Surveyor # interviewed DON-B. Surveyor # asked DON-B if a physician should have been notified of a wound having a strong odor and greenish drainage. DON-B stated that if it was a change the physician should have been notified. On 7/23/16 at 11:15 a.m. RN-S documented, Tx (treatment) done to coccyx, Slough noted at open wound center. Old dressing saturated with urine. Surveyor # reviewed Resident #1's treatment administration record and noted that the treatment with an order date of 6/8/16 for the coccyx wound to Cleanse with normal saline. Pat dry. Apply skin prep to periwound. Apply Santly to wound base. Next apply saline moistened gauze. Cover with border gauze. Change daily and prn (as need) every evening shift remained in place until Resident #1's discharge from the facility on 7/24/16. Surveyor # noted that Resident #1's plan of care and wound treatment was not updated when Resident #1's wound began having greenish drainage and a strong odor. On 7/24/16 at 4:15 p.m. an SBAR (Situation, Background, Assessment, Response) Change of Condition note documents, Situation: Temp 100.6 Lethargy, yellowish discharge from penis, increased drainage from coccyx pressure ulcer, decreased appetite. Background: Chronic pai[DIAGNOSES REDACTED], retention of urine, pressure ulcer of coccyx, DM (diabetes mellitus),[MEDICAL CONDITION](hypertension), AFIB (arterial fibrillation), constipation, history [MEDICAL CONDITIONS], muscle weakness Assessment: Temp 100.6 P79 R20 Bp 146/70 Spo2 91% RA (room air) Resident is lethargic, yellowish discharge from penis decreased appetite. RN assessed. Response: (Physician-R) updated New order to send to West Memorial Hospital. (Emergency contact) updated. (DON-B and NHA-A) updated. On 9/26/16 Surveyor # reviewed Resident #1's hospital record. ED (emergency department) Provider Notes document on 7/24/16 at 6:10 p.m., Sacral decubitus ulcer to buttock with small amount of bleeding from wound. Wound is also pustulating and has surrounding [DIAGNOSES REDACTED]. Wound is superior to the rectum. No tenderness to perineum. Under ED Course at 6:17 the Initial Impression is documented as, I performed the initial assessment and evaluation of the patient. I discussed his plan of care since he is febrile, weak, and has an infected wound, that he will need IV abx (antibiotics) . The hospital Discharge Summary dated 7/26/16 includes final [DIAGNOSES REDACTED]. sacral ulcer with underlying [DIAGNOSES REDACTED] and underwent debridement with (MD). He was placed on broad-spectrum IV antibiotics and transferred to ICU. His blood cultures are positive for gram-positive cocci in chains. He was placed on boar spectrum IV antibiotics. Path is still pending. At this point, wound care team recommends aggressive hyperbaric treatment. At this point, they recommend aggressive hyperbaric treatment, which will be initiated at St. Luke's Medical Center .Remains bed bound. He will need a diverting ostomy . An encounter note date 7/25/16 documents, .In the emergency department a large sacral decubitus ulcer was seen in (MD) was consulted and he was taken to surgery today. He was noted to have a stage IV decubitus wound/necrotizing soft tissue infection measuring 12x15x3.5cm and going down to the coccyx and sacrum necessitating removal of the coccyx On 7/26/16 Resident #1 was transferred to a different hospital. An infectious disease consult with a date of service of 7/27/16 includes the impression of 1.[MEDICAL CONDITION] secondary to necrotizing sacral wound infection, status [REDACTED]. Sacral and coccygeal osteo[DIAGNOSES REDACTED] On 7/30/16, Resident #1's procedure encounter notes document that Resident #1 had a Laparoscopic and sigmoid [MEDICAL CONDITION] and debridement, excisional sacral wound, 15x15 cm skin, subcutaneous tissue, muscle, and bone. A plastic and reconstructive surgery consult on 8/3/16 documents, All surgical options result in a permanent scar. Every effort will be made to keep closure as simple as possible. A local rotation flap will be required which necessitates additional incisions that borrow tissue from adjacent areas, thus resulting in longer scars. The consult continues to say that, The wound however, is not ready for surgical closure. It is recommended that patient continue with local wound care with the wound VAC for now. Once the wound shows evidence of healing, flap closure will be considered/planned. The facility's failure to provide necessary treatment and care when Resident #1's pressure injury showed signs of infection, such as the dressing noted to be saturated with greenish drainage and a strong odor noted on the wound, created a finding of Immediate Jeopardy for Resident #1 beginning on 7/22/16. The immediate jeopardy was removed on 9/30/16 when: · Resident #1 was discharged to the hospital on [DATE] and did not return. · The skin of all residents was assessed on 9/28/16. · The Braden scale has been reviewed for prior interventions and identification of risk. · Pressure reduction devices have been inspected to determine adequate interventions. · The Care Cards and Care Plans have been updated for anyone who is identified as having a risk for pressure. · Any Changes in Condition noted during the assessment will be communicated to the Physician or Physician extender on 9/28/2016. · Nursing staff and Unit Manager received training from a Wound Care Certified nurse on pressure ulcers, wound documentation and skin integrity guidelines. Licensed nursing staff received in-servicing on identifying and immediately reporting any skin changes to the Physician or Physician Extender, Director of Nursing Services or designee and all responsible parties when applicable. 16 out of 30 licensed staff has signed the in-service training with the remaining being trained prior to the start of their next scheduled shift. · Healogics (Provider of Advanced Wound Care Services) will provide weekly Wound Care Professional Services. · Residents at risk for the development of wounds will be reviewed daily at clinical start-up for any change in skin integrity. · 10 random audits will be performed weekly to ensure compliance. Audits will be reviewed at monthly QAPI (Quality Assurance and Program Improvement). Once it has been determined by the QAPI members that compliance has been reached consistently, the committee members may make a determination as to the frequency of the auditing process. · The Executive Director is responsible to ensure that this process occurs. This deficient practice continues at a scope and severity level of G (actual harm/isolated) as evidenced by example #3a (Resident #3) based upon the following: 2. The facility's SKIN INTEGRITY GUIDLINE with no date noted states under Documentation of Weekly Skin Evaluation/Observations, Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS) UDA (user defined assessment) (one UDA per wound identified). Surveyor # reviewed Resident #2's medical record. Resident #2 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was admitted to the facility with a stage 4 pressure injury to the left ischium. The Wound Evaluation Week 3 signed 8/31/16 documents the wound to be 2.6 cm length x 3.4cm width x0.6 cm depth. The Current Wound Status/Additional Comments section documents, Wound is showing great improvement. Wound vac was discontinued. New order was given by (Wound Physician-E) to apply silver alginate. Therapy was notified. The Wound Evaluation Week 4 signed 9/14/16 (2 weeks from the previous evaluation) documents the wound to be 3 cm in length x 2.8 cm in width x 0.4 cm in depth. The Current Wound Status Additional Comments section documents, Wound does not show any signs of infection. Resident will be picked up by therapy for wound care. Surveyor # noted that there were no documented wound evaluation between 8/31/16 and 9/14/16. On 9/28/16 at 3 p.m., Surveyor # interviewed RN Manager-C regarding Resident #2 not having wound evaluation completed between 8/31/16 and 9/14/16. RN Manager-C informed Surveyor # that she did not work on 9/7/16 and that RN Manager-D should have done the wound evaluation for that date, and was looking for more information. On 9/28/16 at 3:30 p.m. during the daily exit meeting with the facility Surveyor # informed NHA (nursing home administrator)-A and DON (Director of Nursing)-B of Resident #2 not having a documented wound evaluation between 8/31/16 and 9/14/16. On 9/29/16 at approximately 12:30 p.m. RN Manager-D informed Surveyor # that it appeared that Resident #2 did not get added to the wound round list for 9/7/16 and it appeared that he was missed that week for wound rounds. 3a. Surveyor # reviewed Resident #3's medical record. Resident #3 was admitted to the facility on [DATE], discharged to the hospital on [DATE], and re-admitted to the facility on [DATE]. Resident #3 has [DIAGNOSES REDACTED]. Resident #3's initial Minimum Data Set ((MDS) dated [DATE] indicates Resident #3 requires extensive assistance from one staff member for bed mobility and extensive assistance from two staff members for transferring. The MDS indicates Resident #3 is at risk for pressure injury and the MDS indicates Resident #3 has an unhealed pressure injury at stage 1 or greater. The Care Area Assessment (CAA) associated with the 4/8/16 MDS indicates Resident #3 is at risk for pressure injuries and indicates Resident #3 has a pressure injury on the coccyx and two suspected deep tissue injuries to the left foot. The intervention listed is to turn and reposition Resident #3 and the decision was made to develop a care plan. On 9/27/16 at 11:09 A.M., Surveyor # received a copy of Resident #3's care plan dated 3/25/16 that states, At risk for Alt (altered) skin integrity related to [MEDICAL CONDITIONS], dementia, decreased mobility, and [MEDICAL CONDITION]. The interventions listed include: · Evaluate need for skin management program · Assess resident entire skin upon admission · Administer good peri care to include use of barrier agent following any incontinent episode · Initiate reposition schedule in w/c (wheelchair) and in bed every 2-3 hours and PRN (as needed). · Implement your facility's system for identifying res at risk for skin breakdown · Involve resident in increased mobility activities. · Assess skin daily during cares · Initiate appropriate pressure reduction devices: w/c cushion, mattress · Evaluate effect of cognitive impairment upon resident's ability to understand · Nutritional assessment prn · Involve the resident in decision making regarding daily choices · When transferring, turning and repositioning use proper techniques so as to avoid friction and shear. Resident #3 has an additional care plan with a focus listed as, Potential for alteration in skin integrity r/t (related to) pressure ulcers, impaired mobility,[MEDICAL CONDITION](cerebral vascular disease), [MEDICAL CONDITION] ect. The date initiated is listed at 5/27/16. The goals are listed as, Will remain free from further breakdown, and Pressure ulcer will heal without complication. The interventions listed include: · Assist res. (resident) to reposition q 2-3 hours and prn, Use proper techniques to avoid friction and sheer. Date initiated 5/27/16 · Complete Braden Scale per Living Center Policy Date initiated 5/27/16 · Do not massage over bony prominence Date initiated 5/27/16 · Monitor skin daily with cares and weekly with showers and body assessments. Report any new open areas or areas of redness, rashes, blisters, bruises, ect. Date initiated 5/27/16 · Monitor wound progress weekly with wound nurse. Date initiated 6/2/16 · Nutritional and hydration support date initiated 5/27/16 · Podiatry consult 6/2/16 · Prevalon or similar heel boots on at all times until wounds are healed. Date initiated 5/27/16 · Provide pressure reducing wheelchair cushion Date initiated 5/27/16 · Provide thorough skin care after incontinence episodes and apply barrier cream Date initiated 5/27/16 · Skin assessment to be completed per Living Center Policy Date initiated 6/2/16 · Treatments as ordered. Date initiated 5/27/16 Resident #3's Clinical Health Status form dated 4/2/16 indicates that Resident #3 had two skin conditions upon admission. Skin condition #1 was the coccyx pressure injury stage 2. This was first observed according to the form on 4/2/16. This section was completed by a different nurse completing Skin condition #2. Skin condition #2 is listed as a heel deep tissue injury. This is signed by a different nurse whose signature is not listed on the last page which is the signature page. The measurements were listed as 6cm x 4cm and the date first observed is listed as 4/4/16 which is 2 days after Resident #3 returned from the hospital. The form indicates boots as an intervention to prevent pressure injury, but there was no evidence that the intervention was implemented. The form includes a Braden Scale Assessment score of 12 which indicates Resident #3 is at high risk of acquiring a pressure injury. Resident #3's nursing progress notes include the following: 4/2/16 at 2:58 P.M., Resident arrived at facility at 1130 via paramedic. Resident alert and able to make some needs known. Resident c/o (complain of) right foot discomfort at 3/10 improved when foot was repositioned. No further complaints of pain to report . Resident has stage 2 wound to right buttock length 8 width 4.5, depth 0.1. Wound is 80% beefy red with a yellow center the size of a dime. Serosang drainage on dressing. No odor to report and Resident tolerated dressing change well. There is no indication that upon admission Resident #3 had a pressure injury to the left heel. The following progress note was entered 4/6/16 at 2:26P.M., Situation: CNA (Certified Nursing Assistant) reports to writer that resident has a wound to his left foot. Background: Resident has a stage III pressure ulcer to his right buttock. He is incontinent of bowel and bladder. Assessment: Upon assessment, resident has two DTIs to his left lateral foot and heel. Area to left lateral foot measures 9.5cm x 3cm. The area to the left heel measures 6cm x 4 cm. There is no drainage or break in skin. Both areas are dark in color. Periwound is normal. Resident does not show any signs of pain or discomfort. Response: (Wound Physician-E) is in to assess. New order was given to skin prep to these areas and continue to offload. The documentation indicates that the pressure injury was first discovered on 4/6/16, which is 4 days after re-admission to the facility. Resident #3's Wound Evaluation Flow Sheet has an effective date of 4/6/16. The Wound Evaluation Week 1 indicates Resident #3 has a pressure wound on the left lateral foot. The measurements are 9.5cm by 3cm with 0 depth noted. The stage is listed at Suspected Deep Tissue Injury. The wound is listed as identified on 4/6/16. From 4/2/16 to 4/6/16 there is no indication in the nursing progress notes that Resident #3's heels were being offloaded or that prevalon boots were being applied to prevent pressure injuries. There is no indication that the pressure injury was assessed according to the nursing notes until 4/6/16. There is also no indication of prevalon boots or offloading of pressure to heels as an intervention on the initial care plan. On 9/28/16 at 9:10 A.M., Surveyor # interviewed Wound Physician-E regarding Resident #3's multiple pressure injuries to both heels, including the left heel which was first discovered 4/6/16. Wound Physician-E indicated to Surveyor that Resident #3's heel injuries were from pressure, and that they (the wound team) had called them pressure. On 9/28/16 at 3P.M, Surveyor # interviewed Registered Nurse (RN)-D regarding Resident #3's heel pressure injury and asked what was done from 4/2/16 to 4/6/16 to prevent the development of the pressure injury. RN-D indicated to Surveyor that (Resident #3) had old boots that were placed on Resident #3 and that they were replaced with new boots. RN-D did not have documentation to show when the boots were placed and could not remember the dates the boots were placed and replaced with new boots. RN-D indicated to Surveyor # that Resident #3 would have had a specialty mattress, MA65 mattress, in place prior to Resident #3's arrival to the facility. RN-D indicated that the specialty mattress would prevent pressure injuries from occurring by offloading pressure. Surveyor # asked for documentation showing that Resident #3 was o

Based on record review and interview the facility did not consult with the resident's physician when there was a significant change in the resident's physical status for 2 (Resident #1 and Resident #3) of 10 sampled Residents. Resident #1 had a pressure injury to his coccyx area. The facility failed to consult with a physician when the pressure injury was noted to have a strong odor and the dressing was noted to be saturated with greenish drainage on 7/22/16. On 7/24/16 Resident #1 was sent to the hospital and was admitted in serious condition [MEDICAL CONDITION]. Resident #1 was found to have the coccyx wound infected,[MEDICAL CONDITION] and septic shock. On 7/25/16 Resident #1 had to have surgery which included the removal of his coccyx and wide debridement of skin, subcutaneous tissue, muscle fascia, and muscle. On 7/30/16 Resident #1 had surgery to have a diverting [MEDICAL CONDITION] placed. The facility's failure to promptly consult with the physician to obtain guidance and orders for treatment when Resident #1's pressure injury dressing was saturated with greenish drainage and when a strong odor was noted on the wound created a finding of Immediate Jeopardy for Resident #1 beginning on 7/22/16. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy and substandard quality of care on 9/28/16 at 1:40p.m. The Immediate Jeopardy was removed on 9/30/16 when the facility implemented their action plan; however, the deficient practice continues at a scope and severity level of D (potental for harm/isolated) as the Facility has not fully implemented its removal plan. Resident #3 had no evidence of physician notification when his wound was noted to have green drainage. Findings include: Cross-Reference F314 According to the PREVENTION AND treatment of [REDACTED]. 1. Have a high index of suspicion of local infection in a pressure ulcer in the presence of: · Lack of signs of healing for two weeks; · Friable granulation tissue, · Malodor · Increased pain in the ulcer · Increased heat in the tissue around the ulcer; · Increased drainage from the wound; · An ominous change in the nature of the wound drainage (e.g., new onset of bloody drainage, purulent drainage); · Increased necrotic tissue in the wound bed; and/or · Pocketing or bridging in the wound bed. The facility's NOTIFICATION OF CHANGE IN RESIDENT HEALTH STATUS policy with an effective date of 11/12/2014 states, The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: .(B) Acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e. deterioration in health, mental, psychosocial status in either life-threatening conditions or clinical complications.) Criteria: life threatening conditions are such things as a [MEDICAL CONDITION] or stroke. Clinical complications are such things as development of a stage 2 pressure sore when ulcers were previously present at stage 2 or higher, onset or recurrent periods of [MEDICAL CONDITION], recurrent urinary tract infection, or persistent decline in psycho social status. Appropriate notification time: immediate. (C) A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment because of adverse consequences (e.g. an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g. the use of any medical procedure, or therapy that has not been used on that resident before.) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Clinical Health Status document with an admission date of [DATE] also documents under the section SKIN CONDITIONS a skin concern first observed 6/3/16 a 2.5cmx1.0cm wound to the coccyx with a description of wound 100% slough. Resident #1's Wound Evaluation Week 1 flow sheet signed 6/7/16 documents the pressure injury measurements as 3cm (L) x1.8cm (W) x0.1cm (D) and 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. Exudate is documented as serous, thin, watery, and with a small/minimal amount. No odor is documented as present. Wound bed is documented as 100% slough. Wound Evaluation Week 2 signed 6/8/16 documents the pressure injury measurements as 2.6cm (L) x2cm (W) x0.1cm (D) and unstageable. Exudate is documented as serous, thin, watery, and with a scant amount. Odor is documented as not present. Wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Under Current Wound Status/additional comments: is documented Wound does not show any signs of infection. Wound Physician-E's progress note dated 6/8/16 documents, Wound #1 coccyx is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.6cm length x 2cm width x 0.1cm depth, with an area of 5.2 sq. cm and a volume of 0.52 cubic cm. There is a small amount of serous drainage noted. Wound bed is 76-100% adherent, yellow slough. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Wound Evaluation Week 3 signed 6/15/16 documents the pressure injury measurements as 2.6cm (L) x 1.6cm (W) with no documented depth. It is documented as a stage III pressure injury. Exudate is documented as serous, thin, watery and with a small/minimal amount. Odor is documented as not present. Wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented No signs of infection noted to site at this time. Wound Evaluation Week 4 signed 6/23/16 documents the pressure injury measurements as 2.2 cm (L) x 4.1 cm (W) x 0.1cm (D) and as a stage III pressure injury. Exudate is documented as serosanguineous, thin, watery, and with a small/minimal amount. Odor is documented as not present. Wound bed is documented as 25% slough, and 25% skin; odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented No signs of infection noted to site at this time. Wound Physician-E's progress note dated 6/22/16 documents, Wound #1 coccyx is an Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.2cm length x 4.1 cm width x 0.1cm depth, with an area of 9.02 sq cm and a volume of 0.902 cubic cm. There is a small amount of serous drainage noted. Would bed is 1-25% [MEDICATION NAME], 1-25% adherent, yellow slough, 26-50% non-granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. General Notes: 50% Non granulation: area shows features of a DTI (deep tissue injury) Wound Evaluation Week 5 signed 6/29/16 documents the pressure injury measurements as 4.4cm length x4cm width X 0.1cm Depth and as unstageable. Exudate is documented as serous, thin, watery, and a small/minimal amount. No odor is documented. The wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented, Wound is 100% slough so it is unstageable. The features of a DT (deep tissue injury) noted previously have decreased. Wound Physician-E's progress note dated 6/29/16 documents, Wound #1 Coccyx is Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 4.4cm length x4cm width x0.1cm depth, with an area of 17.6 sq cm and a volume of 1.76 cubic cm. There is a small amount of serous drainage noted. Wound bed is 51-75% adherent, yellow slough, 1-25% non-granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. General notes: Features of DTI noted previously decreased. Wound Evaluation Week 6 signed 7/6/16 by RN(registered nurse)-D documents the pressure injury measurements as 8.1cm length x 4.7cm width x0.1cm depth and as unstageable. Exudate is documented as serous, thin, watery, and a moderate amount. Odor is documented as not present. The wound bed is documented as 25% granulation and 75% slough, odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented No signs of infection noted to site at this time. On 9/28/16 Surveyor # interviewed RN-D. Surveyor # asked if RN-D recalled notifying a physician when Resident #1's wound increased in size from 4.4cm length x4cm width x0.1cm depth on 6/29/16 to 8.1cm length x 4.7cm width x0.1cm depth on 7/6/16. RN-D stated that he does wound rounds with Wound Physician-E on Wednesdays, and although he did not document notifying Wound Physician-E he believes that they discussed Resident #1's wound on 7/6/16. Wound Evaluation Week 7 signed 7/13/16 documents the pressure injury measurements as 6.5cm length x 4cm width x0.1cm depth and as unstageable. Exudate is documented as serous, thin, watery, and a moderate amount. Odor is documented as not present. The wound bed is documented as 100% slough, odor and purulent drainage are not checked as present. Under Current Wound Status/Additional Comments is documented, Wound was debrided today per (Wound Physician-E). Resident tolerated well. Wound Physician-E's progress notes dated 7/13/16 documents, Wound #1 (Pressure Ulcer) is located on the coccyx. Medical Necessity: The ulcer base is slough/necrotic. A skin/subcutaneous tissue level excisional debridement was performed by (Wound Physician-E), MD. Adipose, Dermis, Epidermis, and Subcutaneous were removed along with devitalized tissue: exudate and slough. The following instruments(s) were used: blade and forceps. Total area debrided was 26sq cm. Pain control was achieved using None. A time out was conducted prior to the start of the procedure. A minimal amount of bleeding was controlled with pressure. The procedure was tolerated well with a pain level of 0 throughout and a pain level of 0 following the procedure. Post debridement Measurements: 6.5cm length x 4cm width x0.2 cm depth with a Percentage Debrided at 100% and a volume of 5.2 cubic cm; post debridement stage notes as a Stage 3 Pressure Injury. On 7/19/16 at 1:55 p.m. and 9:29 p.m. LPN (licensed practical nurse)-F documented, Drsg (dressing) changed to coccyx this am shift. Odor noted slough noted. Resident in bed at this time with no complaints call light within reach. There is no documentation of physician or a RN notification regarding the presence of an odor to the wound. Surveyor # noted that this was the first time the presence of an odor was documented. On 9/27/16 at 8:11 a.m. Surveyor # interviewed RN Manager-C, who is part of the wound team. Surveyor # asked if RN Manager-C, had been notified of an odor to Resident #1's wound. RN Manager-C informed Surveyor # that she could not recall if she had been notified of an odor, but she would have documented on the Wound Evaluation Week 8 signed 7/20/16 if she had noted an odor to the wound at that time. On 9/27/16 at 3:25 p.m. Surveyor # interviewed LPN-F. Surveyor # asked LPN-F if she had notified a physician or RN regarding the presence of an odor to the coccyx. LPN-F informed Surveyor # that she could not recall for sure, but believes that because 7/19/16 was a Tuesday she would have left a sticky note for the wound team, which includes Wound Physician-E and RN Manager-C, to evaluate on Wednesday; as the wound team rounds on Wednesday. The Wound Evaluation Week 8 signed 7/20/16 by RN Manager-C documents the pressure injury measurements as 6.2cm length x 5cm width x0.1cm depth and as unstageable. Exudate is documented as serous, thin, watery, and a small/minimal amount. Odor is documented as not present. The wound bed is documented as 100% slough; odor and purulent drainage are not checked as present. Physician-R's progress note dated 7/20/16 documents vitals stable, afebrile, and that patient to be closely monitored. The progress note does not document any information regarding Resident #1's pressure injury. On 7/21/15 at 6:38 p.m. LPN-G documented, Drsg (dressing) to coccyx was changed this pm shift. Resident had no discomfort this pm shift. Foley patent and draining yellow urine. Resident in bed at this time repositioned with cares. Call light within reach. Will continue to monitor. LPN-G did not document the presence of drainage or an odor. On 7/22/16 at 7:14 p.m. LPN-G documented, Drsg (dressing) to coccyx was changed this pm shift. Dressing saturated with greenish drainage. Strong odor noted on the wound. Resident had no discomfort this pm shift. Foley patent and draining yellow urine. Resident in bed at this time repositioned with cares. Call light within reach. Will continue to monitor. There is no documentation of physician notification, or of an RN assessment completed following the presence of the dressing being saturated with greenish drainage and a strong odor. Surveyor # noted that this was the first time greenish drainage is documented. No temperatures are documented on 7/22/16. On 9/26/16 at 4:55 p.m., Surveyor # interviewed LPN-G. Surveyor # asked LPN-G if she recalled notifying an RN or physician on (Friday) 7/22/16 regarding Resident #1's wound having greenish drainage and a strong order. LPN-G informed Surveyor # that 7/22/16 was a Friday, and that the wound team would have seen the wound on Wednesday (7/20/16). LPN-G stated that she did not think that this was a change for that wound. LPN-G stated that she would have documented notifying the physician or an RN. LPN-G confirmed that she did not believe that she contacted the physician on 7/22/16 regarding Resident #1's dressing being saturated with greenish drainage and a strong odor noted on the wound. On 9/27/16 at 1p.m., Surveyor # interviewed Wound Physician-E over the phone. Surveyor # asked Wound Physician-E if he recalled Resident #1's wound having odor or green drainage. Wound Physician-E informed Surveyor # that he did not recall being notified of an odor or green drainage. Wound Physician-E stated that with a change of status to the wound (such as odor/green drainage) he would either see the patient or change the treatment. Surveyor # asked Wound Physician-E if he would expect to be notified of green drainage and a strong odor. Wound Physician-E stated yes and that he is always available by multiple routes for the facility to contact him. On 9/26/16 at 5:21 p.m., Surveyor # interviewed Director of Nursing (DON)-B. Surveyor # asked DON-B if a physician should have been notified of a wound having a strong odor and greenish drainage. DON-B stated that if it was a change the physician should have been notified. On 7/23/16 at 11:15 a.m., RN-S documented, Tx (treatment) done to coccyx, Slough noted at open wound center. Old dressing saturated with urine. No temperature is documented on 7/23/16. On 7/24/16 at 4:15 p.m. an SBAR (Situation, Background, Assessment, Response) Change of Condition note documents, Situation: Temp 100.6 Lethargy, yellowish discharge from penis, increased drainage from coccyx pressure ulcer, decreased appetite. Background: Chronic pai[DIAGNOSES REDACTED], retention of urine, pressure ulcer of coccyx, DM (diabetes mellitus),[MEDICAL CONDITION](hypertension), AFIB (arterial fibrillation), constipation, history [MEDICAL CONDITIONS], muscle weakness Assessment: Temp 100.6 P79 R20 Bp 146/70 Spo2 91% RA (room air) Resident is lethargic, yellowish discharge from penis decreased appetite. RN assessed. Response: (Physician-R) updated New order to send to West Memorial Hospital. (emergency contact) updated. (DON-B and NHA-A) updated. On 9/26/16, Surveyor # reviewed Resident #1's hospital record. ED (emergency department) Provider Notes document on 7/24/16 at 6:10 p.m., Sacral decubitus ulcer to buttock with small amount of bleeding from wound. Wound is also pustulating and has surrounding [DIAGNOSES REDACTED]. Wound is superior to the rectum. No tenderness to perineum. Under ED Course at 6:17 the Initial Impression is documented as, I performed the initial assessment and evaluation of the patient. I discussed his plan of care since he is febrile, weak, and has an infected wound, that he will need IV abx (antibiotics) . The hospital Discharge Summary dated 7/26/16 includes final [DIAGNOSES REDACTED]. sacral ulcer with underlying [DIAGNOSES REDACTED] and underwent debridement with (MD). He was placed on broad-spectrum IV antibiotics and transferred to ICU. His blood cultures are positive for gram-positive cocci in chains. He was placed on boar spectrum IV antibiotics. Path is still pending. At this point, wound care team recommends aggressive hyperbaric treatment. At this point, they recommend aggressive hyperbaric treatment, which will be initiated at St. Luke's Medical Center .Remains bed bound. He will need a diverting ostomy . An encounter note date 7/25/16 documents .In the emergency department a large sacral decubitus ulcer was seen in (MD) was consulted and he was taken to surgery today. He was noted to have a stage IV decubitus wound/necrotizing soft tissue infection measuring 12x15x3.5cm and going down to the coccyx and sacrum necessitating removal of the coccyx On 7/26/16 Resident #1 was transferred to a different hospital. An infectious disease consult with a date of service of 7/27/16 includes the impression of 1.[MEDICAL CONDITION] secondary to necrotizing sacral wound infection, status [REDACTED]. Sacral and coccygeal osteo[DIAGNOSES REDACTED] On 7/30/16 Resident #1's procedure encounter notes document that Resident #1 had a Laparoscopic and sigmoid [MEDICAL CONDITION] and debridement, excisional sacral wound, 15x15 cm skin, subcutaneous tissue, muscle, and bone. A plastic and reconstructive surgery consult on 8/3/16 documents, All surgical options result in a permanent scar. Every effort will be made to keep closure as simple as possible. A local rotation flap will be required which necessitates additional incisions that borrow tissue from adjacent areas, thus resulting in longer scars. The consult continues to say that The wound however, is not ready for surgical closure. It is recommended that patient continue with local wound care with the wound VAC for now. Once the wound shows evidence of healing, flap closure will be considered/planned. The facility's failure to promptly consult with the physician to obtain guidance and orders for treatment when Resident #1's pressure injury dressing was saturated with greenish drainage and when a strong odor was noted on the wound created a finding of Immediate Jeopardy for Resident #1 beginning on 7/22/16. The immediate jeopardy was removed on 9/30/16 when: · Resident #1 was discharged to the hospital on [DATE]. · Interdisciplinary progress notes reviewed from July 22, 2016 to present and anyone showing a change of condition was communicated to the physician will have that notification made upon identification for any recommended interventions. · Licensed nursing staff has been immediately in-serviced on the notification process to physicians and/or physician extenders, responsible parties and community case management of change requirements in a resident condition. 16 out of 30 licensed staff has been in-serviced as of 9/29/16 with remaining staffing being trained prior to the start of their next scheduled shift. · Change in resident condition will be added to the nursing 24-hour reporting board and reviewed at clinical start-up. · 5 random audits will be performed weekly to ensure compliance. · Audits will be reviewed at monthly QAPI. Once it has been determined by the QAPI (Quality Assurance and Program Improvement) members that compliance has been reached consistently, the committee members may make a determination as to the frequency of the auditing process. The Executive Director is responsible to ensure this process occurs. This deficient practice continues at a scope and severity level of D (potential harm/isolated) based upon the following; 2. Resident #3 was admitted to the facility on [DATE], discharged to the hospital on [DATE], and re-admitted to the facility on [DATE]. Resident #3 had [DIAGNOSES REDACTED]. Resident #3 also had multiple pressure injuries including a left heel pressure injury and a right heel pressure injury that were being treated by Wound Physician-E on a regular basis. Resident #3's initial Minimum Data Set ((MDS) dated [DATE] indicates that Resident #3 required extensive assistance from one staff member for bed mobility and extensive assistance from two staff members for transferring. The MDS indicates that Resident #3 is at risk for pressure injuries and the MDS indicates Resident #3 has an unhealed pressure injury at stage 1 or greater. The Care Area Assessment (CAA) associated with the 4/8/16 MDS indicates Resident #3 is at risk for pressure ulcers and indicates that Resident #3 has a pressure ulcer on the coccyx and two suspected deep tissue injuries to the left foot. The intervention listed is to turn and reposition Resident #3 and the decision was made to develop a care plan. On 9/27/16 at 11:09 A.M., Surveyor # received a copy of Resident #3's care plan dated 3/25/16 that states, At risk for Alt (altered) skin integrity related to [MEDICAL CONDITIONS], dementia, decreased mobility, and [MEDICAL CONDITION]. The interventions listed include: · Evaluate need for skin management program · Assess resident entire skin upon admission · Administer good peri care to include use of barrier agent following any incontinent episode · Initiate reposition schedule in w/c (wheelchair) and in bed every 2-3 hours and PRN (as needed). · Implement your facility's system for identifying res at risk for skin breakdown · Involve resident in increased mobility activities. · Assess skin daily during cares · Initiate appropriate pressure reduction devices: w/c cushion, mattress · Evaluate effect of cognitive impairment upon resident's ability to understand · Nutritional assessment prn · Involve the resident in decision making regarding daily choices · When transferring, turning and repositioning use proper techniques so as to avoid friction and shear. Resident #3 had an additional care plan with a focus listed as, Potential for alteration in skin integrity r/t (related to) pressure ulcers, impaired mobility,[MEDICAL CONDITION](cerebral vascular disease), [MEDICAL CONDITION] ect. The date initiated is listed at 5/27/16. The goals are listed as, Will remain free from further breakdown, and Pressure ulcer will heal without complication. The interventions listed include: · Assist res. to reposition q 2-3 hours and prn, Use proper techniques to avoid friction and sheer. Date initiated 5/27/16 · Complete Braden Scale per Living Center Policy Date initiated 5/27/16 · Do not massage over bony prominence Date initiated 5/27/16 · Monitor skin daily with cares and weekly with showers and body assessments. Report any new open areas or areas of redness, rashes, blisters, bruises, ect. Date initiated 5/27/16 · Monitor wound progress weekly with wound nurse. Date initiated 6/2/16 · Nutritional and hydration support date initiated 5/27/16 · Podiatry consult 6/2/16 · Prevalon or similar heel boots on at all times until wounds are healed. Date initiated 5/27/16 · Provide pressure reducing wheelchair cushion Date initiated 5/27/16 · Provide thorough skin care after incontinence episodes and apply barrier cream Date initiated 5/27/16 · Skin assessment to be completed per Living Center Policy Date initiated 6/2/16 · Treatments as ordered. Date initiated 5/27/16 Resident #3 acquired a deep tissue injury pressure injury on the left heel which was first observed on 6/1/16 at the facility. Resident #3 also acquired a deep tissue injury on the right heel which was also first observed on 6/1/16. The right heel pressure injury was noted to be a stage 3 once the wound bed was observed. The left remained a suspected deep tissue injury. Resident #3's nursing and physician progress notes [REDACTED]. Resident #3's wound progress note dated 9/14/16 signed by Wound Physician-E states, Wound #3 left, lateral heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed Wound bed is 76%-100% dry, black eschar. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The progress note also states, Wound #4 Right Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed . Wound bed is 76%-100% dry, black escar. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The above documentation indicated that on 9/14/16, Wound Physician-E did not see green periwound or green drainage . 9/24/16, at 1:32 P.M., Bilateral heel dressings changed today by writer, green drainage detected on left heel, no odor present no c/o (complaints of) pain, continues to heal, all dressings clean, dry and intact. This is the first nursing progress note that indicated presence of green drainage. There is no note indicating that the doctor was updated regarding the green drainage. 9/25/16 at 10:17 A.M., Bilateral heel dressings changed today by writer, green drainage detected on left heel, no odor present no c/o pain, continues to wear prevlon boots as ordered, scheduled pain medications given as ordered, right heel area continues to heal, green drainage also noted, all dressings clean dry and intact. Treatment also applied to scrotum surrounding skin pink area continues to heal no drainage noted. This is the first note indicating green drainage on the right heel. There is no documented evidence that a doctor was notified regarding the change in the wound. There is no indication that Wound Physician-E was notified of the wound changes noted on 9/24/16 and 9/25/16 which included newly assessed green drainage. On 9/26/16 at 7:57 A.M., Surveyor # observed Registered Nurse Manager-C and Licensed Practical Nurse (LPN)-X perform Resident #3's dressing change. Surveyor # observed Resident #3's left heel peri-wound to be green in color and the drainage in agreement as per the documentation. Resident #3's wound progress note dated 9/28/16 signed by Wound Physician-E's states, Wound #3 left, lateral heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed There is a small amount of green drainage noted. Wound bed is 1-25% adherent yellow slough, 51%-75% granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The progress note also states, Wound #4 Right Heel is a stage 3 Pressure Injury and has received a status of Not Healed . There is a small amount of green drainage noted. Wound bed is 76%-100% granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. On 9/28/16, Wound Physician-E changed Resident #3's treatment to the left and right heels to include a 5 minute Dakin's soak. There is no evidence in Resident #3's medical record that either the primary physician or the Wound Physician-E was updated when the green drainage was first observed for each the left and right heel wound. There is no evidence that the physician was updated regarding the change in Resident #3's wound until 9/28/16 when the Wound Physician-E was in to assess the wound. On 9/29/16, at 1 P.M., Surveyor # interviewed RN-D regarding the physician notification of the wound changes noted on 9/24/16 and 9/25/16. RN-D indicated to Surveyor that both RN-D and RN Manager- C call Wound Physician-E frequently and that RN Manager-C would have called Wound Physician-E that evening. RN-D indicated that Wound Physician-E indicated to keep the treatments in place. Surveyor # requested evidence of physician contact or documentation related to Wound Physician-E stating to keep the treatment the same, and RN-D was unable to provide evidence that the physician had been notified of the change in condition of the wound. RN-D indicated that after Wound Physician-E observed the wound (9/28/16), Wound Physician-E changed the dressing due to the assessment and wound changes which included the green periwound color. Surveyor shared that Surveyor had also observed the green periwound during the dressing change on 9/26/16. The above information was shared with the NHA-A on 9/28/16 at 3:07 P.M., and no additional information was provided to the surveyor indicating that the physician was notified when a change in condition was noted to Resident #3's left heel pressure injury on 9/24/16 and right heel pressure injury 9/25/16.

Based off of interview and record review the facility did not ensure that 1 (Resident #2) of 1 Residents reviewed with incontinence associated [MEDICAL CONDITION] received the necessary care and services in accordance to his plan of care to promote healing of the area and that 5 (Resident #2, #12, #17, #4 and #13) of 5 Residents with fistulas received the necessary care and services regarding the care of the fistula. Resident #2 had no documented wound evaluation from 8/31/16 to 9/14/16 during which time his incontinence associated [MEDICAL CONDITION] coccyx wound progressed to be full thickness breakdown. The facility did not do a weekly assessment of the area which prevented them from promptly identifying changes to the area and initiating changes to prevent further worsening of the wound. Residents #2,#12, #17, #4, and #13 have documented blood pressures taken on their fistula arm. Example #1 rises to a scope and severity level of G (harm/isolated.) Findings include: 1. The facility's SKIN INTEGRITY GUIDLINE with no date noted states under Documentation of Weekly Skin Evaluation/Observations, Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS) UDA (user defined assessment) (one UDA per wound identified). Surveyor # reviewed Resident #2's medical record. Resident #2 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set assessment with an assessment reference date of 8/24/16 documents that Resident #2 is occasionally incontinent of urine, requires extensive assistance of staff for toilet use, and has moisture associated skin damage. The Wound Evaluation Week 1 signed 8/24/16 documents that Resident #2 had a 1.5cm length x1.5cm width x0.1cm depth area of excoriation that was identified on 8/17/16. The current treatment is documented as Cleanse with normal saline. Pat dry. Skin prep the periwound. Apply [MEDICATION NAME] to areas of excoriation. Change qMWF (every Monday, Wednesday, Friday) and as needed. The Wound Evaluation Week 2 signed 8/31/16 documents the wound to be 1cm length x 1cm width x0.1cm depth. The wound bed is documented to be 100% granulation tissue. The current treatment ordered 8/31/16 is documented to Apply zinc barrier cream twice daily. Under comments the form documents, Wound is showing great improvement. New order was given to apply zinc barrier cream twice daily. The Wound Evaluation Week 3 signed 9/14/16 (2 weeks from the previous evaluation) documents the wound to have increased in size to 5cm length x7.5cm width x0.1cm depth. Under the section surrounding tissue additional notes section of the evaluation is documented, involved area is excoriated. There are multiple small openings measuring no greater than 1cm x 1cm within the total area measured. The form documents the Current treatment with a treatment ordered dates as Cleanse with ½ strength dakins solutions. Pat dry. Cover with zinc barrier cream. Wound Physician-E's progress note on 9/14/16 documents the wound as Wound #2 is a Full Thickness Incontinence Associated [MEDICAL CONDITION] and has received a status of Not Healed. Initial wound encounter measurements are 5cm length x 7.5cm width, with an area of 37.5 sq cm. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. General Notes: Excoriation seen, within measured area; 25 to 50% full thickness breakdown. Surveyor # noted that there were no documented wound evaluation between 8/31/16 and 9/14/16. Resident #2's wound had progressed into a wound documented to be full thickness breakdown. The facility did not do a weekly assessment of the area which prevented them from promptly identifying changes to the area and initiating changes to prevent further worsening of the wound. The Wound Evaluation Week 4 signed 9/21/16 documented the wound as 1.6cm length x1.1cm width x0.1cm depth, stages the wound as a stage 3 and comments, Area measured is area of pressure. Excoriation is noted throughout the bilateral buttocks. The wound bed is documented to be 75% granulation and 25% slough. The current treatment ordered 9/21/16 is documented as, Cleanse with ½ strength dakins solution. Pat Dry. Apply skin prep to the periwound. Apply santyl to the wound bed. Cover with a border gauze. Further offload with border foam. Change daily and as needed. Under Current Wound Status/Additional Comments is documented, Wound is showing Characteristics of becoming a pressure wound. Wound will be staged III due to the presence of slough to the wound bed. Resident continues on therapy and they are treating the wound. Wound Physician-E's progress note on 9/28/16 documents the area as Wound #2 sacral is a Full Thickness Incontinence Associated [MEDICAL CONDITION] and has received a status of Not healed. Subsequent wound encounter measurements are 2.7cm length x1.5cm width, with an area of 4.05 sq. cm. On 9/28/16 at 3 p.m. Surveyor # interviewed RN Manager-C regarding Resident #2 not having a wound evaluation completed between 8/31/16 and 9/14/16. RN Manager-C informed Surveyor # that she did not work on 9/7/16 and that RN Manager-D should have done the wound evaluation for that date, and was looking for more information. RN Manager-C also informed Surveyor # that Wound Physician-E had seen the wound on 9/28/16 and was considering the area to be incontinence associated [MEDICAL CONDITION] and not pressure. On 9/28/16 at 3:30 p.m. during the daily exit meeting with the facility Surveyor # informed NHA (nursing home administrator)-A and DON (Director of Nursing)-B of Resident #2 not having a documented wound evaluation between 8/31/16 and 9/14/16. On 9/29/16 at approximately 12:30 p.m. RN Manager-D informed Surveyor # that it appeared that Resident #2 did not get added to the wound round list for 9/7/16 and it appeared that he was missed that week for wound rounds. 2. [MEDICAL TREATMENT] is a needed procedure when the human kidneys cannot filter the blood anymore. Blood is removed from the body and filtered through a machine multiple times a week. A fistula is a surgically created vein which is used to remove blood from the body in large quantities to send through the machine that cleans the blood before returning the blood back to the body. A fistula needs to be monitored and observed for signs of infection and functionality. Additionally, it is important to not bump the fistula or take blood pressures over the fistula to prevent complications with the fistula. Surveyor # obtained the above Information from <https://www.niddk.nih.gov/health-information/health-topics/kidney-disease/vascular-access-for-[MEDICAL TREATMENT]/Pages/index.aspx#sec6> and <https://medlineplus.gov/ency/patientinstructions/ 1.htm> related to not taking blood pressure over fistula. Surveyor # reviewed the facility's [MEDICAL TREATMENT] GUIDELINE policy with an effective date of 4/04/2016 under the section Care of the Fistula/Graft states and is underlined, No blood pressures are to be taken on the access arm. Resident #2 has [DIAGNOSES REDACTED]. Resident #2's Alteration Kidney Function-[MEDICAL TREATMENT] care plan includes Do not take BP (blood pressure) on arm with fistula. Resident #2's progress notes on 8/17/16 documents, .Resident has an AV fistula to left upper arm bruit and thrill present. On 9/26/16 during cares, Surveyor # observed a dressing on Resident #2's left upper arm over the fistula. Surveyor # reviewed Resident #2's blood pressure documentation which shows on 8/18/16, 8/19/16,8/20/16, 9/12/16, 9/13/16, 9/14/16, 9/15/16, 9/16/16, 9/17/16, 9/18/16, 9/19/16 ,9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, and 9/27/16 the blood pressure was documented as being taken from the left arm (the arm that Resident #2's fistula is on). On 9/28/16, at 7:30 A.M., the Nursing Home Administrator (NHA)-A came into the conference room and discussed with Survey team the following; NHA-A indicated that after seeing the blood pressures the Survey team had requested, NHA-A talked to staff and indicated that some staff were documenting the wrong arm, but that a few were taking them (blood pressures) in the affected areas. NHA-A indicated that training was started immediately regarding not taking the blood pressure in the affected arm. 3. Surveyor # reviewed Resident #12's medical record. Resident #12's original admission to the facility was 12/9/2011 with a most recent re-admission to the facility of 6/22/16. Resident #12 has [DIAGNOSES REDACTED]. Resident #12's most recent Minimum Data Set ((MDS) dated [DATE] is a quarterly assessment and indicates Resident #12's Brief Interview for Mental Status Score is 12 out of 15 indicating Resident #12 is moderately cognitively impaired. Resident #12 was deemed interviewable by Registered Nurse (RN)-D during the initial tour on 9/22/16, and who answered Surveyor # appropriately. Resident #12's Care Plan had an initiation date of 12/22/15 and the focus stated, Alteration in kidney function due to [MEDICAL TREATMENT] r/t (related to) [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]). Fistula LUE (left upper extremity), risk for bleeding/infection of fistula, ect. Under interventions the Care Plan stated, Do not take blood pressure, blood samples, or insert IV in arm with access site. Encourage patient not to sleep on arm with access site. On 9/29/16 at 12:30 P.M., Surveyor # observed Resident #12 in Resident #12's room. Surveyor introduced self and asked Resident #12 if Surveyor could see the fistula. Resident #12 showed Surveyor # the fistula which was large and on the left upper arm. Surveyor # reviewed Resident #12's vital signs back to January 1, 2016. Since January 1, 2016, Resident #12 has had the blood pressure taken in the left arm 3 times according to the vital sign documentation. Resident #12 should not have the blood pressure taken on the left arm to avoid complications to the fistula. On 9/28/16 at 7:30 A.M., the Nursing Home Administrator (NHA)-A discussed with Survey team the following; NHA-A indicated that after seeing the blood pressures the Survey team had requested, NHA-A spoke to staff stating some staff were documenting the wrong arm, but a few were taking them (blood pressures) in the affected areas. NHA-A reported training was immediately started regarding not taking the blood pressure in the affected arm. On 9/29/16, at 10:44 A.M., Surveyor # interviewed the unit manager, RN-D regarding the documentation that indicated multiple residents including Resident #12 received blood pressure readings on an arm with a fistula. Surveyor # asked RN-D what RN-D's expectations were for nursing staff when taking vitals on a resident with a fistula? RN-D stated, My expectation is don't take blood pressure on site with the fistula. The above was discussed with the NHA-A on 9/28/16. 4. Surveyor # reviewed Resident #17's medical record. Resident #17's original admission to the facility was 1/17/2016. Resident #17 has [DIAGNOSES REDACTED]. Resident #17's most recent Minimum Data Set ((MDS) dated [DATE] is a significant change MDS and indicates Resident #17's Brief Interview for Mental Status Score is 7 out of 15 indicating Resident #17 is moderately cognitively impaired. Resident #17's Care Plan has an initiation date of 3/3/16 and the focus stated, Alteration in kidney function due to End Stage [MEDICAL CONDITIONS], evidenced by [MEDICAL TREATMENT], Risk for infection related to fistula site, Left arm AV fistula. Under interventions the Care Plan states, Do not take blood pressure, blood samples, or insert IV in arm with access site. Encourage patient not to sleep on arm with access site. The intervention was dated 3/3/16. On 9/29/16 at 8:00 A.M., Surveyor # observed Resident #17 in Resident #17's room. Surveyor introduced self and asked Resident #17 if Surveyor could see the fistula. Resident #17 showed Surveyor # the fistula which was large and on the left upper arm. When Surveyor asked if staff take blood pressures (BP) on the left arm, Resident #17 stated, they take the BP in the right arm. Not really the left arm. Surveyor # reviewed Resident #12's vital signs back to January 14, 2016. According to the vital sign documentation, since January 14, 2016, Resident #17 has had the blood pressure taken in the left arm 16 times. Resident #17 had a fistula in the left arm and should not have a blood pressure taken on the left arm in order to avoid complications with the fistula. On 9/28/16 at 7:30 A.M., the Nursing Home Administrator (NHA)-A discussed with Survey team the following; NHA-A indicated that after seeing the blood pressures the Survey team had requested, NHA-A spoke to staff stating some staff were documenting the wrong arm, but a few were taking them (blood pressures) in the affected areas. NHA-A reported training was immediately started regarding not taking the blood pressure in the affected arm. On 9/29/16 at 10:44 A.M., Surveyor # interviewed the unit manager, RN-D regarding the documentation that indicated multiple residents including Resident #17 received blood pressure readings on an arm with a fistula. Surveyor # asked RN-D what RN-D's expectations were for nursing staff when taking vitals on a resident with a fistula? RN-D stated, My expectation is don't take blood pressure on site with the fistula. The above was discussed with the NHA-A on 9/28/16. 5. Surveyor # reviewed Resident #4's medical record. Resident #4's original admission to the facility was 7/26/2010. Resident #4 has [DIAGNOSES REDACTED]. Resident #4's most recent Minimum Data Set ((MDS) dated [DATE] is a quarterly MDS and indicated that resident #4's Brief Interview for Mental Status Score is 5 out of 15 which indicated that Resident #4 is severely cognitively impaired. Resident #4 was deemed not interviewable during the tour and throughout the survey. Resident #4's CNA Care Plan with no date indicated that Resident #4 had a fistula in the left upper extremity, but did not give direction to staff to not take the blood pressure in the left arm. Surveyor # reviewed Resident #4's vital signs back to February 23rd, 2016. According to the vital sign documentation, since February 23rd, 2016, Resident #4 has had the blood pressure taken in the left arm 82 documented times. Resident #4 had a fistula in the left arm and should not have a blood pressure taken on the left arm in order to avoid complications with the fistula. On 9/28/16, at 7:30 A.M., the Nursing Home Administrator (NHA)-A came into the conference room and discussed with Survey team the following. NHA-A indicated that after seeing the blood pressures the Survey team had requested, NHA-A talked to staff and indicated that some staff were documenting the wrong arm, but that a few were taking them (blood pressures) in the affected areas. NHA-A indicated that training was started immediately regarding not taking the blood pressure in the affected arm. On 9/29/16, at 10:44 A.M., Surveyor # interviewed the unit manager, RN-D regarding the documentation that indicated multiple residents including Resident #4 received blood pressure readings on an arm with a fistula. RN-D stated, My expectation is don't take blood pressure on site with the fistula, when asked by Surveyor # what RN-D's expectation is of nursing staff taking vitals for a resident with a fistula. The above was discussed with the NHA-A on 9/28/16. 6. Surveyor # reviewed Resident #13's medical record. Resident #13 was admitted on [DATE] and experiences end stage [MEDICAL CONDITION] and receives [MEDICAL TREATMENT] treatments three times weekly. Resident #13 has what is identified as a Fistula in the right upper arm that allows access to her veins and arteries for the the [MEDICAL TREATMENT] process. This extremity is not to be used for blood draws or blood pressures as doing so can cause damage to the site including the potential for blood clots. Per clinical record physician orders, the resident is to have daily blood pressures with reporting to the physician when the systolic is above 150. A review of the documented vitals flow sheet, from 01/16 through 09/13/16 (13 times) licensed staff have been documenting blood pressure readings from the right arm. A review of the resident's care plan under, Alteration in Kidney Functions due to end stage [MEDICAL CONDITION]. Surveyor # noted that the care plan interventions include, check access site every shift LUE (left upper extremity) A-V fistula for signs of infection. Resident 13's Fistula (access site) is on the right upper extremity and not on the left upper extremity as indicated in Resident #13's care plan. The care plan also directs staff to Check bruit and thrill on LUE (left upper extremity) fistula every shift and prn (as necessary). These interventions were initiated 02/14/14 and revised 12/23/14.

Based on interview and record review, the facility did not ensure that 1 (Resident #16) of 8 residents reviewed for pressure ulcers did not develop a pressure ulcer unless it was unavoidable and that the pressure ulcer(s) received appropriate care and treatment once it had developed. Resident #16, who was admitted without pressure ulcers, developed multiple unidentified pressure ulcers, which were not comprehensively assessed and did not receive the necessary treatment and services to promote healing. Resident #16 was admitted to the hospital on [DATE] with 9 possible pressure ulcers, some of which were unstageable and one that was necrotic. Findings include: According to the National Pressure Ulcer Advisory Panel (NPAUP) 2009 Pressure Ulcer Treatment Quick Reference Guide indicates for assessment: Assess the pressure ulcer initially and reassess it at least weekly documenting findings. With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g. wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications). Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. 3.2. Length and width: select uniform, consistent method for measuring wound length and width to facilitate meaningful comparisons of wound measurement across time. 3.4. Use pressure ulcer assessment findings to plan interventions that will best promote healing. The facility policy and procedure titled skin integrity guideline dated 2013 indicates under the section titled: Licensed nurse will be responsible for performing this skin evaluation/observation ...Licensed nurse to document weekly on all wounds using the "Wound Evaluation Flow Sheet"...Determine care plans consistently implemented, evaluated, and revised based upon the needs of the resident ... A complaint was received by SERO/DQA (Southeastern Regional Office/Division of Quality Assurance) on 4/7/14 regarding Resident #16 who had been transferred from the facility to the hospital on [DATE]. The complaint indicates the resident was admitted to the hospital for pneumonia and that the resident had open wounds on both of his feet and an open area on his knee and scrotum. On 4/22/14 the hospital records were reviewed by Surveyor # . The ED (Emergency Department) assessment upon arrival by NP N on 4/7/14 at 11:45 a.m., with agreement by hospitalist, Dr. O, indicates Resident #16 "has multiple decubiti, notably in his scrotal region. He also has ulcers to his bilateral feet and heels, left greater than right, with evidence of necrosis." The hospital assessment completed by Hospital RN P on 4/7/14 at 5:23 pm indicates: a Stage II pressure ulcer is located bilaterally on the upper scrotum measuring 5 cm (length) X 5 cm (width), one on the right medial buttock measuring 1cm x 1 cm, another on the left buttock measuring 3 cm x 2 cm, a Stage II pressure ulcer on the left lateral knee measuring 1 cm x 1 cm; also on the left lateral foot an unstageable pressure ulcer is present measuring 3.5 cm x 3 cm, and on the left posterior foot an unstageable pressure ulcer is identified as measuring 4cm x 4 cm. The hospital record also indicates that Resident #16 has pressure ulcer areas on the Right foot/heel with necrosis. A review of Resident #16's medical records was completed by Surveyor # from 4/21/14 through 4/22/14. Resident #16 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The Nursing Care Plan initiated on 3/15/13 identifies that Resident #16 is at risk for pressure ulcers due to: Assistance required in bed mobility, desensitization of skin, [DIAGNOSES REDACTED]. Protective measures/interventions put in place include: completion of a Braden scale, weekly skin inspections, diabetic foot monitoring, float heels, heel boots, nutritional and hydration support, podiatry consult, provision of a pressure reducing wheelchair cushion and pressure reduction/relieving mattress, provision of thorough skin care after incontinent episodes with application of barrier cream, referral to therapy, and treatments as ordered. All interventions were initiated on 3/15/13. The physical functioning deficit related care plan dated 3/15/13 includes an intervention stating: inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge. The alteration in blood glucose care plan dated 3/15/13 indicates as an intervention: assessment of skin and foot condition weekly by licensed nurse and report to nursing/physician any changes in poorly healing wounds. Review of Resident #16's medical record wound evaluation flow sheets shows that pressure ulcers developed as follows: Right heel: On 6/28/13 Resident #16's right lateral heel was identified as an unstageable pressure ulcer measuring 0.4 cm (length) x 0.4 cm (width) with a treatment of [REDACTED]. On 7/15/13 the treatment order was changed to cleanse the site followed by Santyl and a dry dressing with therapy completing treatments at that time. On 9/5/13 the ulcer is identified as a Stage II pressure ulcer measuring 0.2 cm x .02 cm and weekly measurements continue until 10/11/13 and 10/18/13 when it is assessed as closed. An Immediate Plan of Care at Risk for Alt. (altered) Skin Integrity form dated 11/12/13 indicates through a notation on 11/11/13 that a blister to the medial aspect of the right heel was identified indicating a suspected DTI (deep tissue injury) related to friction. Additional interventions include reposition every one hour, pillows for repositioning, an MA65 air mattress, with an added note to reposition in wheelchair and bed every 2 hours and prn (as needed). On 1/29/14, Resident #16 was seen by Dr. Y Podiatrist for foot care, the treatment note states, "Trimmed Calluses x1 to patient's tolerance." The progress note indicates "non-professional treatment is hazardous to the patient. No signs of infection." The podiatric diagnostic note states, "[MEDICAL CONDITIONS] and NIDDM (non-insulin dependent diabetes mellitus): Rt Heel wound dry eschar." Surveyor # noted that there are no facility wound sheets for Resident #16 that reflect wound care monitoring of the right heel's eschar as referenced in the podiatrist note. Outer aspect right heel: On 12/6/13 is the wound evaluation flow sheets indicate that the outer aspect of the right medial heel is identified as a Stage II pressure ulcer measuring 0.4 cm x o.3 cm with treatment order to cleanse site followed by wound gel, gauze dressing and Kerlix wrap. On 12/20/13, 1/3 and 1/10/14 the wound is described as closed. Right buttocks: On 4/27/13, the wound evaluation flow sheets indicate the right buttocks was identified as a having a Stage II pressure ulcer on 4/27/13 and treatment order of placement of a [MEDICATION NAME] dressing every three days was ordered this wound was assessed as closed on 5/14/13. Scrotum: Physician orders [REDACTED]. An Immediate Plan of Care at Risk for Alt. (altered) Skin Integrity form dated 11/12/13 indicates an area on the oa of the scrotum also identified as related to incontinence. Left knee: On 11/14/13 a nursing treatment order for the left knee skin tear includes cleaning with wound cleanser, apply wound gel and sure prep around the area and wrap it with a dry dressing. Right heel: On 12/6/13 an order was put into place to cleanse the right medial heel followed by wound gel (hydrogel) a dry dressing and a Kerlix wrap Q day with no end date. Review of the Wound Assessment/Line List log provided by Administrator A indicates: 1/2/14: unstageable pressure ulcer to the right lateral and medial heel, apply skin prep q (each) day. O/A to left lateral knee, cleanse site follow by wound gel Q day. Pressure boot, R (right) foot secondary to heel and great toe, SDTI. 1/8/14: Unstageable pressure ulcer to right lateral and medial heel, apply skin prep Q day. O/A to left lateral knee, cleanse site followed by wound gel Q day. Pressure boot R foot secondary to heel and great toe, SDTI. 1/29/14: Scrotum, knee, and R heel all closed and healed. 2/7/14: healed, continue tx (treatment) for protection. 2/12/14: healed, continue tx for protection. (Note: The annual MDS (Minimum Data Set) of 2/23/14 indicates Resident #16 was severely cognitively impaired, needed extensive assistance with mobility, transfers, hygiene, toileting and received nourishment via a feeding tube (PEG). Section M, Skin Conditions of the MDS indicates that Resident #16 does not have one or more unhealed pressure ulcers at Stage I or higher. However, Resident #16 has a history of healed pressure ulcers. The CAAs (Care Area Assessments) dated 2/23/14 indicates that the resident is at risk for developing pressure ulcers with triggering conditions of total dependence regarding bed mobility, incontinence of bowel and bladder, [MEDICAL CONDITION]/[MEDICAL CONDITIONS]([MEDICAL CONDITION]) with functional limitation in range of motion and diabetes.) 2/24/14: healed, continue tx for protection. 3/7/14: healed, continue tx for protection. 3/14/14: left heel SDTI 3/21/14: left heel SDTI, o/a measures 0.3cm x 0.5 cm Upon review of the Wound logs, Surveyor # noted that the documentation of the wounds did not include details such as specific location, category/stage type, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence or absence of granulation tissue, and [MEDICATION NAME]. Review of Resident #16's nurse's notes from 1/24/14 to 4/7/14 indicates that staff were occasionally documenting that they were completing treatments to Resident #16's open areas to include: the scrotum and heels/feet. Nurse's notes occasionally document that the treatments are intact with no other assessment or wound details. Surveyor # ' s review of Resident #16's weekly shower/bath skin assessment sheets indicates that on 1/18/14 Resident #16 was identified to have a reddened left knee and open areas to the scrotum and right heel; these areas were identified and signed off on the form by a Certified Nursing Assistant (CNA) and nurse. Also on that date, a Foot Check Form was completed indicating Resident #16 had calluses on his feet and a pressure ulcer on his heel. Surveyor # noted that despite this notation on the weekly skin/bath sheet no formal assessments of the areas are noted and no weekly wound care sheets exist regarding these areas. Additional review of the weekly shower sheets indicates on 1/27/14 a reddened scrotum is noted with no new open areas; this is signed by the CNA but is not signed by the nurse. Weekly shower sheets dated 2/12/14 and 2/26/14 indicate that no areas of concern were noted and this document is signed by the CNA with no nursing signature. On 2/25/14 bruising to the feet and reddened areas on buttocks are noted on the weekly bath sheet; this is signed by the CNA but not signed by the nurse and on 3/19/14 the weekly bath sheet indicates that Resident #16 has a reddened area to the genitals and is marked as an "old opening" signed by the CNA but is again not signed by the nurse. Surveyor # noted despite the indication on the bath sheets that Resident #16 has areas on his knee, buttocks, and scrotum no weekly wound sheets could be located in Resident #16's medical record that detailed wound assessments. A nurse's note dated 2/25/14 at 20:57 (8:57 pm) includes an entry from RN Y indicating: "Assessed skin after placed in bed, noted to left knee Band-Aid approx. dime size area, where old scab came off, left side of scrotum red, [MEDICATION NAME] as ordered, also left heel very dry skin, part of the dry skin off and lotion applied, left wound nurse a voicemail, to reassess ..." There is no documentation or indication that the physician had been called at this time or that the wound nurse had assessed these wounds. The next documented note referencing Resident #16's left heel is by the Wound Care nurse, Registered Nurse (RN) L, on 3/13/14 when a change of condition was initiated and Dr. J was called for an updated order. There is no indication that any follow up or assessment was completed regarding the open area on Resident #16's left knee and scrotum as referenced in the 2/25/14 nurse's note. On 3/13/14 the wound evaluation flow sheet initiated by wound nurse RN L indicates the left heel has a SDTI (suspected deep tissue injury) measuring at 5.0 cm x 4.0 cm with additional measurement of the outer aspect at 1.5 cm x 1.3 cm. Dr. J was notified and an order was received for [MEDICATION NAME] to left medial heel followed by gauze dressing and a Kerlix wrap. On 3/20/14, according to the wound evaluation flow sheet, the SDTI measures 4.7 cm x 4.0 cm with the outer aspect measuring 0.3 cmx 0.5 cm. The nursing note completed on the same date by RN L also indicates dark tissue present. Treatment and dressing were applied. Surveyor # noted that this is the last documented assessment of Resident #16's left heel wound. On 4/21/14 at approximately 11:15 am Surveyor # interviewed Administrator A regarding Resident #16's wounds and what staff were/are responsible for wound care. Administrator A indicated that wound measurements were completed by RN L until he left the faciity on [DATE] and that the last documented wound measurements for Resident #16 that she is aware of was completed on 3/20/14. Administrator A indicated that she would look to see if there is any additional documentation on DON K's computer related to Resident #16. Administrator A indicated that to her knowledge, Resident #16's wounds were healed before he went to the hospital on [DATE]. Regarding overall pressure ulcer care, Administrator A indicated that after RN L left the facility, Director of Nursing (DON) K was to take over wound rounds. Administrator A indicated that she thought DON K completed rounds on 3/27/14, however, Administrator A indicated DON K did not complete documentation from the rounds prior to leaving the facility on 4/1/14. Administrator A indicated she delegated 2 units to RN D and 2 units to RN M to complete the wound evaluation process after DON K left the facility. On 4/21/14 at 4:05 pm Surveyor # spoke with RN D regarding her involvement with wound assessments. RN D indicated she had covered for RN L in the past on 11/25/13 and 12/13/13 when RN L was off. RN D indicated she was not on the floor very often and had not seen Resident #16 recently and was unaware of any wound measurements. Surveyor # noted that this was despite Administrator A's indication that RN D was delegated to be responsible for wound care following DON K's departure. On 4/22/13 at 11:35 am, a phone interview was conducted by Surveyor # with LPN R who more recently cared for Resident #16 on 4/5, 6, and 7/2014. LPN R indicated she had completed treatment to both heels. The left heel was treated with [MEDICATION NAME] and gauze, an ABD pad (dressing pad) and then wrapped with Kerlix. She indicated she has completed this treatment for [REDACTED]." The right heel was treated with wound gel (hydrogel), a dressing and then also wrapped with Kerlix. She completed this treatment since she had begun working in the facility since August 2013. LPN R does not recall any other wounds. LPN R indicated that they did apply [MEDICATION NAME] as ordered to the Resident's scrotum. She does not recall any open areas on the knees. LPN R also indicated she was unaware of who was doing wound measurements after RN L and DON K left. An attempt was made to contact RN Y by telephone. A message was left by Surveyor # with a contact phone number for Surveyor # for RN Y to return the call. On 4/22/14 at 12:10 pm Dietician S was interviewed by Surveyor # . She indicated the wound information included in her documentation for Resident #16 was received from RN L prior to his leaving the facility or from RN D and RN M who were also involved in wound evaluation. On 4/22/14 at 10:25 a.m., Surveyor # interviewed Director of Rehab- Y in regards to Resident # 16 being evaluated and treated by the rehabilitation department as historically indicated in Resident #16's medical record. Director of Rehab- Y was able to verify that Resident #16 had been seen by the physical therapy department for the treatment of [REDACTED]. Director of Rehab stated that Clinical Specialist- Z was at the facility on 3/26/14 and did a screen of new potential residents who would benefit from physical therapy services to aide in wound healing. It was noted that Clinical Specialist- Z did not actually see residents in person to comprehensively assess them, but did conduct a review of the medical records and wound documentation. Surveyor # was provided with a copy of Clinical Specialist- Z's screening notes and it was indicated that on 3/26/14, Resident #16 had a left heel suspected deep tissue injury, measuring 0.3 centimeters by 0.5 centimeters with an onset of 3/13/14, noted to be improving. It was indicated that the physical therapy department would not pick up Resident #16 as a new client as he did not meet the criteria because he either had a wound that was already improving on its own or if the wound was new within 30 days of the screen. On 4/22/14 at 12:45 pm Dr. I the facility Medical Director was interviewed regarding his knowledge of Resident #16's wounds. Dr. I indicated he was not the resident's primary physician and would not see him unless requested. He indicated he would have to check his file if he had seen the resident he would have a written note. He was not aware of what this resident's wounds looked like as he did not see him recently. He understood the resident was very weak with decreased mobility which would make the heels susceptible to pressure injuries. Dr. I stated wounds will get worse if not taken care of. Dr. I indicated DTI's (deep tissue injuries) were discussed at a facility QA (Quality Assurance) meeting about a month ago. He indicated staff would let him know if there was a problem with wound care. He was made aware the wound care nurse and the past DON had left the facility. He understood there to be a division of the units in the facility between RN, D and RN, M who would be covering wound assessment for the facility in that 2 week interim. Dr. I stated there was a breakdown for about 2 weeks as this did not happen. Following the interview Dr. I provided a copy of a physician note confirming that he had seen Resident #16 on 11/13/13, Dr. I completed a right foot exam noting on the physician progress notes [REDACTED]. Palpitation of surrounding skin reveals damage to deeper soft tissue." Dr. I assessment reveals DTI (deep tissue injury) a Rt foot surface - PAD (peripheral artery disease) 1) Protect foot from any form of excessive pressure 2) Decrease skin dryness a moisturizing lotion 3) Possibly use barrier cream. If skin opens up a can potentially lead to worse wound as healing is at risk secondary to PAD. On 4/22/14 at 1:30 pm Administrator A was interviewed Regarding Resident #16's pressure ulcers and the facility's wound care process. Administrator A indicated wounds, or anyone at risk for wounds are discussed at the daily clinical meetings. Administrator A indicated she was made aware of any problems through staff communication. Administrator A indicated skin impairments for Resident #16 would have been documented in the nurses' notes and assessments were completed on the wound assessment form. Administrator A indicated that there was no documentation completed on the wound assessment form after the 3/20/14 documentation completed by RN L and DON K did not complete the wound evaluation flow sheet after that date. Administrator A was asked if the facility ever looked to help determine how Resident #16 developed the facility acquired pressure ulcers that he had. Administrator A indicated that she just knew that Resident #16 would have wounds that would develop and then heal and then reopen. Administrator A was asked if she was aware of how many wounds Resident #16 did have while in the facility Administrator A indicated that she is not sure. It was then shared with Administrator A that Resident #16 left the facility with potentially 9 facility acquired pressure ulcers based upon the hospital emergency records that appear were not properly assessed and monitored. Administrator A was asked if Surveyor # has been provided with all of the wound sheets and documents related to Resident #16 and Administrator A indicated yes. As of exit from the facility no additional information has been submitted by the facility for review.

Based on observation, staff interview, and record review, Facility staff did not ensure 2 of 3 Residents (#15 & #4) who experienced a decline in bowel continence received necessary care and services to attain their highest practicable level of physical and psychosocial well-being. Staff did not investigate and assess for possible causes of the residents' decline in bowel continence nor did they assess and care plan for possible interventions to improve their bowel incontinence. Example 1 involving Resident #15 is determined to be an example at scope and severity of "G" actual harm/isolated. The remaining example is determined to be severity level of potential for harm. Findings include: 1. Surveyor # reviewed Resident #15's medical record on 4/17/14 to 4/21/14. Resident #15 was initially admitted to the facility on [DATE] and has had multiple hospitalization s. The latest readmitted is 2/6/14. Resident #15 is transferred with a hoyer lift, does not ambulate and has a Foley catheter. The alteration in elimination of bowel and bladder plan of care dated 11/30/13 includes interventions also dated 11/30/13 of "Bowel medications as ordered. Monitor use and effectiveness"; "Call bell within and reminders to use call bell as needed"; "Discuss medications with physicians which may be contributing to incontinence"; "Encourage exercise"; "Monitor and report changes in ability to toilet or continence status";"Monitor bowel status frequency" and "Use of briefs/pads for incontinence protection." There are interventions dated 12/12/13 of "Encourage fluids" and "Encourage foods high in fiber." The Admission MDS (minimum data set) with an assessment reference date of 12/6/13 documents that Resident #15 is frequently incontinent of bowel. The incontinence tracking form dated 12/10/13 reveals that Resident #15 was incontinent of bowel at 9:00 a.m. The incontinence tracking form dated 12/11/13 reveals that Resident #15 was incontinent of bowel at 4:00 p.m. The incontinence tracking form dated 12/12/13 reveals that Resident #15 was incontinent bowel at 8:00 a.m. and 7:00 p.m. There were no continent episodes. The bowel assessment form is dated "late entry for 12/13/13." The Admission MDS with an assessment reference date of 2/13/14 documents that Resident #15 is always incontinent of bowel. Surveyor # was unable to locate a bowel assessment after this decline. On 4/17/14 at 1:40 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-G and CNA-H transfer Resident #15 from the chair into bed using a hoyer lift. The sling and Resident #15's shoes were removed. CNA-G informed Resident #15 that she was going to see if he was wet or anything. CNA-G lowered Resident #15's pants and unfastened the incontinence product. CNA-G washed Resident #15's penis and catheter tubing. Resident #15 was positioned on his side and CNA-G washed Resident #15's buttocks. Surveyor # noted that Resident #15 did not have a bowel movement during this observation. On 4/21/14 at 10:47 a.m. Surveyor # informed RN (Registered Nurse) Manager-D that Surveyor # noted that Resident #15 had a decline in his bowel continence which was identified on the admission MDS with an assessment reference date of 2/13/14 and asked if a bowel assessment was completed after his last admission. Surveyor # informed RN Manager-D that the Surveyor was able to locate a bowel assessment 12/13/13 which was completed prior to the decline. RN Manager-D informed Surveyor # that she will look into this and get back to Surveyor # but the 12/13 bowel assessment may be the only one. On 4/21/14 at 1:33 p.m. RN Manager-D informed Surveyor # that there isn't a bowel assessment since the last admission. RN Manager-D informed Surveyor # that they will be doing a tracking will be started today and then a bowel assessment. Surveyor # asked RN Manager-D what should have happened when Resident #15 returned from the hospital in relations to a bowel assessment. RN Manager-D stated that the next day after Resident #15 returned they should have started a bowel and bladder tracking and then an assessment would be done. During Resident #15's record review Surveyor # was unable to locate an elimination patterning and a comprehensive bowel assessment after Resident #15 declined in his bowel continence and was unable to locate an individualized bowel care plan after this decline. On 4/21/14 at 2:04 p.m. Surveyor # informed the Administrator of the above. 2. Surveyor # reviewed Resident #4's medical record on 4/17/14 to 4/21/14. Resident #4 is legally blind, does not ambulate, and is transferred with a sit to stand. The alteration in elimination of bowel and bladder plan of care dated 6/25/10 includes interventions also dated 6/25/10 of "bowel medication as ordered. Monitor use and effectiveness"; "Call bell within and reminders to use call bell as needed", "Discuss medications with physicians which may be contributing to incontinence"; "Encourage exercise"; "Encourage fluids"; "Encourage foods high in fiber"; "Evaluate frequency/timing of incontinence episodes"; "Monitor bowel status frequency"; "Provide extensive assistance to toilet" and "use of briefs/pads for incontinence protection". There is an intervention dated 6/6/13 of "scheduled toileting plan Q2-3 hrs (every two to three hours) and PRN (as needed), at HS (hour sleep), upon rising in am and per resident request." The last bowel assessment completed for Resident #4 is dated 11/13/12. The annual MDS (minimum data set) with an assessment reference date of 5/24/13 documents that Resident #4 is occasionally incontinent of bowel. The quarterly MDS with an assessment reference date of 11/24/13 documents that Resident #4 is occasionally incontinent of bowel. The quarterly MDS with an assessment reference date of 2/24/14 documents that Resident #4 is frequently incontinent of bowel. Surveyor # was unable to locate a bowel assessment after Resident #4 had a decline in her bowel continence. On 4/15/14 at 2:03 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-C ask Resident #4, who was in her room, if she has to go to the bathroom. Resident #4 replied "yes." CNA-C removed the call light that was clipped to Resident #4's right shoulder, washed her hands, and placed gloves on. CNA-C placed the sit to stand near the bathroom and wheeled Resident #4 over to the sit to stand lift. CNA-C placed a sling around Resident #4 which was then attached to the lift, secured Resident #4's legs and raised Resident #4 out of the wheelchair. Surveyor # observed there was a shower chair in the doorway of the bathroom. CNA-C lowered Resident #4's incontinence product & pants and was lowered onto the shower chair. CNA-C then placed the shower chair over the toilet and removed the incontinence product. Resident #4 urinated in the toilet. CNA-C removed her gloves and washed her hands. At 2:15 p.m. CNA-C placed gloves on and placed an incontinence product on Resident #4. CNA-C wiped Resident #4's frontal perineal area and rectal area with disposable wipe. Surveyor # observed there was bm (bowel movement) on the wipes but did not observe any stool in the toilet. On 4/21/14 at 10:54 a.m. Surveyor # informed RN (Registered Nurse) Manager-D that Surveyor # was unable to locate a bowel assessment after Resident #4 had a decline in her bowel continence that was identified on the last quarterly MDS. Surveyor # informed RN Manager-D that the last bowel assessment that Surveyor # was able to locate was dated 11/13/12. RN Manager-D informed Surveyor # that she would look into this and get back to Surveyor # . On 4/21/14 at 1:35 p.m. RN Manager-D informed Surveyor # that the last bowel assessment that was done was 11/13/12 and that they were going to start her tracking today and do an assessment. RN Manager-D informed Surveyor # that a bowel assessment was not done when she had a decline. During Resident #4's record review Surveyor # was unable to locate an elimination patterning and a comprehensive bowel assessment after Resident #4 declined in her bowel continence and was unable to locate an individualized bowel care plan after this decline. On 4/21/14 at 2:04 p.m. Surveyor # informed the Administrator of the above.

Based on observations, interviews and record review, facility staff did not ensure 1 of 2 sample residents experiencing pain had his pain managed in accordance with the Resident's goals. Staff did not fill Resident #3's [MEDICATION NAME] and [MEDICATION NAME] prescriptions timely; they did not set up an appointment with a pain clinic as orderd in a timely manner; they did not conduct a comprehensive reassessment of Resident #3's pain after his admission assessment when he reported no pain until two months later, after months of daily rating his pain as severe, i.e., 8 or 9 on a scale of 0-10, with 10 being the worst pain imaginable. Findings include: 1. Surveyor # interviewed Resident #3 on 10/3/12. During this interview, Resident #3 reported the facility has run out of his pain medication ([MEDICATION NAME]) several times, and the PRN [MEDICATION NAME] often does not help his pain. Resident #3 reported the facility has run out of his [MEDICATION NAME] and then some nurses get it out of the contingency box and some just don't give it to him. Resident #3 stated medications are often given hours late. Resident #3 also reported his physician ordered a pain clinic consult weeks ago that has not been scheduled yet. Surveyor # reviewed Resident #3's medical record from 10/3/12- 10/8/12. Resident #3 was admitted to the facility on [DATE] from the hospital with major [DIAGNOSES REDACTED]. During the hospitalization , Resident #3 had infectious disease and neurosurgery consults, and was thought not to be an operative candidate for the diskitis and osteo[DIAGNOSES REDACTED]. Pain management specialists were involved and Resident #3 was managed with oral pain medications. Resident #3's hospital discharge records indicate the Discharge [DIAGNOSES REDACTED]. 2.) Chronic osteo[DIAGNOSES REDACTED] and diskitis level L5-S1 ...6.) [MEDICAL CONDITION] Stage III ...9.) Aortic valve replacement on anticoagulation therapy ... Upon discharge from the hospital, Resident #3 was prescribed the following as needed (PRN) medications: [MEDICATION NAME] Immediate release 5 mg. - take two tablets by mouth totaling 10 mg. every four hours as needed for breakthrough pain; [MEDICATION NAME] with [MEDICATION NAME] ([MEDICATION NAME]) 10/325 (10 mg./milligrams [MEDICATION NAME] and 325 mg. [MEDICATION NAME]), as needed, 1 tablet for moderate pain and 2 tablets for severe pain, every 6 hours; Tylenol ([MEDICATION NAME]) 325 mg. - two tablets (650 mg.) every 4 hours as needed for pain or fever; [MEDICATION NAME] ([MEDICATION NAME]) 5 mg. by mouth every 6 hours as needed for nausea and [MEDICATION NAME] 25 mg. rectal suppository every 12 hours as needed for nausea and vomiting. Resident #3 also was prescribed the following scheduled medications: [MEDICATION NAME] (pregabalin) 100 mg. capsule three times a day for diabetic nerve pain; [MEDICATION NAME] (cyclobenazaporine) 10 mg. three times a day; [MEDICATION NAME] ([MEDICATION NAME]) 5 mg. four times a day for nausea and vomiting; Protinix (Pantoprazole) 40 mg. delayed release, once a day (used to treat [MEDICAL CONDITION] reflux disease (GERD). The hospital discharge summary includes a page of discontinued medications. Resident #3's [MEDICATION NAME] ([MEDICATION NAME]) 75 mcg./hr. patch was listed on a page stating, "STOP taking these previous medications." Surveyor noted [MEDICATION NAME] is a strong opioid [MEDICATION NAME] that provides around the clock medication for 72 hours. Surveyor # reviewed Resident #3's admission orders [REDACTED]. Surveyor # reviewed Resident #3's Admission assessment dated [DATE] which indicates Resident #3 reported no pain at that time; Location of Pain- Back pain intermittent, occasionally; Acceptable level of pain- 0; Current pain treatment plan: [REDACTED]. Resident #3's Initial MDS dated [DATE] with an assessment reference dated of 7/19/12 indicates Resident #3 reported frequent severe pain (scored 8 on a scale of 0-10) over the past 5 days. Resident #3's CAA (Care Area Assessment) for Pain dated 7/25/12 states Resident #3 is alert and oriented x 3 (to person, place and time) and is able to make his needs known. Contributing [DIAGNOSES REDACTED]. Resident #3 is in PT/OT 5x/wk (physical and occupational therapy), needs one-two assist for transfers, toileting, personal hygiene; extensive assist for bathing. W/C (wheelchair) is primary mode of transportation. Surveyor # reviewed Resident #3's Care Plan dated 7/25/12 which states, "Needs pain management and monitoring related to: Chronic back pain, general pain." Goals include: Will not experience a decline in function related to pain; Patient will achieve acceptable pain level goal; Will maintain adequate level of comfort as evidenced by no s/s (signs or symptoms) of unrelieved pain or distress, or verbalizing satisfaction with level of comfort." All Goals have a target date of 10/25/12. Interventions include: Administer pain medication as ordered; Coordinate with patient/family to identify patient's favorite items/activities that could serve to distract from pain; Evaluate and establish level of pain on numeric scale/evaluation tool; Evaluate characteristics and frequency/pattern of pain; Evaluate need for routinely scheduled medications rather than PRN pain med administration; Evaluate need to provide medications prior to treatment or therapy; Evaluate what makes the patient's pain worse; Implement the patient's preferred non-pharmacological pain relief strategies; Observe for potential medication side effects; Refer to Pain Clinic as needed; Refer to rehab as needed. Although changes were made to Resident #3's plan of care, including ordering scheduled [MEDICATION NAME] on 7/29, a dose reduction on 9/16, returning to original dose on 9/26, multiple issues of pain medication not being available, no updates are documented on the Care Plan since it was originally developed on 7/25/12. Surveyor # reviewed Resident #3's Medical Record which includes: [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME]: MD/NP Progress Note 7/16/12- "admitted after hospitalization for intractable back pain. History of osteo[DIAGNOSES REDACTED] and diskitis- not a surgical candidate ... "Assessment and Plan- Chronic back pain- controlled. 7/21/12 4:48 a.m. ...Resident was awake at approximately 11:30 p.m. for PRN (as needed) pain medication. 7/29/12 10:01 a.m., Writer (SW Social Worker-L) approached by unit nurse on this date informing writer that Resident has refused to get OOB (out of bed) since morning of 7/28/12 ...Writer spoke with Resident. Resident would not look at writer when talking to him, faced towards the wall when in bed and stated he was "terrible." When asked why, Resident stated, "My back pain is getting worse and I can't even sit up in my w/c (wheelchair), that's why I haven't gotten up." Writer informed unit nurse of statement. 7/29/12 10:05 a.m., Social Worker informed writer (RN-K) that Resident wanted pain medication. Took PRN [MEDICATION NAME] 5/325 mg. 2 tabs to resident. Resident told writer that he did not want any pain medication at this time. (Note: order is for 10mg/325mg, not 5/325 mg.) 7/29/12 11:35 a.m. SW-L wrote a note indicating Resident #3 was OOB in w/c at that time, watching birds in lobby and propelling self around facility. 7/29/12 12:00 p.m. Note by RN-N, Charge Nurse, stating: Stopped in to see Resident at 11:00 a.m. Unit nurse had informed me that he refused his [MEDICATION NAME] today. He stated that his medication was "not touching" his pain. He wanted the doctor called and new orders given. He stated that he has "taken every kind of pain medication including [MEDICATION NAME]" but he did not know which works for his pain. Unit nurse called NP (nurse practitioner) and got new orders. Updated resident on status of his request. Surveyor # reviewed a telephone order dated 7/29/12 prescribing [MEDICATION NAME] 20 mg. one tab every 12 hours (twice daily) for pain. Surveyor # reviewed Resident #3's "Individual Narcotic Record" (also referred to as Controlled Use Sheet or Proof of Use Log) that the nurses document on each time they take a controlled substance pill for a resident, and is used when the oncoming and off-going nurses count the remaining pills together at the end of each shift. This shows 6 [MEDICATION NAME] 20 mg. tablets were delivered for Resident #3 on 7/29/12; the first pill given at 9:00 p.m. on 7/29 and the last of the 6 given on 8/1/12 at 8:00 a.m. 8/1/12 6:26 p.m. Alert and oriented, diaphoretic (sweating), dry heaves and yellowish fluid vomited. Resident stated, "This happened before, about every other month ..." 8/3/12 9:48 p.m. "Writer walked in to Resident's room with his p.m. meds and Resident asked what pain meds were in there. Said writer told him the medication and then stated, "I did not have his [MEDICATION NAME] because it had not come in yet. Resident started yelling obscenities and was verbally abusive to said writer. And said writer asked Resident to stop the verbal abuse and he stated he wanted out of this place. Reported to the supervisor and put on the board for his behaviors." Surveyor # and DON (Director of Nursing)-B review of the MAR-Medication Administration Record, the Individual Narcotic Records and a print-out requested from the pharmacy detailing what medications were delivered, when they were delivered and in what quantity, shows on 8/1/12 at 8:00 a.m., Resident #3 took the last of the 6 tablets delivered on 7/29/12. No other [MEDICATION NAME] was delivered for Resident #3 until 8/11/12. On the morning of 8/3, it had been two days since Resident #3 last received his [MEDICATION NAME]. The pharmacy print-out shows on 8/4/12, approval was given for staff to remove two doses- two 20 mg. tablets- of [MEDICATION NAME] to be used on 8/4/12 and 8/5/12 and notes **NO SCRIPT ON FILE, NEED NEW.** There is no information documented indicating why the nurse on 8/3/12 did not contact pharmacy to get emergency dispensing of the [MEDICATION NAME] at that time, or why the nurses on 8/2/12 (8:00 a.m. and 8:00 p.m.) did not follow-up with the physician and pharmacy when the [MEDICATION NAME] they should have administered was not available. The Nurses' Notes for 8/2/12 indicate staff talked with the NP (Nurse Practitioner) regarding Resident #3's [MEDICATION NAME] dose change, but there is no documentation indicating staff discussed Resident #3's [MEDICATION NAME] not being delivered/available with the MD or NP until 8/7/12. The August 2012 MAR shows staff circled their initials, indicating the [MEDICATION NAME] was not given. The MAR for 8/3/12 at 8:00 a.m. indicates the [MEDICATION NAME] was simply left blank; the 8:00 p.m. dose has circled initials meaning it wasn't given, and "NA" - not available. The MAR for the 8/4/12 8:00 a.m. dose reflects initials circled indicating (not given). The 8/4/12 8:00 p.m. dose and the 8/5/12 were given as indicated by the initials; retrieving the Ocycontin from contingency after receiving approval from the pharmacy. The 8/6 and 8/7/12 8:00 a.m. dose were circled as not given. The MAR indicates on 8/7/12, the order was DC'd (discontinued). No [MEDICATION NAME] was available for Resident #3 after his 8:00 a.m. dose on 8/1/12 (he was at the hospital for the 8:00 p.m. dose), until it was DC'd during the day on 8/7/12, (9 doses) except for the two doses obtained from contingency. There is no documentation indicating why the nurses were not following up with the MD, NP or pharmacy regarding Resident #3' s medications not being available 8/1/12 through 8/7/12, except getting two pills from contingency for 8/4 p.m. and 8/5 a.m. On 8/4/12, Pharmacy noted they needed a new script - and staff did not contact the MD or NP for the script. Nurses should have known the initial delivery labeled, "Emergency Dispensing" of 6 pills on 7/29/12 was only going to last three days, and they should have worked with the pharmacy and MD/NP to ensure a delivery would be made prior to Resident #3 using up the first 6 pills. Surveyor # reviewed Resident #3's August 2012 Pain Monitoring Tool which is kept with the MAR where nurses document the resident's pain rating before and after providing PRN (as needed) pain medication or other intervention. This pain monitoring tools shows on 8/1 at 5:00 a.m., 8/2 at 11:00 p.m., 8/5 at 8:00 p.m., and on 8/6 at 8:00 p.m., Resident #3 reported back pain of 8 on a scale of 0-10, zero being no pain and 10 being the worst imaginable pain. A review of Resident #3's Pain Monitoring Tools for the rest of August 2012, September 2012 and the first three days in October 2012 indicates Resident #3 reports pain of 8 out of 10 daily, and often multiple times a day. The Follow-up Pain rating is always zero, meaning the medication ([MEDICATION NAME]) was effective, but the goal of pain management would be to avoid the resident from having severe pain daily, as Resident #3 does. Nurses' Notes continue: 8/4/12 10:56 p.m. "Denies pain or discomfort. No emesis, no N/V (nausea/vomiting). Scheduled [MEDICATION NAME]([MEDICATION NAME] sulfate controlled release) given as scheduled. Resident behaviors appropriate throughout the shift." Surveyor # did not see an order for [REDACTED].#3 was given [MEDICATION NAME] 8/4/12. Nurses' notes dated 8/7/12 at 6:30 p.m. state the "NP returned call to the facility, order obtained: DC [MEDICATION NAME]. Start [MEDICATION NAME] sulfate ER (extended release) 30 mg. po (by mouth) BID. Diagnosis: [REDACTED]. All follow-up completed." Surveyor # reviewed a telephone order dated 8/7/12 discontinuing [MEDICATION NAME] 20 mg. every 12 hours, and starting [MEDICATION NAME] sulfate 30 mg. BID (two times a day). The August MAR shows [MEDICATION NAME] sulfate 30 mg. given on 8/7/12 at 8:00 p.m., 8/8/12 at 8:00 a.m. and 8:00 p.m., and on 8/9/12 at 8:00 a.m.; the MAR does not show any [MEDICATION NAME] given on 8/4/12. Nurses' Note dated 8/9/12 states: Writer received call from Family Care. Was informed resident called them to report that he does not want MS Contin, that it was making him sick. Writer called NP to inform her of this. She informed writer Resident's insurance does not cover [MEDICATION NAME] which she prescribed initially. She also informed writer to DC [MEDICATION NAME] to write an order for [REDACTED]., but that she was not sure resident's insurance would cover ... Surveyor # reviewed a telephone order dated 8/8/12 stating: [MEDICATION NAME] 20 mg. by mouth every 12 hours, signed by RN-K. NHA (Nursing Home Administrator)-A had informed surveyors pharmacy delivers at 4:30 p.m. and 10:30 p.m. Surveyor # reviewed Resident #3's August MAR and noted the [MEDICATION NAME] was programmed to be given at 8:00 p.m. on 8/9/12 (since the order was obtained at 6:30 p.m.), but it was crossed out with "X " on 8/9 at 8:00 p.m.; "NA" (not available) was entered on 8/10 at 8:00 a.m.; the nurse circled her initials on 8/10 at 8:00 p.m. indicating it was not given; and on 8/11/12 at 8:00 a.m., the nurse circled her initials and wrote "NA" . The MAR indicates the first dose of [MEDICATION NAME] was given at 8:00 p.m. on 8/11 from the order given in the early evening of 8/9/12. There is no documentation in the nurses' notes on 8/9 or 8/10 indicating the nurses tried to get the medication from contingency or that they contacted the pharmacy and MD/NP to see what the delay in receiving the medication was. Nurses Notes dated 8/11/12 (Saturday) at 1:13 p.m. state: Had received a phone call from DNS (Director of Nursing Services) regarding resident's [MEDICATION NAME] medication- to call the pharmacy and to obtain resident's [MEDICATION NAME] per approval from NHA/ DNS; called pharmacy and talked to (pharmacy representative) who stated they are awaiting on the script; called NP for MD who gave approval for the [MEDICATION NAME] from pharmacy; and updated the pharmacy; updated resident and updated wing nurse for follow-up. A note at 8:00 p.m. states they received the [MEDICATION NAME] from the pharmacy. Surveyor # reviewed a Progress Note documented by the Nurse Practitioner on 8/16/12 stating "C/O (complaint of) shooting pain around left hip and leg that occurs for 1 ? hours after he gets up in the chair and after he gets back to bed. C/O muscle spasms after sitting in chair for hours. "Assessment and plan: Muscle spasms- PT (physical therapy evaluation and treatment; [MEDICATION NAME] (short-acting muscle relaxant) 30 minutes before he gets back in bed at night. Nurses' Notes dated 8/18/12 at 10:54 p.m. state, "Pharmerica faxed and called regarding Resident's order for [MEDICATION NAME] (treats diabetic nerve pain). Pharmacy came but [MEDICATION NAME] still not here. F/U (follow-up) call placed at 11:30 p.m. Order for [MEDICATION NAME] still pending. Surveyor noted that resident had an original admission order dated 7/12/12 for [MEDICATION NAME] 100 mg 3 times a day. Surveyor # reviewed Resident #3's August MAR which showed nurses circled- meaning the medication was not given- Resident #3's [MEDICATION NAME] doses on 8/16/12 and 8/17/12 at 8:00 a.m. and 2:00 p.m., but was initialed as given for the 8:00 p.m. dose both days. It is unclear why the [MEDICATION NAME] wasn't available earlier, but is available at 8:00 p.m. both days. On Saturday, 8/18/12 and Sunday 8/19/12, the [MEDICATION NAME] is circled/not given for all three administration times- 8:00 a.m., 2:00 p.m. and 8:00 p.m. Surveyor # and DON-B reviewed the Individual Narcotic Records for Resident #3 and noted the last dose of [MEDICATION NAME] for one card of pills is signed out on 8/15/12 at 12:30 p.m., and no pills remained on that card at that time- "Amount Remaining-0." The Individual Narcotic Record shows the next card of [MEDICATION NAME] was delivered on 8/19/12 and the first dose from that card was given 8/19 at 9:00 p.m., four days after Resident #3 received his last pill from the previous delivery on 8/15. Nurses' Notes continue: 9/11/12 12:39 p.m. Scheduled [MEDICATION NAME] not available this a.m. Pharmacy called, stated new script needed. NP paged, stated she will return phone call after clinic today. Resident was offered PRN pain medication, but resident declined. 9/13/12 7:46 p.m. NP returned call to facility related to labs dated 9/13/12 (PT/INR); new orders obtained to increase [MEDICATION NAME] to 7 mg. every day. (No mention made of Resident #3's [MEDICATION NAME]). 9/16/12 12:59 p.m. NP updated related to (Resident #3) being out of [MEDICATION NAME] tabs. She will reconcile issue with pharmacy. Meanwhile, she reduced the dosage from 20 mg. to 10 mg. Resident was updated. 9/21/12 12:27 p.m. Scheduled [MEDICATION NAME] not available this a.m. Pharmacy called, stated they needed a signed script. NP for MD (-R) paged, awaiting return phone call. Will continue to monitor. Surveyor # reviewed Resident #3's Individual Narcotic Record for [MEDICATION NAME] 20 mg., which reveals prior to 9/16/12 when the NP lowered the dose, the last dose of [MEDICATION NAME] 20 mg. was signed out for Resident #3 on 9/9/12 at 8:00 a.m. DON (Director of Nursing)-B confirmed with Surveyor # that no other Individual Narcotic Record sheets were found for Resident #3's [MEDICATION NAME] 20 mg. for the time period between 9/9/12 and 9/16/12. A review of Resident #3's September MAR has initials indicating the [MEDICATION NAME] 20 mg. was given at 8:00 p.m. on 9/9/12 and at 8:00 a.m. on 9/10/12; it is left blank at 8:00 p.m. on 9/10; signed out for both a.m. and p.m. doses on 9/11, 9/12 and 9/13; circled/ not given for a.m. dose 9/14; initialed as given 9/14 p.m. dose; left blank on 9/15 for the a.m. dose; circled/not given for the p.m. dose on 9/15 and the a.m. dose on 9/16- then the dose was changed to 10 mg. Surveyor # reviewed the print-out from the pharmacy that showed all the dates and amounts of [MEDICATION NAME] provided for Resident #3, including the record of the authorization for two doses of [MEDICATION NAME] taken from the contingency box back on 8/4 and 8/5. There is no record nurses received any additional authorizations to obtain [MEDICATION NAME] 20 mg. from contingency for Resident #3 from 9/9 to 9/16, and there was no Individual Narcotic Record that any was available for him during that time period. The Nurses' Notes on 9/11, 9/16 and 9/21 also support the lack of [MEDICATION NAME] available for Resident #3. It appears 14 doses of Resident #3's [MEDICATION NAME] 20 mg. were missed. Resident #3's PRN Pain Monitoring Tool indicates he reported pain of 8 out of 10 usually twice a day during that time. When the NP ordered the dose reduction on 9/16/12 to 10 mg. [MEDICATION NAME], she faxed a signed script to the pharmacy for 6 tablets. The tablets are listed as Emergency Dispensing on the pharmacy print-out, and delivered on 9/16/12. While one tablet was signed out on the Individual Narcotic Record on 9/16 at 8:00 p.m. for Resident #3, a nurse circled the empty box on the MAR on 9/16 at 8:00 p.m., indicating it was not given, but there is no documentation indicating it was destroyed, either. The Individual Narcotic Record indicates the other 5 doses were given 9/17 at 8:00 a.m. through 9/19/12 at 8:00 a.m. Doses that were to be given 9/19/12 at 8:00 p.m. through 9/24 at 8:00 p.m. are circled as not given, or marked "NA", not available. This indicates 11 doses of [MEDICATION NAME] 10 mg were missed. Resident #3's PRN Pain Monitoring Tool again indicates he reported pain of 8 on a scale of 0-10 usually twice a day 9/19-9/25, as he does most days. On 9/24/12, Resident #3's physician saw Resident #3 and noted: back pain, plan [MEDICATION NAME] 10 mg. BID (twice a day). MD-R wrote a script for the medication on 9/24/12 and 30 tablets were delivered to the facility late on 9/24/12. Surveyor # and DON-B reviewed the Individual Narcotic Records and pharmacy print-out and did not observe any other [MEDICATION NAME] 10 mg. tablets delivered for Resident #3 until the night of 9/24 and first given on 9/25 at 8:00 a.m., and no entries indicating nurses received approval to remove any of the medication from the contingency box during that time. As of 10/3, the last Nurses' Note documented for Resident #3 states: 9/26/12 4:10 p.m. Resident c/o (complained of) severe pain to back. Writer noted (MD-R) was in facility 9/24 and wrote script for [MEDICATION NAME] 10 mg. p.o. (by mouth) every 12 hours. Resident states pain is not adequately controlled with such a low dose of [MEDICATION NAME]. Per resident, pain was better controlled with [MEDICATION NAME] 20 mg. every 12 hours along with [MEDICATION NAME] RN. New order obtained per NP for MD(-R). [MEDICATION NAME] 20 mg. every 12 hours. Resident aware of new order obtained. All follow-up completed. Surveyor # reviewed Resident #3's medical record to review any pain assessments conducted for Resident #3 since his admission pain assessment showed he was having no pain. The only other assessment located was dated 9/26/12, indicating Resident #3 reported a pain scale rating of 8 on a scale of 0-10; chronic back pain, osteo[DIAGNOSES REDACTED] and diskitis; is better when he receives his medication; pattern- intermittent; aching. Current pain treatment plan ineffective ([MEDICATION NAME] 10 mg. BID, [MEDICATION NAME] 10/325 mg. PRN every 6 hours as needed, [MEDICATION NAME] 5 mg. PRN every 4 hours as needed). The Assessment notes MD-R was updated and new order obtained. On 10/8/12, DON-B confirmed to Surveyor # there were no other comprehensive pain assessments completed for Resident #3, other than the nurses asking Resident #3 what his pain level is before and after administering PRN pain medication. On 10/7/12, Surveyor # noted neither the NP's order, the nurses' notes nor the care plan indicate that the order was to end after three days of emergency dispensing, and asked DON-B why no other 10 mg. tablets were delivered until 9/25, and why the previous two times (once in August and once in September), there was a delay in obtaining the [MEDICATION NAME] 20 mg., and once there was a delay in obtaining Resident #3's [MEDICATION NAME]. DON-B stated the pharmacy must not have been able to get a hold of the physician for the authorization, since they will no longer accept a telephone order from nurses. Surveyor # asked if the nurses also attempt to facilitate obtaining the medication by calling the physician, or alerting DON-B to the need for assistance in obtaining the medication, perhaps from the medical director if Resident #3's physician is not responding in a timely manner. DON-B stated the pharmacy has handled that up until now. Pharmacy staff are to contact the MD when they fill the last of the refill order, and the physicians do not always respond timely. But DON-B stated the pharmacy will now also contact her when they alert the MD that a new script is needed, so she can track receipt of the medication and intervene if needed. Surveyor # noted the change in pharmacy policy requiring a written script from the MD or NP or having the MD or NP giving verbal orders directly to the pharmacist was changed several years ago. On 10/8/12, Surveyor # noted a Nurses' Note dated 10/7/12 at 4:32 p.m. stating MD-W (Corporate Regional Medical Director) "was here to write "scripts" for resident's narcotics; faxed the scripts to the pharmacy; and updated the wing nurse for follow-through with the resident's medications." On 10/8/12 at 10:10 a.m., Surveyor # interviewed MD-P, Facility Medical Director, by phone. Surveyor # asked if facility staff had contacted him when there have been delays in getting a resident's physician to respond to pharmacy timely regarding orders for narcotics. MD-P stated they recently discussed this issue in QA (Quality Assurance), but they are still considering what policies or options they will implement to improve the time it takes to receive the narcotics. MD-P noted a pharmacy representative is also present at the meetings. In reviewing Resident #3's Individual Narcotic Record, it was noted on 10/1/12, nurses signed out an [MEDICATION NAME] 10 mg. tablet at 8:00 a.m., 4:00 p.m., and 8:00 p.m., when the order was one tablet once every 12 hours- there was no order for the 4:00 p.m. dose. Further review of Resident #3's PRN (as needed) [MEDICATION NAME] Individual Narcotic Records indicates nurses have given Resident #3 the [MEDICATION NAME] less than 6 hours after the previous dose. Resident #3's order is for 1 tablet for moderate pain and 2 tablets for severe pain every 6 hours as needed. If Resident #3 consistently needs pain medication prior to the time the next dose is available, a comprehensive pain assessment should be completed and any adjustments to the plan of care should be made. Nurses should not give pain medication outside the parameters specified in the physician's orders [REDACTED]. A sampling of the Individual Narcotic Record indicating the medication was given too soon includes: (All [MEDICATION NAME] 10/325 two tablet doses. When the medication was given, Resident #3 rated his pain as 8/10 each time.) 7/23/12 12:00 p.m. - 5:30 p.m., 5 hours 30 minutes 7/26/12 10:45 a.m. - 4:00 p.m., 5 hours 15 minutes 8/25/12 12:30 p.m. - 4:30 p.m., 4 hours 8/28/12 1:00 p.m. - 5:00 p.m., 4 hours 9/5/12 12:00 p.m. - 5:30 p.m., 5 hours 30 minutes 9/11/12 6:00 p.m. - 10:00 p.m., 4 hours 9/12/12 12:00 p.m. - 5:00 p.m., 5 hours 9/12/12 5:00 p.m. - 9:30 p.m., 4 hours 30 minutes 9/13/12 12:00 p.m. - 5:15 p.m., 5 hours 15 minutes; followed by 9/13/12 at 10:00 p.m., 4 hours 45 minutes 9/14/12 4:00 p.m. (on page 149 of log) - 8:00 p.m. (on page 150 of log), 4 hours 9/17/12 4:00 p.m. (on page 149) - 8:00 p.m. (on page 150), 4 hours; followed by two more tablets at midnight- 4 hours later (page 150). According to the MD orders, if Resident #3 received two tablets at 4:00 p.m., he should then have received two more at 10:00 p.m. if needed and then not due again until 4:00 a.m. 9/19/12 12:00 p.m. -3:45 p.m., 3 hours 45 minutes; followed by two tablets at 9:00 p.m., 5 hours 15 minutes later. 9/20/12 1:00 p.m.- 6:00 p.m., 5 hours; followed by two tablets at 10:00 p.m.- 4 hours after that. 9/22/12 6:00 p.m. (on page 150) -9:30 p.m. (on pg. 18), 3 hours and 30 minutes later. 9/23/12 4:30 p.m. (page 18) - 9:00 p.m. (on page 150), 4 hours and 30 minutes later. 9/24/12 12:00 p.m.(on page 150) - 4:00 p.m. (on page 18), 4 hours later. 9/28/12 12:00 p.m. - 4:30 p.m., 4 hours 30 minutes later. 9/30/12 12:00 p.m. - 2:00 p.m., 2 hours later. 10/2/12 12:30 p.m. - 5:00 p.m., 4 hours and 30 minutes after previous dose. There are more doses documented as given between 5 and 6 hours after the previous dose. Surveyor # reviewed these time frames with DON-B who stated she would look into why the medications were signed out prior to the time the next dose was due. If this order was not meeting Resident #3's needs, nurses should have re-assessed Resident #3's pain and called the doctor. [MEDICATION NAME]: On 10/3/12 at approximately 11:00 a.m., Resident #3 reported to Surveyor # he was not always receiving his [MEDICATION NAME]. Resident #3 stated they run out of it and some nurses take the time to get it from the contingency box, while others just skip it. Resident #3 stated he believed they were out of the medication at that time. On 10/3/12 at 12:04 p.m., Surveyor # observed LPN (Licensed Practical Nurse)-I standing by her medication cart, with the binder with the MARS (Medication Administration Records) on top of the cart. Surveyor # asked for Resident #3's MARs for October. LPN-I opened to Resident #3's MARs and quickly initialed all the 8:00 a.m. medications. Surveyor # asked LPN-I why she was initialing the MARs now, as she had not just given Resident #3 his medication. LPN-I stated she forgot to initial the MAR before, when she actually gave the medication. Surveyor # asked if she remembered administering [MEDICATION NAME] to Resident #3. LPN-I stated she did give Resident #3 his 8:00 a.m. dose of [MEDICATION NAME]. Surveyor # noted Resident #3 thought they were out of the [MEDICATION NAME], and asked to see it. LPN-I looked in the medication cart and could not find any [MEDICATION NAME] for Resident #3. LPN-I stated she now remembers she had to get the [MEDICATION NAME] from the RN (Registered Nurse) who got it from contingency. Surveyor # asked which RN she got it from. LPN-I then stated she actually hadn't asked an RN yet to get it from contingency. LPN-I stated she knew another Resident on another wing takes the same medication, so she went and borrowed one from him to give to Resident #3. When she does get the [MEDICATION NAME] from the RN who will get it from contingency, she will "repay" the resident on the other wing. Surveyor # and DON-B called the pharmacy on 10/8/12, and they stated they delivered 90 [MEDICATION NAME] on July 13th, August 13th, September 5th, and October 3rd. Resident #3 receives one 10 mg. tablet three times a day, so 90 tablets should last 30 days. The 180 tablets total delivered 7/13 and 8/13 would have lasted until 9/10. Another 30 tablets delivered 9/5 should have not run out by 10/3, they should have lasted until 10/9 or 10/10 unless they are "borrowing" for other residents and not replacing it. Surveyor # reviewed Resident #3's MAR and noted all the doses for [MEDICATION NAME] were signed out in September except on 9/3/12- the 2:00 p.m. dose was circled as not given and the 8:00 p.m. dose was left blank. All Resident #3's 2:00 p.m. medications were circled, indicating he refused them or was out of the building; the nurse did not indicate in the MAR or nurses notes why they were not given. When asked on 10/8/12, DON-B stated the nurses should be initialing the MAR indicating the Resident received the medications as soon as they administer them to the resident. Pain Clinic: Social Service notes dated 8/22/12 at 11:30 a.m. indicates a meeting was held with Resident #3, his Family Care

Based on record review and staff interview the facility did not meet professional standards of quality in 1 of 1 sampled residents in a sample size of 16 (Resident #2), and 1 of 2 supplemental sample residents (Resident #17). The facility did not respond appropriately to the needs of Resident #2 after he he missed a [MEDICAL TREATMENT] treatment, had an episode of loose stool, and an abnormally high blood sugar reading. The facility did not document appropriately meeting professional standards. Facility staff did not respond appropriately to the needs of Resident #17, who experienced trouble swallowing on or before 3/22/10, and while nurses referred Resident #17 to Speech Therapy on 3/22, they did not conduct or document any assessment of Resident #17 until he was sent to the emergency roiagnom on [DATE]. Resident #17 was also diagnosed as "questionable diabetes" in October 2009, had elevated blood glucose levels 2/10/10, and lost weight despite taking in a large number of calories such that staff expected him to gain weight. Unusual or unexpected weight loss is a common sign of diabetes. Resident #17 was diagnosed with [REDACTED]. Resident #17 had not been diagnosed as diabetic prior to 3/23/10. Findings include: According to the WISCONSIN NURSE PRACTICE ACT , Chapter N6, N 6.03 Standards of practice for registered nurses, (1) - 1(d). (1) General Nursing Procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedure in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of car by directly administering care or by direction and supervising nursing act delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to the "LONG TERM CARE NURSING DESK REFERENCE" by Barbara Acello,RN,MSN,2005. "Documentation standards: Even in charting by exception system, the state nurse practice act always prevails. "The nurse shall accurately and completely report and document the client's status including signs, symptoms and responses: nursing care rendered; physician, dentist or podiatrist orders; administration of medications and treatments; and client responses; contacts with other health care team members concerning significant events regarding client's status." WHAT TO CHART: assessments, illness and ongoing monitoring, incidents and accidents, care given, communication, refusals, noncompliance, behavior problems, and documentation about the resident and family, test results consultations, intake and output, communication books, shift reports, and anecdotal records. NURSING ASSESSMENT AND DOCUMENTATION GUIDELINES-Guidelines for assessing and documenting on acute conditions. * Identify the resident's actual problems *Identify conditions that are unstable or may become unstable * If the results of an assessment are positive, describe the nursing action taken. Nursing action must be taken on positive assessment findings. Assessments with no action make both the nurse and the facility legally vulnerable and places the resident at risk. * Describe negative findings *Document vital signs * Determine if the abnormal findings are chronic or acute * Describe response to treatment DIABETES Assess and document the following each shift: * Vital signs * Level of consciousness * Skin color, moisture, and temperature * Presence or absence of diaphoresis * Fingerstick blood sugar; report to physician if below 70 or above 250 or according to facility policy or physician's orders [REDACTED].* Lethargy * Noncompliance with diet or medications (etc.) GASTROINTESTINAL CONDITIONS Assess and document the following each shift: * Vital signs * Bowel sounds * Inspection, palpation, and percussion of abdomen, * Complaints of pain on palpation, * Presence or absence of nausea, vomiting, or diarrhea, * Weight loss...(etc) 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He lives on the C-wing in the facility which mainly houses residents with confusion, the doors are secured with a code in order to exit, for the security of the residents. Surveyor # reviewed the medical record and noted that on 11-20-10 Resident #2 was sent out the hospital. The nurse's notes dated 11-20-10 at 5:01 a.m. notes "Writer called to room upon arrival writer observed resident mouth breathing, skin cold to touch, responded to verbal stimuli, further assessment unable to get a temperature, BP 181/88 P-56 then dropped to 36 R-16, skin color ashen. Writer placed call to Dr. (L) received order to send resident out......" Upon review of the Discharge summary from the hospital dated 11-23-10 it notes "The patient was brought to the hospital from the nursing home where he had been found unresponsive and hypothermic. In the ED (emergency department) he was found to be hypoglycemic as well. He was given supplemental glucose, warming was started and he became more responsive over time. He was managed with IV warm saline and warming blanket. On further inquiry, it was revealed that he did not get his scheduled [MEDICAL TREATMENT] on Friday, so on Saturday he got dialysed, which also helped normalize the temperature. By night he was alert. His orientation has stayed clouded. He is able to respond well to verbal commands and questions, but he is not oriented to time and place. He is oriented to person. According to his wife that is his base line. He passed a swallow evaluation and he was restarted on all his p.o. (by mouth) medications In the ED he passed loose motions. Considering that he had a history of [REDACTED]. difficile PCR. His x-ray showed some right lower lobe opacity, so a [DIAGNOSES REDACTED]. He was changed over to oral antibiotics on 10/22. He has considerably improved in the last 24 hours. We would advise continuing the antibiotics for another 5 days to complete a week of administration ...." According to the medical record in November 2010 Resident #2 was attending [MEDICAL TREATMENT] 3 times a week; Monday, Wednesday, and Friday. However, there is no notation within the nursing notes of Resident #2 missing his [MEDICAL TREATMENT] on 11-19-10. Surveyor # conducted an interview with the Director of Nursing (DON) on 2-3-11 at 10:15 a.m. and discussed the concern regarding a lack of documentation within the record as to Resident #2 missing [MEDICAL TREATMENT] treatment and follow up as well as the hospital report with a [DIAGNOSES REDACTED]. On 2-3-11 at approximately 10:40 a.m. the DON indicated to surveyor that she was not aware that Resident #2 did not receive [MEDICAL TREATMENT] on 11-19-10, but did call the [MEDICAL TREATMENT] center and found that they did indeed send him back as he was incontinent of a loose BM (bowel movement). The DON and Surveyor # could not find any documentation from the staff in regards to Resident #2 missing [MEDICAL TREATMENT] or his condition after missing [MEDICAL TREATMENT]. Review of the medical records indicates that the facility did not acknowledge that Resident #2 did not receive his [MEDICAL TREATMENT] treatment; they did not put interventions in place to prevent complications such as fluid overload that may occur from not receiving [MEDICAL TREATMENT] treatment. The facility did not call the physician or put this incident on the 24 hour report for oncoming shifts to become aware and follow up. Also the factor of Resident #2 having loose stool at [MEDICAL TREATMENT] was not addressed. Vital signs were not taken, no further monitoring was conducted, and this information was not documented on the 24 hour report for follow up. The medical record does not contain any of this information as it should based upon standards of practice. Surveyor # discussed the concerns of the findings within the medical record of Resident #2 and the lack of documentation with the facility administration on 2-3-11 at an end of the day meeting. The DON indicated that she would expect staff to monitor a resident that does not receive [MEDICAL TREATMENT] treatment, that fluids should be restricted, that an RN should have documented on this resident at each shift, and that he would be on the 24 hour report. Surveyor # asked administration if Resident #2 eloped on 11-19-10, as the [DIAGNOSES REDACTED].#2. Surveyor # called Midwest [MEDICAL TREATMENT] Center on 2-7-11 at 9:35 a.m. and spoke with RN-J who verified that Resident #2 did arrive to the [MEDICAL TREATMENT] center on 11-19-10 but was sent back to the nursing home without receiving treatment as he was incontinent of loose stool and they do not provide incontinence care at the [MEDICAL TREATMENT] center. RN-J further indicated that they attempted to call the facility to let them know that Resident #2 was being sent back, but there was no answer. Surveyor # asked RN-J if there are things that the staff at the nursing home should monitor for a patient that misses [MEDICAL TREATMENT] treatment. RN-J indicated that fluid over load would be the biggest problem so fluids should be limited, a low salt diet should be enforced. The Resident could become short of breath if becoming overloaded with fluid. The facility should also call the [MEDICAL TREATMENT] center to reschedule an appointment. She indicated that they (the facility) did not do that, but the [MEDICAL TREATMENT] center called the nursing home on 11-20-10 and learned that resident was hospitalized . On 2-7-11 at approximately 10:05 a.m. Surveyor # asked the DON again for further information. She indicated that Resident #2 was not on the 24 hour report for 11-19-10. Staff was unaware that Resident #2 returned early from [MEDICAL TREATMENT]. The DON indicated that she could not find evidence any assessments were done or fluid restriction for Resident #2 at this time in November. Surveyor questioned the fact that Resident would have had to been cleaned up as he was incontinent of loose stool. Also questioned if that issue was pursued at all. Surveyor also questioned what Resident #2's meal intake was for the day. The DON indicated that the unit in which Resident #2 lives eats family style, so he would have just been served. On 2-7-11 at approximately 10:45 a.m. the DON responded to Surveyor # when asked about registered nursing staff. The DON indicated that the RN's on duty on the day shift are herself, the ADON, and the Education nurse. They do not have assigned units in which they are responsible, they respond when an LPN would call upon them. The DON indicated that the facility has now started a communication form with the [MEDICAL TREATMENT] center to ensure better communication and care. Also the DON provided Surveyor # the "Transit" form (used for transport services to sign residents in and out.) dated November 19, 2010; this form indicates that Resident #2 left at 9:05 a.m. and returned at 10:30 a.m. The meal intake record of Resident #2 provided to surveyor has an intake of 50% of breakfast and lunch for November 19, 2010. No supper meal intake was documented. The DON indicated that she had no information regarding his supper meal intake, however he did take in 100% of his supplement and provided surveyor with a copy of the MAR (medication administration record). On 2-7-11 at approximately 11:55 Surveyor # contacted Physician-L who is Resident #2's physician. He indicated that he had "no clue" why Resident #2 was hypothermic as it is warm in the facility. When Surveyor # discussed the concern of Resident #2 returning from [MEDICAL TREATMENT] but did not receive treatment, Physician-L did indicate that nursing staff should assess and follow up with a resident who does not receive [MEDICAL TREATMENT] treatment as well as monitor and restrict fluids. Surveyor # also noted upon review of Resident #2's MAR for November 2010 that Resident #2 had a blood sugar check of 377 and received 10 units of insulin at 17:15 (5:15 pm) on 11-19-10. According to a comparison of blood sugar readings, Resident #2 usually ranges from 74-168 during blood sugar checks and only once received insulin at this time during the month of November. The record shows no evidence that this was noted by an RN, nor is there any further indication that an assessment or monitoring was performed. (The hospital discharge summary dated 11-23-10 noted his admission [DIAGNOSES REDACTED]. There is no documentation within the record showing staff further assessed this resident for his unusual blood glucose level. On 2-8-11, Surveyor # contacted Sinai Samaritan Medical Record department and received a fax from them with the Emergency Department (ED) notes from 11-20-10 with regard to Resident #2. The ED record notes that upon arrival Resident #2 had a blood sugar of 22, an amp of D5 was given, and Resident #2 had a temperature of 87 degrees. This report does not identify the route of how the temperature was taken. On 2-8-11 at approximately 9:10 a.m. facility administration spoke with Surveyor # in regard to Resident #2. The DON indicated that they were unaware that Resident #2 missed his [MEDICAL TREATMENT] until Surveyor # started to investigate. Therefore, no follow up was performed regarding this situation. The RN Consultant-H indicated that the corporate Nurse Practitioner came in last night and reviewed the record of Resident #2 to rule out external factors of the [DIAGNOSES REDACTED].#2 had a [DIAGNOSES REDACTED]. Surveyor # inquired as to why the facility was not able to get a reading from their thermometer on 11-20-10 when the Resident was found unresponsive. Surveyor # asked what the manufacturer guidelines indicate for how low the thermometer will register. The facility was unable to provide that information at the time of this survey. Also discussed was the factor of Resident #2 having loose stool and the follow up and monitoring of this issue. The DON indicated that no follow up was performed. The DON also indicated that once Resident #2 returned from the hospital the information from his discharge summary would have been discussed with the IDT meeting however there is no documentation to confirm this discussion. DON-B indicated that this case should have been looked into further and an investigation should have been started at that time. On 2-8-11 at approximately 11:30 a.m. Physician- N was contacted by Surveyor # and the issues regarding Resident #2 were discussed. Physician -N also indicated that he would expect nursing staff to have monitored Resident #2 after not receiving treatment at the [MEDICAL TREATMENT] center, also that the elevated blood sugar should have been monitored as it was unusual for him, and that the facility should have looked into the hypothermia diagnosis. On 2-9-11 at approximately 10:10 a.m. Surveyor # contacted Licensed Practical Nurse (LPN) -M who was the nurse who documented in the nurses notes on 11-20-10 on Resident #2 and sent him to the hospital. LPN-M indicated that she works the night shift and is usually on duty with another LPN, no RN's are usually on the night shift. LPN-M indicated that she did remember the case somewhat. She indicated that she did not recall having anything on report when starting her shift in regards to Resident #2. LPN-M indicated that CNA's would have been doing rounds about 5:00 a.m. and found Resident #2 to be unlike his normal self therefore, she was notified. Based on the above information. Resident #2 went to [MEDICAL TREATMENT] on 11-19-10 was sent back because of an incontinence episode of loose stool. The facility did not follow up with the loose stool. The facility RN's were unaware of the resident not receiving [MEDICAL TREATMENT] therefore, no assessments were conducted, there was no implementation of fluid restriction or any other review of the conditions that could complicate the health of Resident #2 was performed. The physician was not notified. The oncoming shifts were not notified of the loose stool or lack of [MEDICAL TREATMENT] treatment therefore no further monitoring was done for Resident #2 for loose stool or complications in relation to not receiving his [MEDICAL TREATMENT]. The Resident had a unusually high blood glucose result compared to his normal baseline results on the evening of 11-19-10 and no further monitoring was conducted or communicated onto the next shift. All of this would be expected based upon current standards of practice regarding nursing staff and documentation. Resident #2 was sent to the hospital on the early morning of 11-20-10 and records show he was cold to touch, ashen in color, unresponsive and had a blood sugar of 22 and a temperature of 87 degrees. The facility did not conduct any type of investigation as to how Resident #2 could have missed [MEDICAL TREATMENT] treatment without the knowledge of an RN or how the resident could have had a [DIAGNOSES REDACTED].# . No additional information was provided by the facility regarding Resident #2. 2.) Resident #17 was admitted to the facility in February 2009 with [DIAGNOSES REDACTED]. Resident #17's Initial and subsequent MDS's (Minimum Data Sets) reveal short and long term memory problems and severely impaired cognitive skills for daily decision making. Surveyor # reviewed Resident #17's medical record. Resident #17 was sent to the hospital 3/23/10. The Discharge Summary dated 3/31/10 indicates Resident #17 had [MEDICAL CONDITIONS] and severe dehydration. The last nurses' note prior to Resident #17 being sent to the hospital for a change of condition was a routine note dated 3/9/10, even though ST (speech therapy) evaluated Resident #17 on 3/22/10 after being referred by nursing for increased mastication (chewing) times, not swallowing and coughing. Lab work showed Resident #17 had elevated blood glucose 2/12/10, and a history and physical examination questionable history of diabetes". Resident #17 was eating well- most of large portions, and consuming fluids well, but not gaining weight when his caloric intake should have caused weight gain. Dietary notes from 3/18/10 confirm weight loss while consuming enough calories for expected weight gain. Unexplained weight loss with good caloric intake can be a sign of diabetes, since the glucose can't get in the cells for energy, the body starts burning muscle and other tissue for fuel. WebMD states "Symptoms of Type 2 diabetes may include unexplained weight loss. The American Diabetes Association states unusual weight loss can be a sign of diabetes. Resident #17's medical record does not indicate staff were monitoring Resident #17 for possible new-onset diabetes. Surveyor # asked DON (Director of Nursing) -B if they reviewed Resident #17's medical record upon his readmission to the facility to try to discover how Resident #17 ended up with [MEDICAL CONDITIONS] and severe dehydration. A review is needed to ensure appropriate policies and procedures are in place, and that staff are following them. Surveyor # also asked if there was any additional documentation/ information regarding Resident #17's condition prior to the note when he was sent to the ER (emergency room ), since nursing had referred Resident #17 to speech therapy. DON-B informed Surveyor # back in March, they probably had not reviewed Resident #17's readmission, and there is no additional documentation or investigation of what led to his hospitalization . There are no additional nurses notes between 3/9/10-and 3/23/10. However, they recently initiated a "start up" meeting every morning Monday through Friday following the stand-up meeting, where they now review charts of new admissions and re-admissions to ensure everything is in place and nothing is overlooked. Specific details include: Nurses' Notes Surveyor # reviewed Resident #17's Nurses' Notes. At the time, nurses typed their note on a label, then pasted the label on the page. One sheet of Nurses' Notes contains notes from 2/23/10 and 2/24/10 regarding follow-up after a fall, followed by a note dated 3/5/10 at 4:15 p.m. stating "X-Ray results reported to MD. No new orders. The next note, which is also the last note at the bottom of the page is dated 3/24/10 1:41 a.m. "Call was placed to hospital and resident was admitted ." A further review of Resident #17's thinned file produced additional Nurses' notes dated 3/5/10-3/9/10 regarding a cough, labored breathing, and going out on pass. On 3/9/10 Resident #17's MD was in to see him, no new orders. Another Nurses' Note, on a page by itself, was located dated 3/23/10 at 7:46 a.m. "Writer called to Resident room by staff who was doing ADL's (Activities of Daily Living) on Resident when writer arrived resident was up in w/c (wheel chair) eyes closed resident unable to follow verbal command unable to stand up was placed back in bed by staff T (temperature) 98.1, P (pulse) 64, R (respirations) 20, B/P-R (blood pressure right arm) 218/94, BP left 196/94 Resident responsive unable to make needs known speech garbled skin warm and dry to touch. LCTA (lungs clear to auscultation) no SOB (shortness of breath) or respiratory discomfort noted BS+X4 (bowel sounds present in all four quadrants) write placed call out to MD paging service left message awaiting return call, writer placed call out to Bell ambulance also updated (family) ambulance arrived resident taken to hospital for evaluation and treatment. Will continue to monitor." The next Nurses' Note is dated 3/31/10 at 3:00 p.m. states Resident #17 was readmitted to the facility via ambulance, pleasant and talkative, taking fluids well, orders verified... Labs (Normal ranges are in parentheses): In facility on 2/12/10: Glucose 111 High (65-99); Sodium 143 (135-145); BUN (blood urea nitrogen- measures kidney function) 14 (6-23). Hospital Discharge Summary 3/31/10 indicates labs on admission: glucose 595 ([MEDICAL CONDITION]); sodium 167 ([MEDICAL CONDITION]) and 171, BUN 43. Signs of severe dehydration. The Hospital Discharge Summary lists the first discharge [DIAGNOSES REDACTED]. Dietary Notes 2/10/10 Weight 118#, Ideal body weight [PHONE NUMBER], usual body weight 165# BMI=16. February weight gain of 118.8# reflects significant weight gain of 8.2% in 30 days and insignificant weight gain of 4% in 180 days...Intakes average 92% of mechanical soft meals providing 2024 k/calories...On 2 Cal supplement 4 ounces three times a day, and house supplement three times a day, fortified foods and snacks. Should be easily exceeding estimated needs for weight gain. Takes thin liquids well, no signs/ symptoms of dehydration. 3/18/10 Resident was admitted in February 2009 at 107#. Plan has been for weight gain since admission, however resident struggles to put on weight despite having good intakes and numerous interventions in place. Weight has ranged from 108-118 over the past year with numerous fluctuations. Was up to 118# in February 2010. March weights = 115.2#, 111.4#, 111#. Intakes average 70% of large portion mechanical soft meals, lower than usual, however given large portions should be enough to meet needs...On MedPass 4 ounces three times a day and house supplement three times a day plus fortified foods with all meals and snacks. Unsure why resident is not gaining weight given that his intake far exceeds his estimated needs for weight gain. MD has been informed that he cannot gain weight despite good intakes... Speech Therapy Notes 3/22/10 Medical history related to diagnosis/ condition: Long term resident with [DIAGNOSES REDACTED]. Past medical history: failure to thrive, [MEDICAL CONDITIONS]. Reason for referral: Increased mastication time, coughing after swallow, poor vocal quality, audible breathing. Measurement/Analysis: Resident seen at meal. Increased mastication time >3.5 minutes per bite with cues. Coughing noted after and before swallow. Significant oral residue noted after swallow despite liquid wash. Visual acuity- profound with body lean to right side. No eye contact with SLP with maximum cues. Possible asp. (aspiration), weight loss/pneumonia. Resident with significant decline. Reported to nursing. Surveyor # reviewed Resident #17's March MAR (Medication Administration Record) and noted good intake of his two supplements. Surveyor # reviewed the Meal Intake Record which indicates he frequently ate 100% of breakfast, with occasional 75%, once 25%, and twice 50%- one of those days was 3/22/10. Lunch was more variable, usually 75-100% with occasional 25% and 50%, and twice "none to very little- one of those days was 3/22/10. Dinner most frequently was 75%, with variation. Evening snack varied, but six of the seven evenings ending 3/22 were 100%. At the daily exit meeting on 2/7/11 Surveyor # asked if there was any additional information leading up to Resident #17 being sent to the ER, such as 24 hour report, physician notification of the swallowing problem, orders for Resident #17 to see SLP; or evidence staff reviewed Resident #17's care once he returned from the hospital with [DIAGNOSES REDACTED]. On 2/8/11, DON-B and Corporate RN (Registered Nurse)-H presented Surveyor # with information regarding hyperosmolar hyperglycemic state (HHS), from the journal Diabetes Care, Volume 32, number 7, July 2009. The title of the article is "Hyperglycemic Crises in Adult Patients with Diabetes." It states "diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) are the two most serious acute metabolic complications of diabetes...HHS is characterized by sever [MEDICAL CONDITION], hyperosmolality, and dehydration in the absence of significant ketoacidosis." The article states 20% of patients with HHS have no history of diabetes, leading to delayed recognition of symptoms leading to severe dehydration. Resident #17 was not diagnosed with [REDACTED]. Surveyor # asked if they researched HHS upon Resident #17's readmission to the facility on [DATE], or after asked by Surveyor # what the circumstances were surrounding his hospitalization . DON-B and RN-H stated they researched the information on 2/7/11. Surveyor # asked DON-B if Resident #17 had a HbA1C lab drawn- which reflects plasma glucose concentrations over prolonged periods of time. DON-B stated she did not think Resident #17's physician ordered that lab. DON-B stated Resident #17's physician was notified of the elevated blood glucose on 2/10/10 and gave no new orders. Surveyor # asked if there was any evidence of nursing assessments prior to Resident #17 being sent to the ER, since nursing did refer him to Speech Therapy. No further documentation or information was provided regarding nurses assessing Resident #17.

Based on observation, record review, and staff interview the facility did not provide the necessary care and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care in 1 of 1 residents in a total sample of 16. Resident # 2 missed his [MEDICAL TREATMENT] treatment, which went unnoticed by the facility staff. By evening that same day he had an unusually high blood sugar level compared to his normal baseline results, this was not monitored further by nursing staff. By 5:00 a.m. the next morning he was found unresponsive and hypothermic. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He lives on the C-wing in the facility which mainly houses residents with confusion, the doors are secured with a code in order to exit, for the security of the residents. Surveyor # reviewed the medical record and noted that on 11-20-10 Resident #2 was sent out the hospital. The nurse's notes dated 11-20-10 at 5:01 a.m. notes "Writer called to room upon arrival writer observed resident mouth breathing, skin cold to touch, responded to verbal stimuli, further assessment unable to get a temperature, BP 181/88 P-56 then dropped to 36 R-16, skin color ashen. Writer placed call to Dr. (L) received order to send resident out......" Upon review of the Discharge summary from the hospital dated 11-23-10 it notes "The patient was brought to the hospital from the nursing home where he had been found unresponsive and hypothermic. In the ED (emergency department) he was found to be hypoglycemic as well. He was given supplemental glucose, warming was started and he became more responsive over time. He was managed with IV warm saline and warming blanket. On further inquiry, it was revealed that he did not get his scheduled [MEDICAL TREATMENT] on Friday, so on Saturday he got dialysed, which also helped normalize the temperature. By night he was alert. His orientation has stayed clouded. He is able to respond well to verbal commands and questions, but he is not oriented to time and place. He is oriented to person. According to his wife that is his base line. He passed a swallow evaluation and he was restarted on all his p.o. (by mouth) medications In the ED he passed loose motions. Considering that he had a history of [REDACTED]. difficile PCR. His x-ray showed some right lower lobe opacity, so a [DIAGNOSES REDACTED]. He was changed over to oral antibiotics on 10/22. He has considerably improved in the last 24 hours. We would advise continuing the antibiotics for another 5 days to complete a week of administration ...." According to the medical record in November 2010 Resident #2 was attending [MEDICAL TREATMENT] 3 times a week; Monday, Wednesday, and Friday. However, there is no notation within the nursing notes of Resident #2 missing his [MEDICAL TREATMENT] on 11-19-10. Surveyor # conducted an interview with the Director of Nursing (DON) on 2-3-11 at 10:15 a.m. and discussed the concern regarding a lack of documentation within the record as to Resident #2 missing [MEDICAL TREATMENT] treatment and follow up as well as the hospital report with a [DIAGNOSES REDACTED]. On 2-3-11 at approximately 10:40 a.m. the DON indicated to surveyor that she was not aware that Resident #2 did not receive [MEDICAL TREATMENT] on 11-19-10, but did call the [MEDICAL TREATMENT] center and found that they did indeed send him back as he was incontinent of a loose BM (bowel movement). The DON and Surveyor # could not find any documentation from the staff in regards to Resident #2 missing [MEDICAL TREATMENT] or his condition after missing [MEDICAL TREATMENT]. Review of the medical records indicates that the facility did not acknowledge that Resident #2 did not receive his [MEDICAL TREATMENT] treatment; they did not put interventions in place to prevent complications such as fluid overload that may occur from not receiving [MEDICAL TREATMENT] treatment. The facility did not call the physician or put this incident on the 24 hour report for oncoming shifts to become aware and follow up. Also the factor of Resident #2 having loose stool at [MEDICAL TREATMENT] was not addressed. Vital signs were not taken, no further monitoring was conducted, and this information was not documented on the 24 hour report for follow up. Surveyor # discussed the concerns of the findings within the medical record of Resident #2 and the lack of documentation with the facility administration on 2-3-11 at an end of the day meeting. The DON indicated that she would expect staff to monitor a resident that does not receive [MEDICAL TREATMENT] treatment, that fluids should be restricted, that an RN should have documented on this resident at each shift, and that he would be on the 24 hour report. Surveyor # asked administration if Resident #2 eloped on 11-19-10, as the [DIAGNOSES REDACTED].#2. Surveyor # called Midwest [MEDICAL TREATMENT] Center on 2-7-11 at 9:35 a.m. and spoke with RN-J who verified that Resident #2 did arrive to the [MEDICAL TREATMENT] center on 11-19-10 but was sent back to the nursing home without receiving treatment as he was incontinent of loose stool and they do not provide incontinence care at the [MEDICAL TREATMENT] center. RN-J further indicated that they attempted to call the facility to let them know that Resident #2 was being sent back, but there was no answer. Surveyor # asked RN-J if there are things that the staff at the nursing home should monitor for a patient that misses [MEDICAL TREATMENT] treatment. RN-J indicated that fluid over load would be the biggest problem so fluids should be limited, a low salt diet should be enforced. The Resident could become short of breath if becoming overloaded with fluid. The facility should also call the [MEDICAL TREATMENT] center to reschedule an appointment. She indicated that they (the facility) did not do that, but the [MEDICAL TREATMENT] center called the nursing home on 11-20-10 and learned that resident was hospitalized . On 2-7-11 at approximately 10:05 a.m. Surveyor # asked the DON again for further information. She indicated that Resident #2 was not on the 24 hour report for 11-19-10. Staff was unaware that Resident #2 returned early from [MEDICAL TREATMENT]. The DON indicated that she could not find evidence any assessments were done or fluid restriction for Resident #2 at this time in November. Surveyor questioned the fact that Resident would have had to been cleaned up as he was incontinent of loose stool. Also questioned if that issue was pursued at all. Surveyor also questioned what Resident #2's meal intake was for the day. The DON indicated that the unit in which Resident #2 lives eats family style, so he would have just been served. On 2-7-11 at approximately 10:45 a.m. the DON responded to Surveyor # when asked about registered nursing staff. The DON indicated that the RN's on duty on the day shift are herself, the ADON, and the Education nurse. They do not have assigned units in which they are responsible, they respond when an LPN would call upon them. The DON indicated that the facility has now started a communication form with the [MEDICAL TREATMENT] center to ensure better communication and care. Also the DON provided Surveyor # the "Transit" form (used for transport services to sign residents in and out.) dated November 19, 2010; this form indicates that Resident #2 left at 9:05 a.m. and returned at 10:30 a.m. The meal intake record of Resident #2 provided to surveyor has an intake of 50% of breakfast and lunch for November 19, 2010. No supper meal intake was documented. The DON indicated that she had no information regarding his supper meal intake, however he did take in 100% of his supplement and provided surveyor with a copy of the MAR (medication administration record). On 2-7-11 at approximately 11:55 Surveyor # contacted Physician-L who is Resident #2's physician. He indicated that he had "no clue" why Resident #2 was hypothermic as it is warm in the facility. When Surveyor # discussed the concern of Resident #2 returning from [MEDICAL TREATMENT] but did not receive treatment, Physician-L did indicate that nursing staff should assess and follow up with a resident who does not receive [MEDICAL TREATMENT] treatment as well as monitor and restrict fluids. Surveyor # also noted upon review of Resident #2's MAR for November 2010 that Resident #2 had a blood sugar check of 377 and received 10 units of insulin at 17:15 (5:15 pm) on 11-19-10. According to a comparison of blood sugar readings, Resident #2 usually ranges from 74-168 during blood sugar checks and only once received insulin at this time during the month of November. The record shows no evidence that this was noted by an RN, nor is there any further indication that an assessment or monitoring was performed. (The hospital discharge summary dated 11-23-10 noted his admission [DIAGNOSES REDACTED]. There is no documentation within the record showing staff further assessed this resident for his unusual blood glucose level. On 2-8-11, Surveyor # contacted Sinai Samaritan Medical Record department and received a fax from them with the Emergency Department (ED) notes from 11-20-10 with regard to Resident #2. The ED record notes that upon arrival Resident #2 had a blood sugar of 22, an amp of D5 was given, and Resident #2 had a temperature of 87 degrees. This report does not identify the route of how the temperature was taken. On 2-8-11 at approximately 9:10 a.m. facility administration spoke with Surveyor # in regard to Resident #2. The DON indicated that they were unaware that Resident #2 missed his [MEDICAL TREATMENT] until Surveyor # started to investigate. Therefore, no follow up was performed regarding this situation. The RN Consultant-H indicated that the corporate Nurse Practitioner came in last night and reviewed the record of Resident #2 to rule out external factors of the [DIAGNOSES REDACTED].#2 had a [DIAGNOSES REDACTED]. Surveyor # inquired as to why the facility was not able to get a reading from their thermometer on 11-20-10 when the Resident was found unresponsive. Surveyor # asked what the manufacturer guidelines indicate for how low the thermometer will register. The facility was unable to provide that information at the time of this survey. Also discussed was the factor of Resident #2 having loose stool and the follow up and monitoring of this issue. The DON indicated that no follow up was performed. The DON also indicated that once Resident #2 returned from the hospital the information from his discharge summary would have been discussed with the IDT meeting however there is no documentation to confirm this discussion. DON-B indicated that this case should have been looked into further and an investigation should have been started at that time. On 2-8-11 at approximately 11:30 a.m. Physician- N was contacted by Surveyor # and the issues regarding Resident #2 were discussed. Physician -N also indicated that he would expect nursing staff to have monitored Resident #2 after not receiving treatment at the [MEDICAL TREATMENT] center, also that the elevated blood sugar should have been monitored as it was unusual for him, and that the facility should have looked into the hypothermia diagnosis. On 2-9-11 at approximately 10:10 a.m. Surveyor # contacted Licensed Practical Nurse (LPN) -M who was the nurse who documented in the nurses notes on 11-20-10 on Resident #2 and sent him to the hospital. LPN-M indicated that she works the night shift and is usually on duty with another LPN, no RN's are usually on the night shift. LPN-M indicated that she did remember the case somewhat. She indicated that she did not recall having anything on report when starting her shift in regards to Resident #2. LPN-M indicated that CNA's would have been doing rounds about 5:00 a.m. and found Resident #2 to be unlike his normal self therefore, she was notified. Based on the above information. Resident #2 went to [MEDICAL TREATMENT] on 11-19-10 was sent back because of an incontinence episode of loose stool. The facility did not follow up with the loose stool. The facility RN's were unaware of the resident not receiving [MEDICAL TREATMENT] therefore, no assessments were conducted, there was no implementation of fluid restriction or any other review of the conditions that could complicate the health of Resident #2 was performed. The physician was not notified. The oncoming shifts were not notified of the loose stool or lack of [MEDICAL TREATMENT] treatment therefore no further monitoring was done for Resident #2 for loose stool or complications in relation to not receiving his [MEDICAL TREATMENT]. The Resident had a unusually high blood glucose result compared to his normal baseline results on the evening of 11-19-10 and no further monitoring was conducted or communicated onto the next shift. Resident #2 was sent to the hospital on the early morning of 11-20-10 and records show he was cold to touch, ashen in color, unresponsive and had a blood sugar of 22 and a temperature of 87 degrees. The facility did not conduct any type of investigation as to how Resident #2 could have missed [MEDICAL TREATMENT] treatment without the knowledge of an RN or how the resident could have had a [DIAGNOSES REDACTED].# . No additional information was provided by the facility regarding Resident #2.

Based on record review and interview the facility failed to ensure that 1 of 3 residents received the necessary care and services. Resident #4 did not receive the necessary care and services to his vascular wounds after it was noted by nursing staff that the wounds were deteriorating by the presence of a foul odor and enlargement in the size of the wound. The facility did not ensure Resident #4 was seen at the VA wound clinic in May and June 2010. Findings include: Resident #4 was admitted to the facility on [DATE] from the local VA (veterans administration) hospital after care for his Venous Stasis Ulcer and Left Lower Extremity [MEDICAL CONDITION]. Resident #4 also experienced [MEDICAL CONDITION], Diabetes and [MEDICAL CONDITION]. Review of the admission notes in the clinical record progress notes that Resident #4 had "four areas on his left lower extremity measuring 3.5cm x 2.5cm, 5cm x 5.5cm, 10cm x 5.5cm, 3cm x 3cm, the lower left ankle 2cm x 4.5cm and the right lower leg has discoloration." The discharge orders from the hospital indicated that the resident treatment to the wounds should be "every Monday, Wednesday and Friday" and should have wound care at the VA on Thursdays. The progress notes from the clinical record noted that licensed staff documented from 05/15/10 through 05/25/10 that the dressing to the wounds were "clean, dry and intact." On 05/25/10, the treatment to the left lower leg was changed that included the removal of the use of the Hydofera Blue to [MEDICATION NAME]. From 05/25/10 through 05/29/10 again the licensed staff documented in the progress notes that the "dressing are dry and intact." On 06/01/10 and noted at 12:38 a.m., Licensed Practical Nurse (LPN)-C documented "dressing changed on lower left leg there is evidence of purulent drainage and foul odor....continue to monitor. Per interview with LPN-C on 09/23/10 at 2:35 p.m. with Surveyor # , LPN-C acknowledged that was his documentation. LPN-C was questioned as to what he did with the information regarding the Purulent drainage and foul odor coming from Resident #4 wounds. LPN-C indicated that he "did nothing" with the information. When questioned if he communicated this information to RN-B or any RN as this was the first nursing documented evidence of odor of the wound since admission. LPN-C stated he "could not recall." There was no evidence of communication of the foul odor noted in the clinical record progress notes or of an assessment by an RN until 06/03/10. From 06/02/10 licensed staff from other tours of duty continued to document "dressings are dry and intact." On 06/03/10, RN-B evaluated Resident #4 wounds again according to the wound evaluation flow sheet and documented that the left lateral lower leg now measured 4cm x 3.3 moderate drainage no odor." RN-B documented that the left ankle is "6cm x 14cm with heavy drainage and mild odor." From 06/03/10 through 06/10/10, RN-B conducted another wound evaluation in which she documented on the wound evaluation flow sheet "no odor" for both left ankle and left lower leg and in the progress notes that the "wound rounds were completed 06/09/10, no changes from the last assessment, wound irregular shape, mild odor noted during dressing change, no visible signs/symptoms of infection...will continue to monitor residents skin integrity." It was noted from review of the physician progress notes [REDACTED]." The documentation does not reflect that MD-P actually viewed the left lower extremity and could not be interviewed during this onsite visit as he was out of the country and remains so until 10/09/10. Per the physician progress notes [REDACTED]." The physician's documentation does not indicate whether MD-P actually observed the wound. The licensed staff continued to document in the progress notes that the "dressing is intact" until 06/18/10 at 2:18 p.m. LPN-C notes and documents "writer and other staff observed the extra drainage and foul odor from resident LLE (left lower leg wound)...upon changing dressing, writer observed the condition of the wound to be deteriorating...wound is increasing in size around the ankle." The Physician was contacted by LPN-C and ordered that the treatment including dressing changes be completed daily and that a consultation be set up a wound specialist regarding the condition of the wound. Per interview with LPN-C on 09/23/10 he acknowledged that the RN was not notified of the condition of the residents wounds that he could recall. When questioned as to who the other staff were, LPN-C was not able to provide an answer to Surveyor # . On 06/21/10 RN-B completed the wound evaluation flow sheet that the residents wound to the left lower leg was 4cm x 4cm a noted increase in the width with "positive odor." RN-B noted that the wound to the left ankle was now 18cm x 19cm with positive odor, an increase in size of the length and width of the wound. It was noted that cultures were taken. RN-B also documented in the progress notes that Resident #4 had an appointment for the wound clinic on "Thursday 06/24/10, wound culture taken due to foul smell from wound." On 06/28/10 the resident was sent out to VA hospital for evaluation of the wounds. Per interview with UC-F (unit clerk) on 09/23/10 at 2:09 p.m. Resident was scheduled to be seen in the VA wound clinic on Thursdays according to the discharge summary from the VA. Surveyor viewed the facility scheduling book and noted that documentation of the time of appointments and time of pick up by the VA transportation for the month of June indicated appointments for 06/10/10 for 10:00 a.m. with a pick-up of 9:00 a.m. The next appointment was scheduled for 06/17/10 for an appointment of 1:00 p.m. with a pick -up of 12:00 noon. The appointment after that was for 1:00 p.m. with a pick-up of 12:00 noon. Although these appointments were scheduled, Resident #4 did not go to them. Additionally, based on the date of the Resident's admission, his first appointment should have been 05/20/10 with the second appointment 05/27/10. When questioning UC-F as to where she obtain the information regarding the specific date and time of the appointments she indicated "got appointment from the discharge papers." Review of the discharge papers by Surveyor # and the facility, did not find this information other then the Thursday appointments but no times. Per UC-F Resident #4 never got to any of these appointments at the wound clinic "because (VA) transportation did not show up." It was also noted that Resident #4 also was not seen by the recommended wound consultant as order by MD-P. On 09/27/10 at 10:49 a.m., RN-B stated that the Resident did not go out to the wound consultant because "he had appointments at the VA." However, it was noted and evident that Resident #4 did not keep those appointments at the wound clinic and the facility failed to see that the Resident went to the appointment with the wound specialist ordered by MD-P. On 06/28/10, Resident was sent to the VA hospital and has not been reamitted back into the facility.