Every finding on record at Bayside Village

Based on interview and record review the facility failed to timely provide requested medical evaluation and treatment for two Residents (R1 & R4) out of four residents reviewed for a change in condition. This deficient practice resulted in delayed medical treatment, worsening of condition, and dissatisfaction with care. Findings include:The deficiency pertains to Complaint #3035494.All times noted are Eastern Daylight Savings Time (EDST).Resident R4 Review of Complaint Intake #3035494 revealed allegations that included the following, in part: 1. The facility staff failed to provide care for and services for a significant change in condition, and 2. The facility failed to allow the resident's representative to participate in care decisions.Review of R4's Minimum Data Set (MDS) assessment, dated 5/22/26, revealed R4 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: Alzheimer's disease, and medically complex conditions. R4 was documented with severely impaired cognition, never/rarely made decisions.A telephone interview was conducted on 6/29/26 at 5:00 p.m. with Family Member (FM) A. FM A said they didn't know why the nurse didn't recognize she needed to go to the hospital on Sunday, 5/17/26. [Activated Durable Power of Attorney (DPOA)] B voiced his concerns to more than one person about (R4's) pain during the week (Thursday) prior to R4's transfer to the hospital on Sunday 5/17/26. On Sunday 5/17/26, DPOA B said something was wrong. DPOA B got them to call the facility van transporter, but the van lift was not operational. The facility called an ambulance, when DPOA B said [R4} needed to get to the hospital. R4 was transferred to the [Hospital Name] emergency room (ER) and was admitted to the hospital for 2 nights. FM A stated, In February [R4] was placed at [Facility Name] as a resident for following a UTI (urinary tract infection) and Sepsis. We had the reassurance that if R4 had anything unusual in her behavior or personality that is the first thing they check (for a UTI). [R4] had a decline in health about a week before she was hospitalized . She had a severe UTI .and a stool impaction.Review of the [Hospital Name] History of Present Illness, dated 5/17/26, revealed the following, in part: Patient is an [AGE] year-old with a history of dementia, breast cancer, CAD (coronary artery disease), hypothyroidism, and hypertension who presents from nursing home via EMS (emergency medical services)due to concerns for confusion and altered mental status. Apparently, this is gotten worse since Thursday . Husband saw her a few days ago and said that she is not acting appropriately . Medical Decision-Making: Upon arrival to the emergency department the patient (R4) is tachycardic (elevated pulse), febrile (elevated temperature). She is mildly confused according to husband. I am most concerned for sepsis (Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency.). Given that she cannot give us a lot of information we will obtain CT head, chest, abdomen, and pelvis as well as urinalysis respiratory panel. Patient's blood work did come back with elevated white count, elevated creatinine concerning for an acute kidney injury, as well as a slight elevation of troponin. Initial concern for the troponin would be demand ischemia given that the patient is likely septic . CT was also notable for proctitis (inflammation of the rectum) and a stool ball. I suspect this is the cause of her sepsis. She could also have a urinary tract infection. Regardless she was given vancomycin and Zosyn empirically . I did perform a fecal dis-impaction . Was able to get a large amount of stool out. Will give her an enema following this. Given that she meets the SIRS (system inflammatory response system) criteria for sepsis we will plan for admission for further treatment and monitoring. Final Diagnosis: Proctitis, cystitis (inflammation of the bladder), sepsis, NSTEMI (a type of heart attack), acute kidney injury. Disposition: Admit to floor, Condition on Disposition: Serious. Urine culture was positive for gram-negative rods/Pseudomonas aeroguinosa.Resident R1Review of R1's admission Record, 6/30/26 at 9:54 a.m., revealed R1 was admitted to the facility on [DATE] with diagnoses that included the following, in part: diabetes mellitus, personal history of urinary tract infections (UTIs), and congestive heart failure. While a Resident of the facility R1 was diagnosed with Alzheimer's disease with late onset effective 2/19/25 and unspecified dementia on 8/22/25. R1 had an activated DPOA; DPOA C. Review of the facility admission and Discharge list for the previous three months (April, May, and June), revealed R1 was discharged to the ER on [DATE].During an interview on 6/30/26 at 9:18 a.m., when asked about transfers to the ER for R1, the Nursing Home Administrator (NHA) stated, [R1's DPOA] wants us to always send her out to the hospital.Review of R1's Progress Notes revealed the following, in part:5/28/26 17:17 (5:17 p.m.) - Residents DPOA called and expressed that resident is being irrational, and behavior is not normal. Expressed resident is fixated on daughter and her sisters bringing her home .SN (skilled nurse) called writer and discussed concern with resident yelling at staff while staff are helping. Staff laid resident down per her request and then ten minutes later put her light on stating she'd been left all day. Discussed this with DPOA, DPOA expressed she's been the same with her and other family members. Write is sending secure message to [Physician D] with concerns of ongoing confusion and agitation. SN/staff are monitoring resident and will call MD (physician) if situation gets worse. Resident has received cares and needs have been met.5/31/26 05:49 a.m. (5:49 a.m.,) - Very confused this morning. Wanted staff to take her home. She keeps taking her cannula off and it's been renewed several times during the shift .5/31/26 16:27 (4:27 p.m.) - The Change in condition/s reported on this CIC Evaluation are/were: Altered metal status, Shortness of breath, tired, weak, confused, or Drowsy. Outcomes of Physical Assessment, in part: Respiratory Status Evaluation: Shortness of breath, Labored or rapid breathing, Cough, Abnormal lung sounds/rales, rhonchi, wheezing).Primary Care Provider responded with the following feedback: A. Recommendations: First was to give nebulizer treatment then she said to send her for evaluation . C. New Intervention Orders: Oxygen (if available).5/31/26 17:25 p.m. (5:25 p.m.) - She hasn't been feeling 100% today. She sounds very congested, her lungs sound wet .She is more lethargic and appears to be SOB (short of breath). She says she is not having a hard time but visibly she looks miserable . her breaths are shallow. She also looks pale to me. [Physician D] ordered nebulizer first then this writer was informed by the administrator that [Physician D said to send her to the ED (emergency department) for evaluation.6/1/26 04:20 (4:20 a.m.) - Res (R1) admitted to [Hospital Name] for pneumonia.Review of R1's 5/31/26 ED Provider Note - History of Present Illness included the following, in part: [AGE] year-old woman with past medical history significant for type 2 diabetes, essential hypertension, hyperlipidemia, CHF, who presents from the nursing home with a chief complaint of altered mental status and shortness of breath. [Named] nursing home found the patient to be hypoxic while on 1.5 L. They noted the patient's respiratory effort to be increased and that the patient was more confused than normal. EMS placed the patient on 3 L of oxygen which improved her oxygenation, though the patient's mental status did not improve. EMS found the patient's blood sugar to be 178, GCS 14, heart rate 95, saturation of 91%, blood pressure 138/73, temperature 98.1. EMS gave the patient a DuoNeb breathing treatment. Medical Decision Making: ED Course: Initial vitals were remarkable for heart rate of 95. Physical exam showed an ill-appearing elderly woman lying in the ER bed with moderately increased work of breathing, coarse breath sounds bilaterally, and mild generalized abdominal tenderness without any area of worst tenderness. Differential diagnosis is broad and includes respiratory viral illness, PE, pneumonia, MI, UTI, intra-abdominal infection, among numerous other diagnoses. Infectious workup was initiated. DuoNeb breathing treatment, 125 mg Solu-Medrol was ordered for the patient. Labs came back remarkable for a severe anemia of 7.4 . respiratory viral panel showing human metapneumovirus. CT of the chest, abdomen, pelvis showed dense bilateral pulmonary infiltrates most prominent in the right upper lobe. Patient was admitted to [Hospital Name] for further treatment of bilateral pneumonia, acute hypoxic respiratory failure, likely demand ischemia, chronic diastolic CHF, fluid overload, severe anemia, human metapneumovirus infection.During a telephone interview on 6/30/26 at 9:57 a.m., DPOA C was asked if there were any concerns related to timely addressing changes in condition for R1 as well as the facility responding to the DPOA's concerns related to requests for medical care and/or treatment. DPOA D stated, (One) of the last times she was there (at the ER) I was telling them (the doctor) that something was not right with her . I was telling them right before I left that [R1] was getting mean and started hallucinating. I knew she was getting some kind of infection. The doctor (Physician D) and said her lungs were fine . I had been requesting that she go to the hospital, and they said that I could not do that . [R1's] behavioral therapist called [Facility Name] and me saying there was something wrong with [R1]. They (facility) sent her out (to the ER) on the 31st. They brought her back on the 6/3/26 . I was very unhappy that they did not send her to the hospital when I wanted her to go.During an interview on 6/30/26 at 12:30 p.m., the NHA said that the facility protocol has been to contact [Physician D] prior to discharging any resident to the ER. The NHA confirmed that she had received complaints from facility resident families about not being listened to regarding treatment of their loved ones in the facility and not sending them out (to the ER) for care concerns. The NHA said none of the family members had written grievances related to their verbal complaints but acknowledged administration staff had met with some of the families expressing concerns.During an exit conference on 6/30/26 at 4:16 p.m., the NHA and Interim Director of Nursing (DON) nodded their heads up and down, in agreement, that families had expressed concerns with the delay in transfer to the ED. The NHA said the protocol of always waiting for the physician to order the transfer would be re-examined to expedite emergency medical care for facility residents.

Based on observation, interview and record review, the facility failed to identify high fall risk residents, implement a fall prevention program and care plan interventions to prevent falls for three Residents (R1, R2 and R3) of three residents reviewed for falls. This deficient practice resulted in the potential for continued and/or increased falls with possible injury related to staffs' lack of knowledge of residents identified as high fall risk requiring increased supervision. Findings include: On 5/27/26 at 8:53 a.m., review of R1's Minimum Data Set (MDS) assessment, dated 4/10/26, revealed R1 was admitted to the facility on [DATE] with diagnoses that included the following, in part: History of falling, unspecified dementia, nondisplaced intertrochanteric fracture of the right femur, repeated falls and need for assistance with personal care. R1 scored 4 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment.Review of R1's Fall Risk Evaluation, completed on 4/13/26 (prior to fall with major injury on 5/6/26) with a score of 13, revealed the following instructional information: If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.Review of the Fall Prevention Program policy, reviewed/revised 6/12/25, revealed the following, in part: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes . 6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator (such as star, color coded sticker) on the name plate to resident's room. iii. Place Fall Prevention Indicator on resident's wheelchair . Provide additional interventions as directed by the resident's assessment, including but not limited to: assistive devices, increased frequency of rounds, sitter, if indicated . low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education, (or) therapy services referral. 7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program .Review of R1's Fall Care Plan I have had a fall with major injury, revision on 5/7/26, revealed the following interventions: - Check with me upon waking, before and after meals, at hs (hour of sleep) and every 2 hours during the night and as needed for episodes of incontinence. Offer and assist me to the bathroom at these times to promote continent elimination and to help minimize my risk for falls. Date Initiated: 4/28/26. - I have an alarm on my bed to alert staff when I am getting out of my bed. Date Initiated: 5/12/26. (Added post-fall with major injury) - I have recently had a change in my antipsychotics. I have not had any breakdowns, but I have had increased confusion. Date Initiated: 4/24/26. - If you see me walking encourage me to use my wheelchair. Date Initiated: 2/23/26. - Remove foot pedals when staff is not propelling wheelchair. Date Initiated: 2/23/26.During an interview on 5/27/26 at 9:47 a.m., the Director of Nursing (DON) and the Business Office Manager (BOM) (who also has a Nursing Home Administrator (NHA) license) were asked what Fall Risk Evaluation score would indicate a resident had a high risk of falling. The DON said she did not know and after looking it up stated, A score of 10 or above is high risk for falling. The DON was asked to review R1's Fall Care Plan for a High Risk for Falling status. The DON said the Fall Prevention Program was managed by the IDT (interdisciplinary team) and stated, I have a list of people that fell, but I don't know who is in the Fall Prevention Program. We don't have a (Fall Prevention) program. When asked about symbols/stickers on high fall risk Resident's door name plates and wheelchairs, the DON stated, No, we have no (sic) stickers on doors. They do not have stickers on their wheelchairs. The BOM Manager (assigned supervision of the abbreviated survey during the NHA's limited absence), acknowledged the facility was currently not doing what they indicated they would be doing for high fall risk Residents.Review of the list entitled, Residents that have fallen in the last 3 months, listed 17 facility Residents that had fallen, without high fall risk identified in the care plan or without staff education provided to identify high risk for fall residents. The number of falls identified for these Residents totaled 46 falls in the last three months, with 37 of those falls unwitnessed by facility staff.During an interview on 5/27/26 at 10:00 a.m., the NHA acknowledged the facility had not implemented a Fall Prevention Program which identified high fall risk residents and would have informed staff of the potential need for increased supervision of those Residents to ensure their safety.During interviews with Certified Nurse Aides (CNAs) E and F, on 5/27/26 at 10:20 a.m., both CNAs were asked how they would know if a resident was a high fall risk. CNA E stated, In their care plan. CNA E was asked to review R1's Fall Care Plan and identify if R1 was a low, moderate, or high fall risk. CNA E reviewed R1's Fall Care Plan in the Resident's Electronic Medical Record (EMR) and said R1's care plan did not identify a fall risk. CNA E stated, I think it (resident fall risk level) should be in the care plan . CNA F agreed R1's risk for falling was not detailed in their Fall Care Plan and both CNAs confirmed no symbols or stickers were used to identify high fall risk residents on their name plates, wheelchairs, or anywhere else in the facility. When asked which Residents in the facility were high fall risks, CNA E and CNA F both agreed Residents R2 and R3 may be high fall risks because they had alarms to signal when they were getting up. Both CNAs agreed they did not have any other method to identify high fall risk residents. When asked if knowing which residents were high fall risks would increase their awareness of the increased risk for falls for those individuals, CNA F nodded up and down, signifying an affirmative answer, and CNA E acknowledged agreement.Review of R2 and R3's Fall Care Plans, on 5/27/26 at 11:33 a.m. and 2:47 p.m. respectively, found no documentation of their level of fall risk contained within the care plans.During observation of the facility name plates and wheelchairs of R1, R2, and R3 on 5/27/26 at 2:15 p.m., fall risk indicators (symbols/stickers) were not present on door name plates or wheelchairs. No symbols were identified throughout the facility for any resident.During the Exit Conference on 5/27/26 at approximately 3:30 p.m., the NHA acknowledged residents with high fall risks did not have documentation of such in their care plans, nor did they have any method within the facility of visual identification of residents' increased risk for falls, such as their door name plates and wheelchairs as applicable. This resulted in staffs' lack of knowledge related to increased supervision needs of high-fall residents and the potential for increased fall rates.

Based on observation, interview, and record review the facility failed to ensure supervision, including following care plan interventions to prevent a fall for 1 Resident (#1) of 3 residents reviewed for falls with injury. This deficient practice resulted in a fall with major injury (pelvis fracture) for R1.Findings include:This deficient practice pertains to Intake #2994738.Resident #1 (R1)Review of R1's Comprehensive Minimum Data Set (MDS) assessment, accepted 3/24/26, revealed an admission to the facility on 9/30/24, with active diagnoses that included the following, in part: hip fracture and seizure disorder. R1 scored 3 of 15 on the Brief Interview for Mental Status (BIMS), reflective of severe cognitive impairment.Review of R1's admission Record, printed 4/17/26, revealed the following diagnoses, in part; epilepsy, lack of expected normal physiological development in childhood, anoxic brain damage, fracture of left femur (onset date of 9/30/24), unsteadiness on feet, other abnormalities of gait and mobility, left femur neck fracture (onset date of 3/9/26), repeated falls and dependence on wheelchair (for mobility).On 5/11/26 8:20 p.m., observation of a surveillance video, retained from 4/14/26, of R1's fall with major injury (pelvis fracture) revealed the following, in part:8:32:09 p.m. through 8:36:26 p.m., no staff were observed at the nurses' station in the facility.8:32:09 p.m. - Licensed Practical Nurse (LPN) A enters the medication room, joining LPN B who was already in the med room and shuts the door.8:32:22 p.m. - LPN A takes their personal cell phone out of the right scrub top pocket and continues use of the personal cell phone until 8:34:33. No nursing duties observed.8:34:33 p.m. - LPN A observed to take a drink, converse with LPN B, stand inactive, without the performance of any nursing duties until 8:36:25 a.m.8:35 38 p.m., LPN B observed on their personal cell phone.8:36:24 p.m., R1 is observed falling to the floor outside of the closed medication room door.8:36:26 p.m., LPN A, followed by LPN B leave the medication room to assist R1 who is observed on the floor.Review of R1's Post-Fall Assessment Form, dated 4/14/26 at 1935 (7:35 p.m.), revealed the following, in part: 1. Was this fall observed ? YES. If yes, by whom: [LPN A] and [LPN B].2. Was the resident identified as high risk prior to the fall. YES .4 Why do you (R1) think you (R1) fell? Lost balance - standing at Med Room window.The post-fall assessment form was completed by LPN B, although the surveillance video appeared to show LPN A looking out of the med room window as R1 was standing on the other side looking into the room; immediately prior to R1s' fall.Additional information on the Post-Fall Assessment form, completed by the IDT (Interdisciplinary Team) and signed on 4/15/26, included: Care plan was not being followed as medication room door was closed with 2 nurses in med room. Corrective action will be completed with nurses involved in incident.During an observation on 5/11/26 at 10:00 a.m., R1 was observed in the therapy room, sitting in his wheelchair with socks on his feet. During an interview at this same time, RN C reported R1 routinely refused to wear socks or shoes in the facility.Review of R1's Fall Care Plan prior to the fall on 4/14/26 at 8:36 p.m., revealed the following, in part: Nurses were left this message so that if I (R1) am looking for them in the med room, I can access them. If you are in the med room the door needs to be left open. Have the door shut when you are giving report and counting. Date Initiated: 01/26/2026.Review of the facility Incident Summary submitted to the State Agency on 4/16/2026 at 5:54 p.m., revealed the following, in part: . Resident (R1) did have a care plan intervention at time of fall stating 'Nurses were left this message so that if I am looking for them in the med room, I can access them. If you are in the med room the door needs to be left open. Have the door shut when you are giving report and counting.' Upon review of the cameras, this care plan intervention was NOT being followed by nurses who were in the med room at the time of fall.the two LPNs (LPN A and LPN B) were given a formal written counseling on following care plans because it was in place at the time of fall . Resident is still at baseline prior to fall, propelling independently throughout the facility.Review of R1's ED (emergency room) Provider Note, dated 4/16/26, revealed the following, in part: CT scan demonstrates superior and inferior pubic rami (pelvis) fractures. I did reach out to . [Physician Name] who reviewed the scans. He felt like this was nonoperative and the patient can weight-bear as tolerated .Final Diagnosis: Left superior pubic rami fracture, left inferior pubic rami fracture .Review of LPN A's and LPN B's Employee Counseling Forms, dated 4/15/26 and 4/16/26, respectively, revealed the following, in part: Resident [R1] fell while standing to look into medication room. Cameras were reviewed and at the time of this fall medication door was closed and LPN was inside med room with another nurse. Nurse education from 1/26/26. If you are in med room the door needs to be left open. Have door shut when you are giving report and counting . Safety Violation.Review of the Charge Nurse (RN or LPN) Job Description, received from the facility on 5/11/26 at 10:15 a.m., revealed the following Additional Tasks: .Follows appropriate safety and hygiene measures at all times to protect residents and themselves . Agreement to abide by all standards, policies, and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment.Review of the Personal Cell Phones policy, revised 7/18/25, revealed the following, in part: Policy: It is the policy of this facility to provide quality care to our residents without interruption. Policy Explanation and Compliance Guidelines: 1. The facility prohibits employees from using personal cell phones for any reason on the nursing units or in working areas of the facility. 2. This includes calls, texts, social media or any other use of cell phones. 4. Cell phones may be used by employees while on a scheduled break in break areas only. 5. Employees who violate this policy will be subject to disciplinary action up to and including termination of employment.A telephone interview was attempted on 5/11/26 at 1:48 p.m. with LPN A who appeared to witness R1's fall on 4/14/25 in the surveillance video observation. A voicemail message was reach which included LPN A saying that they may you back or they may not. Message left to return call to this Surveyor. A return call was not received form LPN A prior to the close of the abbreviated survey on 5/11/26.During interviews on 5/11/26 at 9:54 a.m., 9:55 a.m., and 9:56 a.m., when asked about communication or written education regarding leaving the medication room door open on nights when staff are reduced within the facility, Registered Nurse (RN) C, RN D, and LPN E, respectively, all confirmed they were aware of that information.Review of R1's Fall Care Plan post 4/14/26 fall, revealed the following additions, in part: I have a pressure sensor alarm on my wheelchair that will alert staff when I stand up. Date Initiated: 04/16/2026.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:1. Identification of the noncompliance with care plan interventions at the time of R1's fall on 4/15/26.2. Education of all nursing staff, on 4/16/26, regarding the importance of resident care plan review, compliance with resident care plans, and the importance of keeping the medication room door open on night shift for resident safety, and3. Monitoring of compliance with the medication room door remaining open, during night shift between 4/16/26 - 4/30/26, when nursing staff were in the medication room.The facility was able to demonstrate monitoring of the corrective action and sustained compliance as of 4/30/26.

Based on observation, interview, and record review, the facility failed to accurately assess elopement risk assessment, ensure exit doors were properly secured, and provide adequate supervision to prevent an elopement from the facility for one Resident (#1) of 1 resident reviewed for elopement risk. This deficient practice resulted in an Immediate Jeopardy when Resident #1 exited the facility unsupervised for approximately 30 minutes in 53 degree weather without proper attire and was found in a ditch where Resident #1 fell and was complaining of being cold and had head and neck pain, which required transfer to the Emergency Department (ED) for evaluation. after 30 minutes being outside in 53 degree weather without proper attire or footwear.This deficiency pertains to Intake 2635984.Findings include:Resident #1 (R1)The Immediate Jeopardy (IJ) began on 10/6/25 at 5:13 a.m., when R1 eloped from the facility which was undetected by facility staff. R1 was subsequently observed by incoming facility staff arriving for day shift. R1 was found laying in a small ditch adjacent to the main entrance street on 10/6/25 at approximately 5:45 a.m. The Nursing Home Administrator (NHA) was notified of the IJ on 10/7/25 at 3:45 p.m. At that time, a written plan for removal of the immediacy was requested from the facility. This Surveyor confirmed by observation, interview, and record review that the immediacy was removed on 10/8/25 at 9:23 a.m., however, noncompliance remains at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA).Review of a Facility Reported Incident (FRI), submitted to the State Agency (SA) on 10/6/25, revealed the following facility reported event: .Incident Summary: DON (Director of Nursing was contacted by SSD (Social Services Designee) at 5:56 a.m., that upon arrival to work she (SSD) observed [R1] sitting outside in the ditch in front of the gazebo . When did the problem occur? 10/06/2025 05:13 a.m. Review of R1's Minimum Data Set (MDS) assessment, dated 8/19/25, revealed readmission to the facility on 2/28/25, with active diagnoses that included the following, in part: progressive neurological disease, diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, depression, and macular cyst of right eye. R1 scored 7 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Review of R1's Unwitnessed Fall Incident Report, dated 10/6/25 at 05:45 (5:45 a.m.), revealed the following, in part: Resident found outside of building sitting in grass by curb on her buttock. Wheelchair was off to the side. No visible injuries. Resident has been searching for her car all night and has asked if anyone knows where [Town Name] is. Resident states hitting her head and that this is not her home and that she does not want to be here and was looking for her car . Description: Vital signs initiated no complaints of pain with passive range of motion. There are no visible signs of injury at present time when checking resident's skin. Resident taken to hospital? N (NO). Injury Type: No Injuries observed at time of incident. Level of Pain: 0 (zero) . Mobility: Ambulatory without assistance. Mental Status: Oriented to Person, Oriented to Place . NOTES: Resident is confused and has been searching for her car all night. States that she wants to go home and does not want to be here. Resident is ambulatory and is unstable on her feet . Other info: Exit seeking. Not wanting to be here in facility. Incident report completed by LPN C.Review of the facility's surveillance video on 10/6/25 at approximately 8:45 a.m., beginning on 10/6/25 at 3:51 a.m., in the presence of the Nursing Home Administrator (NHA) and DON revealed the following wandering and elopement observations, in part:3:51 a.m. - R1 enters her room pushing wheelchair.3:54:34 a.m. - R1 exits her room pushing wheelchair down the 100 Hall to the nurses' station.4:01:00 a.m. - R1 sitting in wheelchair at nurses' station. Licensed Practical Nurse (LPN) C leaves R1 unsupervised and walks to and enters the bathroom with a cellphone in her hand.4:10:22 a.m. - R1 self-propels wheelchair down the activity/dining room Hall unsupervised.4:11:16 a.m. - R1 enters the dining room, unsupervised.4:13:29 a.m. - R1 Stands up from wheelchair, 4:13:36 R1 sits down in wheelchair, 4:13:56 R1 stands up from wheelchair. Unsupervised.4:14:16 a.m. - R1 pushes wheelchair around the dining room, unsupervised.4:14:42 a.m. - LPN C exits bathroom with cellphone in hand. (14 minutes, 42 seconds in bathroom)4:14:56 a.m. - LPN C observed with R1 in the dining room.4:15:30 a.m. - LPN C observed using personal cell phone at the nurses' station.4:20:20 a.m. - R1 pushes wheelchair back toward front exit door; unsupervised.4:26:24 a.m. - R1 walks back toward nurses' station pushing wheelchair; unsupervised.4:24:35 a.m. - R1 pushed wheelchair toward nurses' station - unsupervised.4:24:46 a.m. - (Certified Nurse Aide) CNA D walks into the break room.4:28:23 a.m. - R1 walks down 100 Hall and back up 100 Hall and looks in her room at 4:33:35.4:31:38 a.m. - CNA B goes downstairs on the elevator. Returns at 4:49:36 a.m.4:34:02 a.m. - R1 no longer on the 100 Hall. R1 moves to nurses' station at 4:34:504:35:12 a.m. - LPN C continues on her personal cell phone observed on her lap at the nurses' station.4:36:35 a.m. - R1 walks down the 200 Hall pushing her wheelchair, unsupervised.4:39:56 a.m. - R1 leaves 200 Hall pushing her wheelchair, unsupervised.4:40:25 a.m. - R1 pushes wheelchair past nurses' station. Speaks to CNA E at 4:42:07.4:42:24 a.m. - R1 heads down the 300 Hall pushing wheelchair, unsupervised.4:49:34 a.m. - R1 exits 300 Hall pushing her wheelchair, unsupervised.4:50:00 a.m. - R1 Walks around nurses' station pushing her wheelchair.4:53:08 a.m. - R1 back to the 300 Hall. 4:53:49 a.m. - R1 goes down the activity/dining room hallway unsupervised.4:55:25 a.m. - R1 wheeled up to front door unsupervised. R1 tried to push the front exit door open. Pushed with her hand and then body. Turns wheelchair around.4:56:02 a.m. - R1 heads into the dining room pushing wheelchair - no staff present.4:56:52 a.m. R1 turns wheelchair around and exits the dining room at 4:57:55 a.m.5:00:23 a.m. - R1 walks past nurses' station pushing wheelchair. Down the 100 Hall. Off camera 5:00:545:03:59 a.m. - R1 walks to end of 100 Hall pushing wheelchair, unsupervised.5:05:39 a.m. - R1 enters and exits another Residents room (confirmed by the NHA and DON).5:06:44 a.m. - CNA B talks to R1 and R1 leaves 100 Hall at 5:07:16.5:07:41 a.m. - R1 walks past empty nurses station pushing wheelchair, unsupervised.5:08:18 a.m. - R1 walks down the 200 Hall. Pushing wheelchair unsupervised.5/11/29 a.m. - R1 comes off of 200 Hall and goes toward the 300 Hall, unsupervised.5:11:57a.m. - R1 in view on the 300 Hall pushing her wheelchair, unsupervised.5:13:20 a.m. - R1 stops at the exit door at the end of 300 Hall, unsupervised.5:13:24 a.m. - R1 pushed on the 300 Hall exit door bar, supposedly activated with a delayed egress 15-second alarm, for two seconds while positioned behind her wheelchair until 5:13:26. R1 repositioned herself closer to the delayed exit door bar and pushed the bar again at 5:13:32. The 300 Hall door opened at 5:13:33 and R1 exited from the building unsupervised at that time.5:16:44 a.m. - CNA D approached the 300 Hall exit door and appeared to reset the 15-second delayed egress alarm on the door bar. She looked out of the 300 Hall exit door window but did not open the door. 5:17:44 - CNA D reset the box alarm on the wall to the left of the door, with a key. At 5:17:52 CNA D looks out the door window again. The surveillance video showed no staff exited the 300 Hall door to look for any elopement resident. During an interview on 10/7/25 at 9:00 a.m., when asked what the policy was regarding the use of personal cell phones on the nursing floor, the DON stated, They are not to have them (personal cell phones) around residents. When the NHA and DON were asked if they had any concerns related to the lack of staff engagement with R1 as she wandered throughout the facility, the NHA and DON acknowledged staff did not appear to implement any interventions to engage R1 in a task, activity, or supervision of her wandering as observed on the surveillance video. Review of the Personal Cell Phones policy, reviewed/revised 7/18/25, revealed the following, in part: Policy: It is the policy of this facility to provide quality care to our residents without interruption .1. This facility prohibits employees from using personal cell phones for any reason, on the nursing units or in working areas of the facility .4. Cell phones may be used by employees while on a scheduled break in break areas only. 4. Employees who violate this policy will be subject to disciplinary action up to and including termination of employment .During an interview on 10/7/25 at approximately 9:45 a.m., the DON and NHA confirmed they assumed the 15-second delayed egress alarm was sounding, however the video did not contain sound. They also confirmed facility staff only looked out the 300 Hall delayed egress exit door window. They did not open the door and move outside to verify all residents remained inside the facility. When asked if all nurses should know to do a head count when an exit door alarm sounds, the DON stated, 'Absolutely.' The DON acknowledged no head count was completed following the STOP alarm (on the wall to the left of the door) sounding when the door seal was broken. The DON said two CNAs ( B and E) were showering [a Resident] on the 100 Hall beginning at 5:11:07. At 5:10:02 CNA D was in a room [with two other Residents on the 200 Hall) until the time CNA D approached and checked the 300 Hall exit door window and then re-engaged the STOP and delayed egress alarms following R1's elopement from the facility. At 5:11 a.m., LPN C was on the 200 Hall with [another Resident]. When asked what priority level was assigned to responding to an exit door alarm, the DON stated, An exit alarm trumps resident care as long as the resident is safe. The DON continued, I watched the camera, and nobody drove by (and found R1 laying in the ditch) until 5:44:47 a.m. when [Housekeeper I] and [Social Service Designee H) came to work. The DON said it was dark outside in the video, and 53 degrees . At 5:48:57 a.m. a wheelchair was brought out of the facility by LPN C. R1 was pushed into the facility in a wheelchair at 5:53:29, wearing a blanket (provided by Housekeeper I), and what appeared to be pajamas, and socks. No gait belt was observed on R1, nor were there foot pedals observed on the wheelchair upon R1 being propelled by staff into the building.Review of R1's Nursing Progress Notes, provided by the NHA/DON on 10/7/25 at approximately 11:20 a.m., revealed the following, in part:08/05/25 08:32 (8:32 a.m.) : Nursing staff reports that resident is not sleeping well at night and is up often.08/28/25 00:09 (12:09 a.m.) : [ R1] up and ambulating the hallway, states she can't sleep.9/5/25 13:27 (1:27 p.m.) : [Physician] was updated that resident continues to not sleep at night.9/10/25 23:21 (11:21 p.m.): [R1] up and walking around the unit. unable to reorient.9/11/25 01:25 (1:25 a.m.) : [R1] convinced there are people outside making a lot of noise. Attempted to go outside the TV room exit .9/23/25 09:14 (9:14 a.m.) : .MD (Physician) was updated that resident (R1) continues to be more confused . No changes made to Cymbalta or Melatonin at this time as resident was up walking the halls during the night not sleeping .9/27/25 09:35 (9:35 a.m.): EMS (emergency medical services) arrived to take resident to [local hospital emergency department (ed)] for Eval (evaluation).10/1/25 16:34 (4:34 p.m.): Res (R1) returned to the facility from [local hospital] . her son said she was very much disoriented while at the hospital and he had to stay with her to make sure she did not get out of bed on her own. He stated that she did have a couple of falls while in the hospital . discharge diagnosis was hypertensive encephalopathy.10/3/25 04:52 (4:52 a.m.): Resident (R1) has been wandering throughout this shift despite staffs attempts to redirect resident back to bed. Resident did not sleep tonight. Resident has set off exit door alarms twice this shift, staff alert and monitoring resident's location.10/6/25 06:19 (6:19 a.m.): Resident found outside of building sitting in grass by curb on her buttock. Wheelchair was off to the side. No visible injuries. Resident has been searching for her car all night and has asked if anyone knows where [town name] is? MD, RP (responsible party), and DON aware. Authored by LPN C.10/6/25 06:20 (6:20 a.m.): .Resident complains of neck and shoulder pain - updated nurse, and that she is cold. Authored by SSD H.10/6/25 06:55 (6:55 a.m.): SN (skilled nurse) arrived at 0645 for shift. Heard from staff that a resident was found outside. The resident was to be on the hall I was taken (sic) over. SN went to resident that was in social worker room. SN instantly did an assessment and started neuro checks. Resident stated, I have neck and back pain. SN start asking questions about how long she was outside? Where and how was she found? SN wanted an ER eval and called 911 . EMR arrived and took 3 assist to get her on stretcher. Authored by Registered Nurse (RN) F.10/6/25 07:36 (7:36 a.m.): Resident sent out for further treatment and evaluation since fall this morning. Family and MD notified. V/S (vital signs) 170/61 (blood pressure), 83 (pulse), 97.6 (temperature), and 18 (respirations), second set (of vitals time unknown) 154/73, 79, 97.6, 18, 97% (oxygen saturation) RA (on Room Air). Authored by LPN C. No neurological evaluations were found documented for the time between the residents return to the facility and the assessment completed by RN F who arrived approximately 1 hour later at 6:45 a.m.10/6/25 07:48 (7:48 a.m.) : Elopement Evaluation: History of elopement while at home: NO. Wandering behavior a pattern or goal-directed: NO. Wanders aimlessly or non-goal-directed: NO. Wandering behavior likely to affect the safety or well-being of self/others: NO. Wandering behavior likely to affect the privacy of others: YES. Recently re-admitted (within past 30 days) and has not accepted the situation: NO. Completed by RN A.Review of R1's Pain Assessment, completed on 10/6/25 at 6:32 a.m., by LPN C, following R1's return into the building following elopement revealed the following, in part: Should Pain Assessment Interview be Conducted: YES. Pain Presence: Ask resident: Have you had pain or hurting at any time in the last 5 days? NO documented.During an interview on 10/7/25 at approximately 10:00 a.m., when asked why R1 had not been considered an elopement risk with a pattern of wandering and entering other resident rooms, the DON said R1 was not observed exit-seeking, and the staff had no idea she had tried to get out the front door the same night. Because staff didn't think she was trying to elope, they did not consider her pattern of wandering a risk for elopement. The DON agreed, after watching the surveillance video, R1 did wander aimlessly, and non-goal oriented, as well as entered other resident rooms posing a risk to their privacy. When asked if the DON understood the concern related to elopement risk when a resident is up wandering for hours during the night, unsupervised, the DON stated, It is our error for this happening. We are going to have an onboarding process (for contract staff), who did not respond to the exit door alarm according to policy. When asked if contract staff had access to the Wandering/Elopement policies, the DON and NHA reported they were on the 'P Drive' on the computer at the nurses' station.Review of R1's Care Plan Report for Risk for Wandering/Elopement Identified, Code alert applied to right ankle . Date Initiated: 10/6/25. Revision on: 10/06/25. The Interventions/Tasks all initiated on 10/6/25 included the following: Clearly identify Residents room and bathroom.Engage Resident in purposeful activity.Identify if there is a certain time of day wandering/elopement attempts occur.Identify wandering/elopement de-escalation behaviors.Provide care in a calm and reassuring manner.Provide clear, simple instructions.Provide reorientation to surroundings, environment. No Care Plan to address R1's wandering was present until after R1 exited the building on 10/6/25 at 5:13:33, although wandering behaviors were documented previously and wandering behaviors were clearly visible on the surveillance video prior to R1's elopement. During an interview on 10/7/25 at 10:30 a.m., R1 was asked if she had left the facility at night recently. R1 said she went outside, because she used to live in the woods and she was not afraid of the dark. R1 reported she had fallen into a small ditch and said she was cold with head and neck pain, so they took her to the hospital. R1 was pleasant, talkative, but could not recall how she exited the building or got into the small ditch.During an observation and interview on 10/7/25 at 10:35 a.m., the Environmental Services (EVS) Director G was asked to test the functioning of the 300 Hall exit door. EVS Director G stated, If you push the door (bar on door) the alarm starts. The door should unlock after 15 seconds. I haven't put a stop watch to it, but we do check these monthly I know for a fact you can't push the door open for 15 seconds. When the door bar was pushed the alarm began to sound. When the door was pushed again it did not open for 15 seconds, unlike the surveillance video observation with the DON and NHA. EVS G was asked to review the surveillance video of 10/6/25 at the time of R1's elopement from the facility and provide his thoughts regarding R1's exit from the building and the timeframe of the 300 delayed egress doors' opening. EVS G observed the surveillance video in the presence of the NHA and DON at approximately 10:45 a.m.During an interview/observation on 10/7/25 at 11:20 a.m., EVS Director G reported he had observed the surveillance video recorded on 10/6/25 of R1's elopement from the facility. When asked how the 300 Hall delayed egress door could have opened so quickly and not be delayed for 15 seconds before opening, EVS Director G stated, The only thing that could have been different is the door was unlocked. If the door was unlocked the alarm would not sound - but when the door (seal) opens the stop box alarm sounds, and we can go and check the door. The door was tested in the presence of this Surveyor and when the 300 Hall delayed egress door alarm was turned off, with the key removed in the upward position, but not turned completely to the right to engage the door lock alarm, no alarm sounded, and the box alarm only began sounding when the door seal was broken and the door was opened. EVS Director G stated, I assume that is what happened. It is the only way the door would open that quickly. In the presence of the NHA and DON, EVS Director G confirmed the surveillance video showed the 300 Hall delayed egress door opened quickly allowing R1 to exit the building, well before the 15 seconds during which the alarm should have been sounding. The NHA and DON also agreed. EVS Director G said the delayed egress door alarm would not have sounded at all if the door alarm was not engaged but left unlocked as he suggested.During an interview on 10/7/25 at 11:47 a.m., SSD H, the first staff member to find R1 in the small ditch, was asked to describe her observations and/or actions. SSD H stated, At about 5:45 a.m., we were coming down past the building (nursing home facility). I had noticed an animal going around the building. It was not a deer, I don't know what it was. I saw someone in the ditch. It was [R1]. I stayed with the Resident. [Housekeeper I] went (ran) in the building and [LPN C] came out with a wheelchair. R1's wheelchair was on the door side of the gazebo. The resident was in the ditch between the gazebo and the road (near the road). [R1] said she was going for a walk, and she goes there all the time. [R1] was laying on her right side with her elbow propped up - and her feet out in front of her. She said she was cold, and she said that her neck and head hurt. She said she hit it (R1's head) on the hard thing behind her. [Housekeeper I] got her (R1) a blanket. I didn't want to leave the resident. She had a t-shirt, capris and grippy socks on. When asked if she wanders in the building at night, SSD H stated, She does wander safely in the building. When asked if she goes into other residents' rooms at night, SSD H stated, She has a specific resident - she will go in and peak on her. SSD H continued, RN A did come and put a wander guard on her before she (R1) left for the hospital. When asked if a gait belt or wheelchair foot rests were placed on the wheelchair prior to R1's transport back into the building, SSD H stated, No, they were not. SSD H said LPN C and another staff member lifted her up into the wheelchair.During a telephone interview on 10/7/25 at 2:12 p.m., when asked if R1 had a pattern of wandering at night when having difficulty sleeping, RN F stated, This wandering started in the last month. I sent her (R1) out last week (to the hospital) and she was talking gibberish with . encephalopathy. Starting last week, she (R1) was going into other resident rooms. When asked about the 10/3/25 progress notes that documented R1's exit-seeking, RN F stated, During the day she is a whole nother (sic) person. When asked why RN F sent R1 to the hospital when this occurred on night shift, RN F stated, I didn't like the way the travel nurse said to me [R1] was so hard to handle. I instantly sent her out. I wasn't even clocked in . I don't understand why no one looked out or went out and looked for her .Telephone calls were made on 10/7/25 at 2:19 p.m. and 2:22 p.m., to LPN C and CNA E with no success. LPN C had no voicemail set up, and for CNA E a message was left with no return call received.During an interview on 10/7/24 at 2:26 p.m., RN A was asked about monitoring for changes in condition related to wandering behaviors and elopement risk, specifically for R1 and the 10/3/25 progress note that documented exit-seeking. RN A stated, I don't always see those progress notes. As soon as I heard she hit the door (on 10/6/25) I put a wander guard on her. I did not see the 10/3/25 progress note. I am not the only person that can put a wander guard on her. I was not informed that she was exit seeking on 10/3/25, and other people could have put a wander guard on her as well. I have been really busy, and I just missed it. RN A said that she (R1) was different for the last month, and had non-goal directed wandering., and did sometimes go into other resident rooms, but RN A said that she did not feel R1 was an elopement risk because she didn't think she was exit seeking. During an interview on 10/7/25 at 2:48 p.m., When asked what staff member was responsible for updating elopement assessments when the residents' wandering behaviors changed. The DON stated, The person who should have been completing the assessment needs to be reading the progress notes. Looking back and reading progress notes to see what her (R1's) status is, is important as you fill out the Elopement Assessment, not just going by what you think the resident is doing. The DON confirmed the RN/MDS Director A would have been responsible for re-evaluating R1's elopement risk. When asked if the DON understood my concerns with documentation of NO to wandering and going into other resident rooms on R1's elopement assessment, the DON stated, I absolutely do.Review of R1's MDS, dated [DATE], Discharge Return Anticipated, showed SSD H completed Section E related to behaviors, which documented R1 did not have any wandering behaviors. During an interview at this same time on 10/7/25 at 3:30 p.m., SSD H said she did not always go back and read the progress notes when completing her portions of resident MDS Assessments.Review of an Elopement Risk Evaluation, completed on 9/26/25, revealed all questions were answered with NO, with a resulting score of zero (0), indicating R1 had no anticipated risk of elopement. Questions included, in part: Wandering behavior, a pattern or goal-directed?Wanders aimlessly or non-goal-directed?Wandering behavior likely to affect the safety or well-being of self/others?Wandering behavior likely to affect privacy of others?During an interview on 10/7/25 at 3:36 p.m., When asked if a complete assessment of R1 was performed following her re-entrance into the building after her elopement, the DON stated, It was not completed because no neuros were completed following the resident's (R1's) fall while outside and complaints of head and neck soreness. The DON acknowledge the day shift nurse who came on duty was the nurse who began neuros an hour later.During a telephone interview on 10/7/25 at 4:03 p.m., R1's Guardian J was contacted regarding R1's elopement/fall on 10/6/25. Guardian J stated, They (facility staff) called me at 6:56 a.m. They said that she got out of the building . they told me the alarms did go off and she (CNA D) didn't look outside. I was not very happy with the nurse (CNA D) who heard the alarm and turned it off but didn't look outside.Review of the Elopement policy reviewed/revised 6/12/25 revealed the following, in part: Policy: 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. Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless. 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 .1. The facility is equipped with door locks/alarms to help avoid elopements.2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner .3. 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.4. 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 .f. Any changes or new interventions will be communicated to relevant staff. 5. Procedure for Locating Missing Resident: (Added to Policy on 10/6/25 following R1's elopement from facility): a. Any staff member becoming aware of the potential elopement or unwitnessed door stop alarm sounding will alert personnel using approved facility protocol (call 6000 - announce Code M. Code M - missing person. b. One facility staff member will go outside via alarming door to search for missing resident immediately, search will continue until Code M is cleared. c. All other facility staff will complete facility head count and search all areas of building until found. If staffing allows, RN will initiate one additional staff to exit through front door and search courtyard to basement door .6. Procedure Post-Elopement: a. A nurse will perform a physical assessment, document, and report findings to physician . The IJ that began on 10/6/25 at 5:13 a.m. was removed on 10/8/25 when the facility took the following actions to remove the immediacy: - Elopement and Wandering Residents Policy reviewed and updated on 10/6/25.- All staff were made aware of mandatory all staff meeting regarding elopement policy and responsibilities during an elopement. Meeting times 10/6/25 at 1:30 p.m., 10/7/25 at 6:00 a.m., and 10/7/25 at 10:00 a.m.- Maintenance director inspected and tested 300 Hall exit door on 10/7/25 at 10:41 a.m., accompanied by Surveyor.- Additional education to all staff regarding proper functioning door alarms was initiated (on 10/7/25) at 11:50 a.m. via text and in person at 1:00 p.m.

This deficient practice pertains to Facility Reported Incident (FRI) 61588.Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent a fall, adequate supervision with use of a razor, and ensure reassessment and follow-up for exit-seeking for three Residents (R7, R23, & R38) of 12 residents reviewed for accidents/hazards/supervision. This deficient practice resulted in harm for R7 who incurred a fall with major injury (right pubis fracture), a tongue injury related to unsupervised access to hazardous hygiene supplies, and lack of accurate assessment data to ensure resident safety. This part of this citation is related to complaint intake #2605430 Findings include: Resident #7 (R7) Review of R7's admission Record, retrieved 9/9/25 at 12:56 p.m., revealed R7 was admitted to the facility on [DATE] with current diagnoses that include the following, in part: fracture of the right pubis (pelvic fracture), pain in left knee, contracture of right ankle, contracture of left ankle, unsteadiness on feet, and abnormalities of gait and mobility. R7 was noted to be their own responsible party for decision-making. Review of R7's Minimum Data Set (MDS) assessment, dated 7/12/25, revealed R7 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) reflective of a moderate cognitive impairment. Section GG – Functional Abilities documented 03 (partial/moderate assistance – less than half the effort) for the following, in part: toileting hygiene, toilet transfer, and walking 10 feet. R7 was noted to have incurred one fall, with no injury, since the prior MDS assessment, and R7 used a manual wheelchair for mobility. Review of R7's previous MDS quarterly assessment, dated 4/23/25, revealed R7 scored 6 of 15, on the BIMS reflective of a moderate cognitive impairment. Review of the Fall Investigative Summary for R7, revealed the following, in part: . Date of Fall 8/13/25, Time of Fall 1700 (5:00 p.m.) Location of Fall: Residents room, Fall reported by Employee. Name of individual reporting fall: [Licensed Practical Nurse (LPN C)]. Injuries sustained during fall: Yes, bump to head and skin tear right elbow. Injuries required medical attention: No, not at time of fall. Name of witnesses to fall: Unwitnessed . Summary of Interview with person's reporting the fall: '[Certified Nurse Aide (CNA E)] put her on the toilet and told resident to hit call light when she's finished. Resident reported not wanting to bother anyone, so she got up herself and fell in the process.' Her PCP (primary care provider) was contacted, and no orders were given. Summary of interview with witness/witnesses: N/A notated. Summary of interview with resident. 'Resident states she walked herself from the toilet to the door that leads to the hallway and when she went to turn around, she lost her balance' . Summary of investigator's findings: Resident had an unwitnessed fall on 8/13/25. PCP (primary care provider) was notified and there was (sic) no recommendations made for outside evaluation. On 8/28/25, Resident (R7) was sent to ER (Emergency Room) for increased anxiety, pain, and increased depression. Upon evaluation, a right pelvic fracture was discovered. Due to the location of the fracture, it is suspected it was a result of the fall on 8/13/25 . Signature – Investigating Representative: NHA (Nursing Home Administrator), Date: 9/3/25. During an interview on 9/9/25 at 11:31 a.m., LPN C said she was present when R7 was found on the floor in their room. LPN C stated, I was there when [R7] was sitting on the toilet. CNA E told [R7] she would be right back. [R7] didn't want to bother anyone so [R7] got . up (off the toilet). When asked if a post-fall assessment was completed, LPN C said an assessment was completed while R7 was on the floor. When asked about vitals and neuros following the fall, LPN C said no vitals or neuros were assessed prior to R7 being moved from the floor to the wheelchair. LPN C said neuros were assessed once R7 got up. LPN C stated, I asked [R7] if she could get up and she said yes. We gait-belted [R7] and we two-personed (sic) (used two people to assist) her into her wheelchair. [CNA E] was the aide who put [R7] on the toilet . I can't remember who came and told me in the dining room. I was in the dining room already for dinner. When asked again if R7 had a gait belt on, while observed on the floor post-fall, LPN C stated, [R7] didn't have a gait belt on. We had to put one on [them]. During an interview on 9/9/25 at 11:42 a.m., CNA E was asked about her knowledge of R7's fall with major injury on 8/13/25. CNA E confirmed she was the staff member who placed R7 on the toilet in [R7's] room. [R7] had rung her bell, and I came and put [R7] on the toilet. When specifically asked about gait belt usage with transfer to and from the toilet, CNA E stated, When we put people on the toilet we leave the gait belt on them. I was gone maybe 10 to 15 minutes (estimated time R7 left on toilet). It was not that long. CNA E said she and LPN C had gone back to assess R7 post-fall. When asked what R7's transfer status was at the time of the 8/13/25 fall, CNA E stated, [R7] was a limited assist of one for transfers. CNA E continued to state, I remember going in there (R7's room) and there were other people in the room (after R7's fall) and they already had her in the wheelchair before I got in there and remember [R7] saying she was going to close the door and down they went. During an interview on 9/9/25 at 2:21 p.m., the NHA was asked for the neuro checks that were completed post-fall on 8/13/25 for R7. The NHA said she would print them out and provide them to this Surveyor. On 9/9/25 at approximately 2:25 p.m., observation of the surveillance video of the 100 hall on 8/13/25 prior to and post-fall for R7 was observed with the NHA. The NHA did acknowledge no surveillance timeline had been completed during the investigation and the NHA was unable to identify all staff that entered and exited R7's room during the time period reviewed. The times and observations on the 100 Hall on 8/13/25 included the following, which revealed CNA F was the first staff member to respond to R7's fall followed by LPN D: 4:50:39 p.m. – CNA E enters R7's room. 4:53:44 p.m. – LPN C enters R7's room. 4:53:50 p.m. – both LPN C and CNA E exit R7's room. 4:53:50 p.m. to 4:58:47 p.m. – CNA E continued to stand outside R7's door. 4:58:47 p.m. – CNA E walks off 100 Hall with LPN C. 5:01:15 p.m. - CNA F enters R7's room and exits at 5:01:21. Appears to walk off of 100 hall. 5:02:07 p.m. – CNA F returns with LPN D. 5:03:36 p.m. – CNA F appears to walk off 100 Hall. 5:04:51 p.m. – CNA F returns with CNA E. Both enter R7's room. 5:04:58 p.m. – LPN D exits R7's room. 5:05:04 p.m. – LPN C appears on surveillance video. 5:05:31 p.m. - LPN C appeared to walk slowly to R7's room. 5:06:35 p.m. – LPN D retrieves wound dressing from clean utility room. 5:06:35 p.m. – LPN D enters R7's room with wound dressing. 5:09:41 p.m. – CNA F exits R7's room. 5:11:16 p.m. – LPN C, LPN D, CNA E all exit room pushing R7 in a wheelchair. All appear to leave 100 hall. The surveillance video showed a vitals machine did not enter or exit R7's room prior to, during or directly following R7's 8/13/25 fall. Review of the Un-witnessed Fall incident report, dated 8/13/25 at 17:02 (5:02 p.m.), revealed the following incident description: Nursing Description: Writer was called to resident's room due to resident sitting on the floor. When this writer arrived other staff nurse had assessed res (resident) for injury. When writer arrived, she witnessed res sitting on her buttocks in the entry way of her room. Created by LPN C . Immediate action taken . Assessed res (resident). Res c/o (complained of) pain in her head, which she has a bump to right side of her head. She also has a skin tear to her right elbow. She said her right thigh is sore. Writer did some mild range of motion and res did not cry out in pain . No injuries observed at time of accident . Level of pain: 5, Mobility: Wheelchair bound . Predisposing Situation Factors documented included: 1. Ambulating with Assist and 2. During Transfer. Review of a CNA Incident Report with the name/signature of CNA F, the first staff to respond to R7's fall. The Incident Report, dated 8/13/25 included the following information, in part: Pain: Yes. Grimaces: yes . When last ambulated: Needs assist . Order for ambulation: Staff assist. During an interview on 9/10/2025 at 8:00 a.m., CNA F was interviewed regarding R7's fall with major injury. When asked how CNA F became aware that R7 had fallen, CNA F stated, I was walking past [R7's] room and saw [R7] on the floor. CNA F said R7 was on the floor, with her body lying on the right side; feet were inside the bathroom door up to her knees (approximately) and the resident's body was lying parallel to the room door. When asked if the CNA E (who placed R7 on the toilet) had informed her (CNA F) that R7 was on the toilet prior to CNA E leaving the floor and going to the dining room. CNA F stated, Nobody (no staff member) told me they were leaving the floor, or that R7 was left on the toilet. I thought CNA E had toileted R7 and brought her down to the dining room. When asked what the expectation between staff was, when a resident was left on a toilet, and the staff member was leaving the floor, CNA F stated, That you tell another staff member that they are leaving so they can monitor that resident closely. When asked what limited assistance and a gait belt with toileting meant to her, CNA F stated, That you stay with the resident and monitor them until they are off of the toilet. CNA F confirmed R7 did not have a gait belt on when CNA F found [R7] on the room floor. When shown the CNA Incident Report, dated 8/13/25, with her name on the bottom of the form, CNA F stated, That is not my signature. The Incident Report clearly noted: Nurse Aide signatures: for two lines included on the form for signatures. Review of R7's Care Plans on 9/9/25 at 1:19 p.m., revealed the following Toileting and Transfer interventions, in part: Toileting Care Plan revision 5/14/25 (in place at time of fall) – TOILETING- I require limited staff assistance of 1 and a gait belt to use the toilet. I dribble urine and need limited assist for toileting hygiene cares when I am incontinent. Date Initiated: 10/02/2024 Revision on: 05/14/2025. Toileting Care Plan revision following identification of right pubic fracture (8/28/25) - TOILETING- I require extensive assist of 2 and a gait belt to use the toilet. I dribble urine and need limited assist for toileting hygiene cares when I am incontinent. Date Initiated: 10/02/2024 Revision on: 08/28/2025. TRANSFERRING- I require limited staff assistance of 1 and a gait belt for transfers using my FWW. Date Initiated: 10/02/2024 Revision on: 05/14/2025 (In Effect at Time of Fall). TRANSFERRING- I require extensive staff assistance of 2 and a gait belt for transfers. Date Initiated: 10/02/2024 Revision on: 08/28/2025. Review of an SBAR (Situation/Background/Appearance/Review) Communication Form completed on 8/13/25 at 5:04 p.m. by LPN C revealed the following in part: Does the resident have pain? Yes. New. Back of head. Right elbow. (No reference to right thigh pain). The SBAR Communication Form was faxed to Physician L on 8/13/25 at 17:25 (5:25 p.m.) per the fax receipt. Physician L's written response of no further orders was faxed back to the facility on 8/22/25, eight days after the form was faxed to the physician. Review of an 8/28/25 SBAR Communication Form, completed upon transfer to the acute care hospital, revealed the following, in part: Situation: Altered mental status. Falls. Pain (uncontrolled). This started on 08/19/2025. Since this started it has gotten worse. Completed by Registered Nurse (RN) G. During an interview on 9/10/2025 at 8:53 a.m., RN G was asked about the SBAR Communication Form she had completed on 8/28/25. RN G said that she had been concerned about R7 since the fall. RN G said R7's anxiety and pain appeared to be escalating. Review of R7's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2025, revealed the following changes, in part: 1. Physician order for Clonazepam (anti-anxiety medication) was changed from 0.5 mg once daily to two times daily on 8/21/25. 2. Pain Assessment for the first 12 days of August (prior to the fall) had the following self-reported pain documentation: No pain level above Level 5. Level five: 1 Level four: 1 Level three: 6 Level two: 6 Level one: 1 Level zero: 23 3. Pain Assessments for August 13 through August 31, 2025 (R7 hospitalized [DATE] – 8/30/25) Level six: 3 Level five: 9 Level four: 4 Level three: 3 Level two: 6 Level one: 3 Level zero: 19 4. Acetaminophen physician order for 650 mg (milligrams) by mouth every 4 hours as needed for pain, administered 7 times between 8/1/25 and 8/13/25, prior or R7's fall on August 13th, administered 30 times between 8/13/25 (following R7's fall) and 8/31/25 (R7 was hospitalized [DATE] – 8/30/25). Review of R7's Progress Notes revealed the following, in part: Effective Date: 08/28/2025 13:00 (1:00 p.m.) Type: Resident (R7) was in dining room and wouldn't eat. (R7) Was freaking out that table was going to fall on her. Crying she couldn't see people. Her head hurt. At this time daughter [Family Member (FM H] walked in and we disguise (sic) (perhaps meant discussed) options. [FM H] wants resident sent to clinic. Clinic nurses advise to send to ER. Facility bus was to take resident to ER. Report was given to [Unit Manager] I and [FM H] would be following her up there (to ER). Review of the acute care hospital discharge documentation for R7's transfer to the ER on [DATE] and inpatient stay in the hospital until 8/30/28, revealed the following discharge documentation, in part: 1. X-ray of R7's right hip, on 8/28/25, identified a comminuted (broken in multiple places), displaced (bones moved out of their normal position), right pubic fracture (more likely to occur from a high-energy event such as a fall or accident). 2. HIP (History of Present Illness): . She is also complaining of right knee and hip pain and occasionally complains of headaches. She has fallen occasionally in the past with her most recent fall on 8/13 when she was found seated on the floor of her room (based on report from FM H documented in the discharge documentation). She reported that she tried to walk to the bathroom herself and fell striking the right side of her body and her head .She states her pain is 10 out of 10 . She eventually states her knees and hips hurt as well as the middle part of her back . Review of Physician Visit Progress Notes found no documentation of a physician visit following R7s fall on 8/13/25, prior to R7's discharge to an acute care hospital on 8/28/25. During an interview on 9/9/25 at 2:45 p.m., the NHA and Director of Nursing (DON) were both asked if staff should be using a gait belt with resident transfers unto and off of the toilet. The NHA stated, Yes, if it was in the care plan. We would also anticipate they would use a gait belt if it wasn't in the care plan. When asked for any witness statements from nursing staff that responded following R7's fall on 8/13/25, the NHA stated, I do not have any interviews with the staff that went into the room. When asked if family was notified of the fall, the DON acknowledged family was not notified promptly of the fall because R7 is her own person and responsible for her own decisions. When asked about the delay in written receipt of the SBAR faxed to the physician on 8/13/25 and received back on 8/22/25, the NHA said she would hope the written response would be within a day and commented that the Physician L was also contacted via the telephone in an attempt to get the written response returned promptly. When asked about Witness Statements, the NHA (who completed the investigation) said she did not have any Witness Statements from the staff who responded to R7's fall. The DON said she had received a Witness document from CNA F, signed 8/13/25. The DON presented the handwritten statement to this Surveyor at this time and stated, It was my error. I did not give it to [the NHA]. The following documentation was requested at this time: Fall and Post-Fall Assessment policies, and second request for neurological checks (second request) completed on R7 post-fall. During an interview on 9/9/2025 at 3:45 p.m., LPN D (the first LPN to respond to R7's fall on 8/13/25) confirmed R7 had no gait belt on when found on the floor. When asked if she had fully assessed R7 prior to moving her off the floor, including completion of vitals and/or neuros, LPN D said she did not complete any assessment of the R7. LPN D said she did go to retrieve a dressing for wound care, because R7 had hit her head. LPN D said she was not the nurse on that hall and was not the nurse providing care to R7 on 8/13/25. LPN D confirmed staff that leave a resident on the toilet, and leave the Hall, should inform the staff they are working with, so that the staff could monitor the resident. During an interview on 9/10/25 at 8:15 a.m., the DON was asked how facility staff monitor vitals for residents. The DON said vitals were taken with a vital machine (attached to a pole with wheels). Asked if the DON would have any concern that a vitals machine was not observed going into R7's room prior to or following her fall, and before she was wheeled down to the dining room for dinner, the DON acknowledged R7's vitals should have been assessed prior to movement from the floor to the wheelchair. On 9/10/2025 at 8:24 a.m., the DON and NHA were observed walking down that hall and the DON was overheard saying she said the machine (vital machine) was in the dining room. When asked if they were talking about R7's fall and failure to obtain vitals prior to removing the resident from the floor, both the DON and NHA acknowledged that vitals were not obtained prior to moving the resident off the floor into her wheelchair with a gait belt and taken down to dinner on 8/13/25. During a telephone interview on 9/10/2025 at 11:33 a.m., FM H was asked if she was notified of R7's fall on 8/13/25. FM H stated, They usually call when things happen. I don't know why they didn't notify me about this occasion. On other falls they have called me . I was not notified on 8/13/25. She (R7) showed me her elbow. That is the only reason I knew she fell. They said they did the vitals protocol after she fell . Review of the Accidents and Supervision policy, last reviewed 6/12/25, revealed the following, in part: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: . Implementing interventions to reduce hazard (s) and risk (s). 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 residents assessed needs and identified hazards in the resident environment. Review of the Incidents and Accidents policy, implemented 7/18/25, revealed the following, in part: .7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so .10. In the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks per protocol and document on the neurological flow sheet .11. The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. Review of the Falls policy, implemented 6/17/24, revealed the following, In part: When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment c. Complete an incident report d. Notify physician and family. e. Review the residents' care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. During the Exit Conference on 9/10/25 at approximately 5:00 p.m., the DON acknowledged a neurological check form was unable to be located showing neuros were performed on R7 post-fall on 8/13/25. Resident #23 (R23) On 8/29/25 at 8:00 AM, an anonymous complaint was reported to the State Agency (SA), which stated R23 was in his room with a razor, cut his tongue, is on a blood thinner and staff had a hard time stopping the bleeding. The anonymous complainant stated that the razor R23 used was the same kind the facility uses on residents. The anonymous complainant stated that they were unsure if a staff member left the razor in the bedside cabinet drawer or how R23 obtained the razor. On 9/2/25 at 2:40 PM, an observation was made of R23 in his room. R23 was sitting in his wheelchair and was observed to have a bruise with various colors of yellow, green, and purple around his right eye and a scab above his right eyebrow. R23 was asked if he had recently cut his tongue and replied with a nodding his head up and down. R23 was unable to explain how he had cut his tongue or with what. Review of R23's progress note, dated 8/26/25 at 1:31 PM, read in part .Resident has a cut on his tongue which was bleeding. He had blood dripping from his mouth down his chin. On inspection showed a elongated cut to left lateral tongue. He is not sure how he did it. Treated with rolled absorbent gauze in mouth as in a dental sponge. The nurse changed x 2 and then bleeding stopped. Review of R23's progress note, dated 8/27/25 at 12:42 PM, read in part SN (skilled nurse) was informed by CNA (certified nurse aide) that resident cut his tongue with a razor on a previous shift. Review of R23's minimum data set (MDS) assessment, dated 8/18/25, revealed under section GG for Personal hygiene section GG0130 Self-Care: Marked for Partial/moderate assistance which includes shaving. On 9/2/25 at 2:50 PM, an interview was conducted with R23's roommate who was asked if he knew how R23 got a razor and replied, It was my razor. I guess the staff left the razor in the bathroom and he (R23) got a hold of the razor and cut his tongue and was bleeding. On 9/5/25 at 9:00 AM, an interview was conducted with CNA F who was asked about R23 cutting their tongue and replied, I don't know anything about it that is what the social worker said. Talk to the social worker. On 9/5/25 at 9:33 AM, an interview was conducted with Social Services Director U who was asked how R23 but his tongue and replied, He did it shaving with a razor. One of the aides told me. Social Services Director U was asked if R23 was safe to have a razor and replied, No and I am not sure why he even had a razor or how he got a razor. I guess it just got left in his room by a staff person. He is not supposed to be shaving himself. On 9/5/25 at 9:40 AM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if there was an incident and accident report completed for R23 having a razor and cutting his tongue and replied, Not that I am aware of. On 9/5/25 at 9:45 AM, an interview was conducted with the Director of Nursing (DON) who was asked if R23 was safe to have a razor or to be shaving himself and replied, No. A CNA told me he was shaving and had his tongue out. He should have not had a razor. The DON confirmed there was no incident and accident report completed after R23 cut his tongue with a razor. Review of policy titled, Accidents and Supervision, dated 6/12/25, read in part Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.5. Supervision.is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Review of policy titled, Incidents and Accidents, dated 7/18/25, read in part Policy: It is the policy of this facility for staff to utilize Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Policy Explanation: The purpose of incident reporting can include.Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences.Compliance Guidelines.5. The following incidents/accidents require an incident/accident report but are not limited to.self-inflicted injuries.12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. Resident #38 (R38) On 9/3/25 at 10:54 AM, R38 was observed in the doorway of another resident's room. The doorways to rooms [ROOM NUMBER] were observed with mesh-type barriers with stop sign notifications on the barriers. The barriers extended across the doorways and were secured with Velcro on each end to attach each end to the doorframes. The electronic medical record (EMR) of R38 documented admission to the facility on 3/12/25. The primary diagnosis of R38 was dementia with psychotic disturbance. An Activities of Daily Living (ADL) care plan in the EMR indicated R38 was independent with transfers, was able to ambulate, and utilized a wheelchair independently for locomotion. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R38 had a primary medical condition of non-traumatic brain dysfunction and experienced hallucinations. Further review of the MDS revealed R38 received antipsychotic medication on a routine basis and scored three of fifteen on the BIMS (Brief Interview for Mental Status) indicating R38 had severe cognitive impairment. The MDS coded R38 as independent with wheelchair mobility. A progress note dated 9/3/25 at 4:07 AM documented, in part: . around 0100 [1:00 AM] resident started to try escaping, tried going through dining room door, pulling at the blinds, broke one of the dining room blinds. Attempted to elope out of the front door, breaking the door open. This RN called patients family who tried talking to her, resident to calm down some, this RN sat and talked w/ [with] her at front of building, around 0400 [4:00 AM] pt [patient] did go into her room but refuses to get into bed or change into pajamas. Resident also is seeing her sister rose outside, stating she needs to get to her before she gets to [sic] cold. A progress note dated 9/3/25 at 8:38 AM documented: Cameras reviewed. Resident did appear to be looking to get out of the building, checking windows, and moving around the perimeter of the dining room and entryway. Resident did push on front door at 02:33:58 [2:33 AM, 58 seconds] and it came off the track. Staff was there with resident and was able to redirect while they put the door back on the track. Maintenance contacted to have door looked at for proper functioning. The EMR of R38 was reviewed on 9/3/25 at 9:30 AM, 9/3/25 at 2:27 PM, 9/4/25 at 8:13 AM, 9/4/25 at 1:20 PM, and 9/5/25 at 7:54 AM. The EMR did not contain an assessment to evaluate R38's risk for elopement after R38 attempted to exit the facility on 9/3/25. None of the care plans for R38 included the resident's elopement attempt on 9/3/25 or interventions to minimize the risk of recurrence. There was no documentation regarding increased supervision or interventions to mitigate recurrence. CNA R was interviewed on 9/4/25 at 1:20 PM. CNA R was asked if the facility had a list of residents who were at risk for elopement. CNA R said there was no list of residents who at risk for leaving the facility unsupervised. When asked how staff knew which residents required increased supervision and monitoring for potential elopement from the facility, CNA R said residents at-risk for elopement wear a WanderGuard™ bracelet (part of a wander management system designed to ensure the safety of individuals, particularly the elderly or those with dementia, by preventing them from wandering away). R38 was observed in the dining room on 9/4/25 at 1:28 PM. A WanderGuard™ bracelet was not visible on the extremities or on the wheelchair of R38. There was no notation in the EMR regarding a WanderGuard™ bracelet for R38. CNA S and CNA T were interviewed on 9/4/25 at 2:32 PM. CNA S confirmed there was no listing of residents who were at risk for elopement from the facility. When asked the names of residents who were at risk for elopement, CNA S said the residents with a WanderGuard™ bracelet were the residents at risk for elopement. When asked how the staff knew which residents required increased supervision and monitoring for potentially exiting the facility unsupervised, CNA R reiterated the residents with WanderGuard™ bracelets were the residents at risk and said if a resident did not have a WanderGuard™ bracelet then the resident was not at risk for elopement from the facility. The nurse manager, RN I, was interviewed on 9/4/25 at 2:02 PM. RN I was asked when elopement assessmen

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) was available for eight consecutive hours during a 24-hour period. This deficient practice had the potential for unmet care needs which could affect all 52 residents that reside in the facility.Findings include:Review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ Staffing Data Report for Fiscal Year (FY) Quarter 2 2025 (January 1-March 31) revealed the facility triggered for No RN hours with infraction dates being: 3/16/25, 3/22/25, 3/23/25 and 3/29/25.Review of facility document reflecting staffing data for the day, dated Saturday March 29th, 2025, revealed no RN coverage for 24-hour period.During an interview on 9/4/25 at approximately 11:00 a.m., Human Resources Manager B reported there was not an RN working on the Schedule for Saturday March 29th, 2025.Review of the timesheets revealed there was no RN in the facility from March 28th at 7:11 pm through March 30th at 7:15 a.m., reflective of an absence of an RN for eight consecutive hours in a 24-hour period.During an interview on 9/5/25 at 7:52 a.m., the Nursing Home Administrator (NHA) acknowledged that on 3/29/25 there was not an RN in the facility for eight consecutive hours in a 24-hour period.

Based on interview and record review, the facility failed to complete a performance review for one of five Certified Nurse's Aides (CNA's) at least every 12 months. This deficient practice resulted in the potential for inadequate care and unmet resident care needs for all 52 residents residing in the facility.Findings include:Review of facility personnel records demonstrated that CNA O was hired on 4/16/24 with no performance review.During an interview on 9/4/25 at approximately 10:55 a.m., the Director of Nursing acknowledged there was no performance evaluation completed for CNA O and stated, The facility does not have a policy regarding performance evaluations or when they should be completed.During an interview on 9/5/25 at 7:52 a.m., the Nursing Home Administrator (NHA) acknowledged the performance review for CNA O was not completed and should have been completed annually.

Based on interview and record review, the facility failed to ensure written communication of Monthly Medication Review (MMR) recommendations to the physician for five Residents (#2, #5, #6, #37, and #38) of five residents reviewed for MMRs. This deficient practice resulted in the absence of written MMR recommendations for the last year and had the potential to affect all 52 residents in the facility. Findings include:Resident #2 (R2), #5 (R5), #6 (R6, #37 (R37), #38 (R38)On 9/10/2025 at 9:10 a.m., an interview with the Director of Nursing (DON), (NHA), and Unit Manager/Registered Nurse (RN) I was conducted. When asked if there was a monthly pharmaceutical review report showing who the pharmacist had seen each month for Monthly Medication Reviews (MMR) reviews, all three agreed there were no written pharmacy recommendations that resulted from the MMRs for any resident in the facility in the last year, including R2, R5, R6, R37, and R38. An interview via telephone or in-person was requested with the facility's consulting Pharmacist J.During a telephone interview on 9/10/2025 at 9:21 a.m., Pharmacist J acknowledged there were no written pharmacy recommendations for any resident in the facility in the last year, including R2, R5, R6, R37, and R38. Pharmacist J stated, If the doctor doesn't want the Gradual Dose Reduction (GDR), (required per regulation), I read the doctor's note (monthly physician note)and I read they don't want a GDR (then) I don't make the recommendation. When asked to clarify, Pharmacist J continued, The physician has already said he doesn't want a GDR (in the progress note). If it (GDR) was something that I was going to recommend a GDR, but they already have written they don't want a GDR, that is kind of why I respond the way that I do. It is already written in his note. When asked if there had been any recommendations for lab draws, increased monitoring, or consideration of blood pressure monitoring in the last year, Pharmacist J stated, I could look through my notes to [the DON]. They (DON) have asked me to look at something and I have in the past. When asked if the review that the facility requested was put into the medical record of the resident when it was completed, Pharmacist J stated, No, it is just in my correspondence with [the DON]. When asked if monthly pharmacy reports were sent to the DON, Pharmacist J stated, I do, yes, as far as the med room inspections. Pharmacist J provided an example of reviewing a patient when the frequency of administration of a medication need to change (such as once daily to two times daily) and then sending a message, via email, to the DON regarding that change. When asked to clarify that if there was a medication frequency change recommendation [Pharmacist J] went through [the DON] to do that and no physician recommendation was completed, by written communication, telephone, or email, Pharmacist J stated, I guess I have just been making [the DON] aware of the recommendation. Pharmacist J confirmed he was making pharmacy recommendations, but they were sent to [the DON) via emails but acknowledged that he did not know, in every case, that there was follow-up with the physician. Pharmacist J stated, I have never made a (written) recommendation that [was] submitted to the physician . If I am notified after a fall I review those meds. When asked if he was notified of R7's fall on 8/13/25 that resulted in a fall with major injury, Pharmacist J stated, No I was not. During an interview on 9/10/2025 at 9:32 a.m., the Nursing Home Administrator (NHA) was asked what was expected of the facility consultant pharmacist. The NHA stated, The expectation is that he is communicating any discrepancies, and he would be reporting the recommendations to the medical doctor. When asked if those recommendations could be verbal, the NHA stated, It would probably be best if it was done in writing. The pharmacist should have a recommendation to the physician, with a cc (carbon copy) to [the DON] so she can follow up with the physician to ensure it is completed.

Based on interview and record review, the facility failed to ensure performance improvement projects/activities were conducted to ensure problem areas were identified, tracked, and improvement attained. This deficient practice resulted in lack of improvement in previously deficient finding areas which has the potential to affect all residents residing in the facility. Findings include: During an interview on 9/10/25 at 3:10 p.m., the Nursing Home Administrator (NHA) was asked what the QAPI (Quality Assurance Performance Improvement) committee had been working on. The NHA stated, Putting out fires. When asked what performance improvement projects (PIPs) the facility had been working on in the last year, the NHA (two months in new position) was uncertain of what projects had been implemented. The NHA was asked if they would like another staff member present for the QAPI task interview, and she responded affirmatively. The Director of Nursing (DON) was added to the QAPI interview. During an interview on 9/10/25 at 3:21 p.m., the NHA and DON were asked to provide examples of PIPs the facility had conducted in the last year. The DON said they have not done any PIPs in the last year because the former NHA said the facility got cited anyway, so they weren't going to do them (PIPs) anymore. The DON stated, Historically, most managers would have one PIP. No PIPs were available for discussion or review. Review of the QAPI (Quality Assessment Performance Improvement) Change Process policy, implemented 6/12/25, revealed the following, in part: . 5. The facility must conduct distinct performance improvement projects, based on the scope and complexity of facility services and available resources, identified in the facility assessment. 6. The facility must conduct at least one improvement project annually that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis. 7. Performance Tracking - a. Once actions are implemented, the facility continues to track performance to ensure that improvements are realized and sustained . c. At least annually, the facility conducts a self-assessment to determine the facility's performance improvement culture. Corrective action is taken as appropriate .

Based on interview and record review the facility failed to ensure quality assessment and assurance (QAA) committee meetings were held quarterly with the participation of all required members. This deficient practice resulted in the absence of a required QAA member (Medical Director) in the second quarter of 2025, which had the potential to affect all facility residents. Findings include: During an interview on 9/10/25 at 3:10 p.m., the QAA committee sign-in sheets were reviewed with the Nursing Home Administrator (NHA). Committee meeting sign-in sheets were located by the NHA, detailing the only one QAA committee meeting was held in the second quarter of 2025 (6/12/25). The Medical Director, Physician V's signature was absent from the sign-in sheet, indicating he was not present at the June 2025 meeting. The NHA was asked for QAA committee sign-in sheets for April and May of 2025. The NHA stated, I don't believe there was a QA meeting in April or May of 2025. No sign-in sheets for any additional QAA committee meetings in the second quarter were provided for review.

Based on interview and record review, the facility failed to ensure Certified Nurses Aide (CNA) training of no less than 12 hours per year was completed for one CNA O of five CNA's reviewed for nurse aide training hours. This deficient practice resulted in the potential for unmet resident care needs for all 52 residents that reside in the facility.Findings include:During an interview on 9/4/25 at 10:41 a.m., Human Resources Manager B revealed the annual 12-hour CNA training is based on the CNA hire date.Review of facility document titled Bayside Village Staff Disaster Notification provided from the Director of Nursing (DON) revealed CNA O was hired on 4/16/24 and had only 9 hours of training in a year.Review of Facility Assessment (FA) last reviewed 8/21/25, read in part .Required in-service training for nurse aide.must be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year.During an interview on 9/5/25 at 7:52 a.m., the Nursing Home Administrator (NHA) acknowledged the CNAs must have 12 hours of training a year.

Based on observation and interview, the facility failed to provide a homelike environment as evidenced by serving residents their meals on institutional trays and having a common area with a worn down and deteriorating conditions of furnishings and wall finishes at the nursing station. Findings include: On 9/3/25 at 11:40 an observation was made of the facilities nurses' station. The nurses' station entrances were both observed to have lifted and peeled off paneling on the side and corners of the entrance. On the front wall of the nurses' station there was one area of wallpaper that was missing and one area of wallpaper the size of a small basketball that was peeled off and hanging. On 9/3/25 at 11:50 AM, an interview was conducted with Registered Nurse (RN) G who was asked if the nurses' station was very homelike and if she would leave the condition of the station in her own home and replied, No, it looks rough and could use a revamp. We can't even keep anything like scissors or resident information lying around. Because the nurses' station does not lock on the entrance areas and residents get inside and one resident has the one entrance all marked up because they get their wheelchair caught on the side trying to get in. On 9/5/25 at 9:33 AM, an interview was conducted with the Social Services Director U, who was asked about the condition of the nurses' station and replied, It is not very functional for the nurses, and it needs a lot of TLC (tender loving care). It needs to be repaired. During the breakfast meal on 9/3/2025 at 8:45 AM, Residents were observed in the facility dining room with their meals in front of them on institutional trays. Meal trays were being distributed by staff in no particular order. Residents were not served together with their tablemates. During the lunch meal on 9/3/2025 at 12:25 PM, the meal was also served on trays and was observed along with Dietary Manager (Staff) Y. Staff Y was asked why the facility staff were serving resident meals on trays, Staff Y said, That is a good question. The DON (Director of Nursing) asked me why the food is served on the trays also. The CNAs (Certified Nurse Aides) just put them on the table. Staff Y concluded, If the trays were not used it would be a better dining experience. Staff Y was asked if there was a dietary policy regarding this aspect of meal service, but none was presented by the close of the survey.

Based on interview and record review, the facility failed to:- provide written information on the facility's bed hold policy for five Residents (#27, #15, #2, #3, and #7).- provide written transfer notifications to the resident, and resident's representative for four Residents (#15, #2. #3 and #7).of five residents reviewed for transfers out of the facility. Findings include: Resident #27 (R27) was transferred to the hospital Emergency Department (ED) on 7/26/25. There was no documentation in the Electronic Medical Record (EMR) indicating the resident/responsible party was provided a bed hold notice. During an interview on 9/4/25 at 2:25 p.m., the Nursing Home Administrator (NHA) reported, the facility had not been giving bed hold information to the resident/responsible party when discharged to the hospital. Review of policy titled Transfer and Discharge date implemented 4/11/25, read in part .Emergency transfers to acute care.the facility will.provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge in a form and a manner that the resident can understand.provide a notice of transfer and the facility's bed hold notice policy to the resident or representative. Review of policy titled Bed Hold Notice date implemented 4/11/25, read in part .It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave.the facility will keep a signed and dated copy of the bed-hold notice information given tot the resident and or resident representative in the residents file and or medical record. Resident #3 (R3) was hospitalized on [DATE]. The EMR did not specify the facility provided written notice of the reason for the transfer or written notice of the bed hold policy to R3 or R3's resident representative. Resident #7 (R7) was hospitalized on [DATE]. The EMR did not specify the facility provided written notice of the reason for the transfer or written notice of the bed hold policy to R7 or R7's resident representative. During an interview on 9/4/2025 at 12:13 PM, the Nursing Home Administrator and Director of Nursing both agreed they did not send a written notification of transfer explaining the reason for hospitalization or an explanation of the current bed hold policy to the resident or responsible party. Resident #15 (R15) was admitted to the facility on [DATE]. The EMR revealed R15 was transferred to the ED on 8/5/25 and was subsequently admitted to the hospital. There was no documentation in the medical record indicating R15 or R15's resident representative was provided with written notification of the reason for the transfer. The EMR did not include the provision of the facility bed hold policy to R15 or R15's resident representative. Resident #2 (R2) was initially admitted to the facility 10/12/22. Review of the EMR disclosed R2 was transferred to the ED on 7/22/25 and 8/27/25. The EMR did not specify the facility provided written notice of the reason for the transfer or written notice of the bed hold policy to R2 or R2's resident representative.

Based on observation, interview, and record review, the facility failed to ensure one medication cart of three medication carts reviewed were attended and or locked and all resident medications were secured and or consumed for one Resident (#27) of fifteen residents reviewed for medication storage. Findings include: On 9/4/25 at 12:11 PM, an interview was conducted with Registered Nurse (RN) A who was asked about medication pass and where she was in the process and replied, I have a couple more to do. I have to go check on a resident for feeding assistance. RN A walked away from her medication cart and left it unlocked/unattended and walked into an adjacent resident room [ROOM NUMBER]. On 9/4/25 at 2:30 PM, an observation was made of the 300-hall medication cart that was located at the entrance of the 300-hall unlocked and unattended. This Surveyor walked over to the 300-hall medication cart and opened several drawers which were in a resident common area. RN A was sitting at the nurses' station and was asked how often she leaves her medication cart unlock and unattended and replied, Oh, no! Is it unlocked? This Surveyor then opened the third drawer and replied, Yes, it is. On 9/10/2025 at 2:30 PM, an interview was conducted with the Director of Nursing (DON) who was asked what her expectation was of the medications carts and if they should be locked when nurses are not attending them or preparing medications and replied, Yes, the medication carts should be locked at all times if not attended by a nurse. Review of policy titled, Medication Storage, dated 7/18/25, read in part Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of policy titled, Medication Administration, dated 7/18/25, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines.15. Observe resident consumption of medication. Resident #27 (R27) Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/24/22. R27 scored 15 out of 15 on the BIMS (Brief Interview for Mental Status) assessment reflective of intact cognition. During an observation on 9/3/25 at 12:46 p.m., R27 had a medicine cup on his bedside table with antacid medication. During an interview on 9/3/25 at 12:47 p.m., R27 reported that the nursing staff leaves the medication at bedside sometimes. Review of the Electronic Medical Record (EMR) revealed R27 did not have a physician order to self-administer medication and R27 did not have self-administration of medication assessment that had been completed. Review of policy titled Medication Administration last reviewed/revised 7/18/25, read in part .medications are administered by licensed nurses or other staff who are legally authorized to do so.as ordered by the physician and in accordance with professional standards of practice.administer medication as ordered.observe resident consumption of medication. Review of policy titled Medication Storage last reviewed/revised 7/18/25, read in part .All drugs and biologicals will be stored I locked compartments ie. Medication carts, cabinets, drawers.medication rooms.only authorized personnel will have access t the keys to locked compartments.During a medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart.

Based on interview and record review the facility failed to attempt a gradual dose reduction for one resident (Resident #37) out of five residents reviewed for psychotropic drug use. Findings include:Resident #37 (R37)Review of R37's minimum data set (MDS) assessment, dated 9/9/25, revealed medical diagnoses of hypertension, diabetes mellitus, dementia, depression, and aphasia (a condition where a person finds that they have slight or serious difficulty with either their language or their speech). Review of R37's MDS, section E: Behaviors lacked any documentation of having behaviors. On 9/9/25 at 10:40 AM, an observation was made of R37 resting in his wheelchair in the day room with his eyes closed. Review of R37's physician order, dated 8/21/24, revealed quetiapine (an antipsychotic medication) 25 milligrams (mg) twice daily for dementia without behavioral disturbances and escitalopram (antidepressant medication) 10 mg once daily. On 9/10/25 at 11:15, an observation was made of R37 resting with his eyes closed in the day room sitting in his wheelchair. R37 was asked how he was doing and how his day was going and R37 did not respond or open his eyes. Review of R37's task for behavior monitoring question one: What behavior(s) was observed? That included physical, verbal, and socially inappropriate behaviors in the last 30 days were blank and no behaviors were checked as exhibited by R37. Review of R37's monthly medication regimen reviews from the pharmacy, dated 8/27/24 through 8/28/25, revealed no recommendations and no gradual dose reduction (GDR). Review of R37's GDR request for quetiapine and escitalopram, dated 6/9/25, revealed the lack of a last GDR, previous failed attempt, behavioral care recommendations, behavior notes, and a declination on 6/17/25 from Physician K stating to continue same meds - GDR contraindicated given his history of behaviors in past and currently stable with no side effects. On 9/10/25 at 11:20 AM, an interview was conducted with Social Services Director U who was asked if there was a specific area where staff was to be charting on behaviors or if R37 had any behaviors in the last three months and replied, Actually he (R37) has been good lately. Staff are to document behaviors in the electronic medical record in the tasks area and in a binder then I follow up with the resident who is having any behaviors. Social Services Director U was asked to see any documented behaviors for R37 and had two communication logs for behaviors on 3/19/25 and 6/10/25 both in the evening. Review of R37's social services progress note, dated 7/9/24, read in part Writer completed well check on resident. Resident was in the hall at this time roaming safely in the facility. Resident was pleasant. When asked resident said he was good.No concerns at this time. Review of R37's social services progress note, dated 6/30/24, read Writer completed well check on resident. At this time resident is roaming safely through the facility. Resident mood is pleasant, no behavioral concerns at this time. Resident is not agitated or being aggressive. When asked resident states he's doing good, and then smiles. Review of R37's social services progress note, dated 3/10/24, read Resident pleasant during assessment. Mood was stable. Review of R37's social services progress note, dated 3/10/24, read Resident pleasant during assessment. Mood was stable. Review of R37's social services progress note, dated 1/21/24, read Writer did wellness check up with resident. Residents mood was stable. Resident smiling and laughing. On 9/10/25 at 1:30 PM, an interview was conducted with Physician K who was asked why a GDR was not completed in the last year for R37 and replied, He (R37) is stable and is contraindicated for having a GDR. I am afraid of doing a GDR because I don't want to lose ground and take a step back. Physician K was asked if there was a risks verses benefits completed for R37 and replied, No. Physician K did not give any real clinical contraindication for the lack of a GDR. Review of physician progress note, dated 6/17/25, read in part .is doing well and has no complaints.Nursing staff has no concerns.He is awake, alert, happy. Review of physician progress note, dated 4/29/25, read in part The resident is doing well and has no complaints. Staff reports no increased behaviors.He seems to be always happy and is jovial and joking with Examiner. Review of physician progress note, dated 2/25/25, read in part The resident is doing well and has no complaints. Staff reports no increased behaviors.He seems to be always happy and is jovial and joking with Examiner. On 9/10/25 at 1:40 PM, an interview was conducted with the Director of Nursing (DON) who was asked why R37 did not have an attempted GDR for his quetiapine or escitalopram and replied, There should at least be one attempt to see how R37 would respond. Review of policy titled, Gradual Dose Reduction of Psychotropic Drugs, dated 6/12/25, read in part, Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.Policy Explanation and Compliance Guidelines: 1. Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic drugs. Therefore, dose reductions and behavioral interventions are part of medication management.2. Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility will attempt a GDR in two separate quarters (with at least one month between the attempts).4. The timeframes and duration of attempts to taper any medication shall depend on factors including the coexisting medication regimen, the underlying causes of symptoms, individual risk factors, and pharmacological characteristics of the medications.c. Opportunities during the care process to consider whether the medications should be continued, reduce, discontinued, or otherwise modified include: i. During the monthly medication regimen review by the pharmacist.

Based on interview and record review the facility failed to ensure the PASARR (Preadmission Screening/Annual Resident Review) level I ([one] (DCH-3877) was obtained annually for one Resident (#6) of two residents reviewed for PASARR requirements . Findings include:Review of R6's electronic medical record (EMR) revealed an initial admission to the facility on 3/25/2022 with diagnoses including depression, unspecified hallucinations, unspecified psychotic disorder with delusions due to known physiological condition, anxiety disorder, and Alzheimer's disease. A review of R6's Minimum Data Set (MDS) quarterly assessment, dated 7/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 2 of 15 indicating severe cognitive impairment. Section E under Behavioral Symptoms revealed R6 was coded as having physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring every 1 to 3 days.A review of the active physician's orders for R6 included an antipsychotic drug quetiapine, prescribed on 7/21/2024, as well as a current order for an antidepressant drug sertraline prescribed 9/27/2024. The care plan for R6 included focus areas which read in part: I have potential to demonstrate behaviors aeb (as evidenced by) I sometimes exhibit physical and verbal behaviors towards others, refuses cares, mediations, and interventions.- I have impaired cognitive function or impaired thought processes r/t (related to) Alzheimer's diagnosis, delusions and hallucinations, impaired decision making, short-term memory loss.- Trauma Informed Care: I have a history of trauma that can negatively impact my care and treatment.- I use antipsychotic medications: Seroquel (quetiapine) r/t Alzheimer's disease with hallucinations and psychotic disorder with delusions.The EMR for R6 contained a PASARR Level one (DCH - 3877) dated as filed 3/26/24 and marked as ARR (ANNUAL RESIDENT REVIEW). A current annual PASARR Level I (DCH - 3877) for 2025 annual resident review could not be located in the EMR.During an interview on 9/4/2025 at 1:57 PM, the Director of Nursing (DON) stated she does the PASSAR's and took the lead in that area. She reviewed the EMR for R6 and could not find a current annual PASSAR level I (DCH-3877). The DON said, PASSAR's are definitely a work in progress. There is not a level I (for R6) since 3/26/24. The undated facility policy titled Resident Assessment - Coordination with PASARR Program read in part, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID) or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on observation, interview, and record review the facility failed to update a comprehensive care plan for 1 Resident (#23) of 15 residents reviewed for care plans. Findings include:Resident #23 (R23)On 9/2/25 at 2:40 PM, an observation was made of R23 in his room, sitting in his wheelchair. R23 was observed with a bruise with various colors of yellow, green, and purple around his right eye and a scab above his right eyebrow. R23 was asked if he had fallen and how and replied by pointing to the bathroom and nodding yes. R23 was not able to say when he had fallen.Review of R23's incident and accident report, dated 8/18/25 at 3:20 PM, read in part Un-witnessed fall.Incident description: Nursing description: Was told by and aid '[Resident's name] fell and is bleeding from his head.' Upon arriving in room, resident was sitting on the edge of the bed with blood dripping from his forehead (sic). Resident description: Resident stated he fell and hit his head on the floor coming from the bathroom. Resident stated 'I hit my head on the floor when I fell.' 'I was coming from my bathroom.'.Immediate action taken: Description: Pressure applied, neuro check WNL (within normal limit).Ambulance was called to take resident to the hospital for evaluation and treatment. Review of R23's progress note, dated 8/18/25 at 10:38 PM, read in part .Resident fell in his room and has a laceration that required sutures.Diagnosis: Fall, right forhead (sic) laceration required 3 sutures.discharged at 6:00 PM. Review of R23's care plan, dated 11/6/23, read in part Focus: I had a fall with no injury. Revised on: 3/2/25. Goal: To minimize my risk of falls with serious injury thru the next review date. Revised on 3/2/25. Interventions/Tasks: I have been educated to call and wait for staff assistance when I transfer to minimize my risk for falls. Date initiated: 3/1/25. My bed has been positioned against the wall per my preference to establish boundaries. This does not restrict my movement in bed or my ability to get into and out of bed. Date initiated: 6/2/25. No other interventions, added interventions, or updated care plan for fall with injury to prevent further falls.Review of R23's fall risk assessment, dated 8/15/25, revealed a blank assessment which had not been completed.Review of R23's fall risk assessment, dated 6/1/25, revealed R23 was at risk of falling. Review of R23's progress note, dated 8/29/25 at 8:10 AM, read in part Writer educated by nurse that.ambulance coming to get resident to take (local ER name) to be evaluated.Review of R23's emergency room (ER) visit, dated 8/29/25 at 8:40 AM, revealed a return to the ER for adding an additional three sutures to stop bleeding. Review of a progress note, dated 8/29/25 at 11:56 AM, read in part Area to forehead with stitches from previous fall, bleeding without stopping. Pressure applied for 20 mins (minutes) with no relief. Res (resident) transported to (local ER name) for evaluation via ambulance.Res returned from ED (emergency department) with 3 new stitches to area.Review of a progress note, dated 9/1/25 at 5:34 PM, read in part Res has picked one if not two stitches out of forehead causing excessive bleeding. Compression dressing applied x 2 resulting in bleed throughs. Res continues on (brand name anticoagulant) [rivaroxaban] 20 mg (milligrams) daily.Review of ER visit, dated 9/1/25 at 8:35 PM, revealed R23 had stitches removed from his forehead, electrocautery was performed, and silver nitrate was applied to his forehead. A bandage was also applied to prevent R23 from picking at the area of his forehead. On 9/5/25 at 9:45 AM, an interview was conducted with the Director of Nursing (DON) who was asked about the process after a resident falls and replied, Well first assess them, then treat them, completed and incident report, and update the care plan to prevent further falls. The DON was asked what added interventions were put in place for R23 after his fall and replied, I don't see a note from me in the risk management note. Review of policy titled, Fall Prevention Program, dated 6/12/25, read in part Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines.g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes.9. When any resident experiences a fall, the facility will.e. review the resident's care plan and update.Review of policy titled, Fall Risk Assessment, dated 6/12/25, read in part Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. Policy Explanation and Compliance Guidelines: 1. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified.3. An At Risk for Falls care plan will be completed for each resident.5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.

Based on observation, interview, and record review, the facility failed to obtain physician orders for supplemental oxygen and ensure respiratory equipment was changed, labeled, and appropriately stored for two Residents (#13 & #27) of two residents reviewed for respiratory care and services. Findings include: On 9/2/25 at 2:49 PM, Resident #13 (R13) was observed with a nebulizer (a drug delivery device used to administer medications into the lungs) on the bedside stand. The tubing attached to the nebulizer was unbagged and labeled with the date 7/30/24. The nebulizer tubing was placed directly atop the nebulizer without a barrier beneath the tubing. On 9/2/25 at 2:49 PM, an oxygen concentrator was observed adjacent to R13's bed. The nasal cannula tube (tubing that delivers supplemental oxygen) was unbagged and undated. The nasal cannula tubing was placed directly atop the concentrator without a barrier between the concentrator and the tubing. R13 said she used oxygen when she experienced respiratory difficulty and received respiratory treatments through the nebulizer when needed for shortness of breath. Review of the electronic medical record (EMR) disclosed R13 was admitted to the facility 11/9/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R13 experienced shortness of breath with exertion and utilized supplemental oxygen therapy while a resident. Further review of the MDS revealed R13 had a medical diagnosis of COPD (Chronic Obstructive Pulmonary Disease – irreversible lung and airway damage). R13 had a BIMS (Brief Interview for Mental Status) score of 15 indicating R13 had intact cognition. The physician's orders for R13 did not include an order for supplemental oxygen. A care plan for the use of supplemental oxygen was not located in the EMR. There was no physician documentation regarding the use of supplemental oxygen. On 9/3/25 at 3:16 PM and 9/4/25 at 9:02 AM, during an observation, the nebulizer tubing remained unbagged and without a barrier and labeled with the date 7/30/24. The nasal cannula tubing continued to be unbagged and undated without a barrier between the tubing and the oxygen concentrator. The Director of Nursing (DON) was interviewed on 9/10/25 at 8:40 AM. The DON confirmed a physician's order was required to implement and utilize supplemental oxygen. The DON said the facility had standing orders to implement supplemental oxygen when indicated. When queried regarding the process to implement standing orders, the DON said nurses were required to enter a physician's order into the EMR and the order should be brought to the attention of the physician, so he is aware the standing order was implemented. The DON verified supplemental oxygen was expected to be incorporated into the respiratory care plan, and tubing should be changed and dated at least weekly and as needed. Resident #27 (R27) Review of MDS assessment dated [DATE], revealed admission to the facility on 2/24/22, with active diagnoses including COPD. R27 scored 15 out of 15 on the BIMS assessment reflective of intact cognition. During an observation on 9/3/25 at 12:53 p.m., R27 had an oxygen concentrator next to his bed and an oxygen tank on his wheelchair. The oxygen tubing on the wheelchair was not marked. The oxygen tubing on the concentrator had a date of 8/12/25. During an interview on 9/3/25 at 12:55 p.m., R27 revealed he was unaware of when the oxygen tubing was last changed. During an observation on 9/4/25 at 10:02 a.m., the oxygen tubing for R27 was wrapped around the right wheel of the wheelchair, under the wheelchair, and R27 was sitting on the oxygen tubing and nasal cannula. During an interview on 9/4/25 at 10:04 a.m., Registered Nurse (RN) A reported the oxygen tubing was not properly stored and the oxygen tubing was not dated. RN A reviewed the oxygen concentrator and acknowledged the oxygen tubing had a date of 8/12/25 and reported the oxygen tubing was supposed to be changed weekly. Review of doctor's orders with a start date of 8/18/25 revealed the oxygen tubing was to be changed weekly on Mondays on night shift. Review of doctor's orders dated 8/9/25, read in part Oxygen sats (O2 sats) check two times daily or as needed. Place resident on 2-4 Liters(L) if O2 saturation is less than 90. Place O2 on resident when sleeping or napping as his O2 saturations decrease when he sleeps. Review of O2 sats revealed that O2 sats were not obtained on 8/10/25, 8/11/25, 8/12/25, 8/13/25, 8/15/25, 8/16/25, 8/17/25, 8/19/25, 8/21/25, and 8/23/25 through 9/4/25. Review of R27's care plan revealed no interventions for monitoring oxygen saturation (O2 sats), changing oxygen tubing, or proper storage of oxygen tubing. During an interview on 9/5/25 at 8:43 a.m., the DON acknowledged there were no interventions in the care plan regarding changing oxygen tubing, monitoring oxygen saturation, or proper storage of oxygen tubing. Review of policy titled Oxygen Administration last reviewed/revised 7/18/25, read in part .oxygen is administered under orders of a physician.the residents care plan shall identify the interventions for oxygen therapy based upon the resident's assessment and orders, such as but not limited to: A. the type of oxygen delivery system. B. when to administer, such as continuous or intermittent and/or when to discontinue. C. equipment setting or the prescribed flow rates. D. monitoring of SpO2 (oxygen saturation levels and/or vital signs as ordered.staff shall.change oxygen tubing and mask/cannula weekly and as needed and.keep delivery devices (oxygen tubing) covered in a plastic bag when not in use.

Based on interview, and record review, the facility failed to ensure physician assessments and visit progress notes, including review of the program of care and resident condition, were available in the medical record of one Resident (#25) of 15 residents reviewed for physician visits. This deficient practice resulted in potential delinquent execution of care, unmet care needs, and lack of coordination of care. Findings include:Resident #25 (R25) was admitted to the facility 12/9/21. Review of the electronic medical record (EMR) disclosed a primary diagnosis of acute embolism and thrombosis of the deep veins of the left lower extremity. During an interview with Registered Nurse (RN) I on 9/10/25 at 11:05 AM, RN I said she contacted the physician of R25 on 7/16/25 to report medication errors that occurred with R25 for eight consecutive days, from 7/8/25 through 7/15/25. When RN I was asked if the physician assessed R25 after the medication errors were reported, RN I said, I don't know.The EMR of R25 was reviewed on 9/10/25. The most recent physician documentation available in the EMR was dated 12/27/24. On 9/10/25 at 2:01 PM, the Director of Nursing (DON) was asked if the physician had assessed or visited R25 in the year 2025. The DON said he had been in the facility and assessed R25 but could not recall the last visit. The DON was asked where the physician assessments and documentation were located. The DON said the physician documents would be in progress notes or in documents in the EMR. The surveyor and DON reviewed the EMR or R25. No physician visit notes or documentation for R25 was in the EMR since December of 2024. The DON said the physician should document findings at each visit and the documentation should be in the EMR.On 9/10/25 at 2:11 PM, The Administrator (NHA) asserted the physician had visited R25 since December 2024. The NHA was asked if the EMR contained documentation by the physician of the physician's assessment of the resident and the resident's current medical regimen and needs since 12/27/24. The NHA confirmed there was no documentation in the EMR indicating the physician had assessed R25 since 12/27/2024.The policy Physician Visits and Physician Delegation dated as revised 6/12/24 read, in part: .The licensed Nurse should: . f. Remind the physician to date and sign all orders and write a progress note. The physician should: . b. resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a physician. c. Review the resident's total program of care including medications and treatments at each visit. D. Date, write and sign a progress note for each visit.

Based on interview and record review the facility failed to ensure physician visits were completed timely for two Residents (#7 & #8) of 15 sampled residents reviewed for physician visits. This deficient practice resulted in extended time frames between physician visits and the potential for unaddressed medical needs.Findings include:Resident #7 (R7)Review of R7's admission Record, retrieved 9/9/25 at 12:56 p.m., revealed R7 was admitted to the facility on [DATE] with a primary admitting diagnosis of generalized anxiety disorder. R7 was their own responsible party for decision making.Review of Physician Visit Progress Notes, retrieved on 9/9/25 at 2:01 p.m., revealed R7 had the following physician visits completed by Physician L following R7's admission to the facility:1. 10/21/24 - initial Physician Visit completed, documented as a late entry on 10/24/24. Completed by Physician L.2. 11/19/24 - second Physician Visit was documented by Physician L.3. 1/28/25 - third Physician Visit was documented as a late entry on 2/2/25, greater than 60 days from the previous physician visit. Resident #8 (R8)Review of R8's admission Record, retrieved Resident R8 was admitted to the facility on [DATE] with diagnoses that included the following, in part: pulmonary embolism, pneumonia, and unspecified dementia. R8 had a guardian in place for decision making.Review of R8's Physician Visit Progress Notes revealed physician/practitioner visits were completed as follows. 6/24/25 - first documented physician visit completed by Physician L nearly two months following R8's admission to the facility. 8/26/25 - second Nurse Practitioner (NP) visit completed by NP M More than two months from the previous physician visit. 9/9/25 - third NP visit completed by NP M. On 9/10/2025 at 11:20 a.m., an interview was completed with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding the untimely physician/practitioner visits completed for R7 and R8. Upon review of the Physician Visit Progress Notes and R7's and R8's complete medical record, both the NHA and DON acknowledged physician visit documentation present in both R7's and R8's medical record revealed physician visits were not completed at 30-day intervals for the first 90 days following admission. The NHA and DON acknowledged difficulty with completion of timely physician visits by Physician L. Review of all facility residents, by the NHA, revealed Physician L was the primary physician for only Residents R7 and R8 residing in the facility.Review of the Physician Visits and Physician Delegation policy, revised 7/18/25, revealed the following, in part: Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents . The Physician should . b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State Law . d. Date, write and sign a progress note for each visit . h. At the option of the physician, required visits in SNFs (Skilled Nursing Facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist . 3. The Director of Nursing or Designee should: a. Conduct monthly audits for timeliness of physician visits. b. Contact the physician regarding an overdue physician's visit. Record the physician's response regarding the overdue visit in the nurse's notes. c. Notify the Medical Director of the need to make a visit, for the attending physician, if he/she is unable to visit. 4. The Medical Director should: a. Visit residents who are not seen by their attending physician or alternate physician according to schedule. B. Document a progress note and orders for care as needed. c. Notify the attending physician and family of the results of the visit.

Based on interview and record review, the facility failed to ensure: 1. Proper care of a catheter, 2. Accurate and timely documentation was entered for care decisions, and 3. Notification of significant changes were communicated to the physician for one Resident #5 (R5) of three residents reviewed for quality of care. This deficient practice resulted in harm when R5 was hospitalized due to a ruptured bladder, urinary tract infection, and septic shock (a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.), with continued decline resulting in death. Findings include: Review of R5's admission Record, retrieved on July 3, 2025, revealed R5 was admitted to the facility on [DATE], with active diagnoses that included the following, in part: benign prostatic hyperplasia with lower urinary tract symptoms, urine retention and type 2 diabetes mellitus with hyperglycemia. R5 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition. Review of R5's Progress Notes revealed the following, in part: 5/24/25 22:33 (10:33 p.m.), Writer alerted by CNA that resident had blood in his brief, writer assessed, resident had blood coming from the pin point area at tip of penis . 5/26/25 19:16 (7:16 p.m.) ,Resident has a large area of swelling to his left inner thigh. It feels boggy, no pain to touch and no redness. His lower legs have increased edema . This was not seen on 5/25/25. This needs to be seen by the DR (doctor). 5/27/25 10:17 a.m., Physician Progress Note, included the following, in part: . He has an indwelling Foley catheter. Extremities with 1+ pitting edema to his bilateral legs. According to the nurses he has a small breakdown of skin behind his heel .Assessment/Plan: . 4. BPH (benign prostatic hyperplasia) with lower urinary tract symptoms with indwelling Foley catheter . 9. Lower extremity edema - start furosemide 40 mg daily x 2 weeks, follow weights, leg measurements and urine output. Check labs with a BMP in 2 weeks. There was no documentation related to the 2/24/25 blood in his brief and on the tip of his penis, and no mention of the large area of swelling to his left inner thigh that was boggy. 5/29/25 17:44 (5:44 p.m.) LATE ENTRY Nursing Progress Note, entered on 6/24/25 (26 days following the provision of care to R5.) Res (resident) started to c/o (complain of) lower abdominal discomfort around 11:00 (a.m.) and he did not have but 150 mls (milliliters) (of urine) in catheter bag. This writer asked if he felt like he needed to urinate and he said he did. So, this writer flushed foley with 60 mls of sterile water, and then urine immediately started to flow back into the drainage tubing. Then early afternoon res c/o lower abdominal pain again. This writer checked his foley bag and there wasn't much more urine in the bag since flush. Around 200 ml. Urine was yellow in color. So, after discussing what the resident wanted nurse to do, we decided on changing his foley catheter, When removing the old catheter there was blood at the tip (of the deflated balloon) of his foley. This writer then used sterile technique to insert the new foley . urine immediately started filling foley bag. Urine was bloody 5/30/25 04:52 (4:52 a.m.) Nursing Progress Notes Urine continues to be bloody. Had emesis x 3. Hasn't slept much, increasingly confused. Demanding to get out of bed now. 5/30/25 9:56 a.m., At 0940 (9:40 a.m.) CNA (Certified Nurse Aide) came to SN (skilled nurse) and stated resident had a facial droop and was pocketing his food. SN went to assess right hand grasp were not equal. Right side was greatly weaker. Right side of face is dropping (sic), and speech has changed, Vitals 104/69 (blood pressure), 126 (heart rate), 20 (respirations), Temp 98.4 . Resident was sick during the night and vomited 3x (times). Also, vomited this morning but states it was just drool . Tylenol was given for headache this am. Cath was changed yesterday and there is blood in urine. 5/30/25 10:25 a.m., Resident (R5) left facility with EMS (emergency medical services). 5/30/25 11:53 a.m., Report from local hospital (ER). Resident WBC (white blood cell count) is elevated around 18,000 (reflective of infection), and lactic acid at 7 . (indicative of sepsis). 5/30/25 15:12 (3:12 p.m.), Report from [ER]. Resident has a ruptured bladder - looking to send out to [Regional Medical Center]. ER Nurse will call me with up (update) on where resident will be shipped if [Regional Medical Center] can't take him. 5/31/25 10:43 a.m., .Resident was transferred to [Regional Medical Center] for further care. 6/16/25 11:38 a.m., . Resident arrived at facility via stretcher from [Regional Medical Center. On 6/16/25 at 3:00 p.m., R5's Brief Interview for Mental Status (BIMS) was completed with a score of 15 out of 15, reflective of intact cognition . 6/17/25 2:43 a.m., .elevated temp 100.8 degrees . During an interview on 7/3/25 at 11:30 a.m., when asked if there was an incident report for R5's ruptured bladder, the Director of Nursing (DON) stated, No the nurse did not do an incident report for that. When asked about the late progress note, entered on 6/24/25, for replacement of R5's foley catheter on 5/29/25, the DON stated, I have a huge problem with late progress notes, and I have a huge problem with this (absence of investigation documentation, including R5's urine outputs from the investigation file). During an interview on 7/3/25 at 12:43 p.m., Registered Nurse (RN)/Unit Manager M was asked why there was no documentation about the blood in R5's brief, and on his penis on 5/24/25. RN M stated, I don't think he (Physician P) was updated on the blood in the urine. RN/Unit Manager M confirmed RN S had placed a LATE ENTRY progress note in R5's medical record on 6/24/25, when R5's catheter change occurred on 5/29/25. RN M confirmed the facility was aware of R5's ruptured bladder, urinary tract infection, and septic shock diagnoses prior to documentation of the 6/24/25 nursing note by RN S. When asked if it was acceptable practice to document care in the medical record nearly one month late, RN M stated, I would say it is not acceptable . During a telephone interview on 7/3/25 at 1:30 p.m., following review of R5's Physician Progress Note on 5/27/25, Physician P was asked if he was informed by facility staff of any urinary issues, including blood in R5's brief and on his penis on 5/24/25, the large boggy area on R5's upper left thigh, bloody urine and decreased urinary output. Physician P responded, No, paused and stated, I did not know anything until I read the emergency room notes. Review of the local Hospital ED (Emergency Department) Provider Note: 5/30/25 10:42 a.m., Presents from . nursing home with a chief complaint of nausea and vomiting. [Facility] had initially expressed concern for some left-sided neurologic deficits but no evidence of this on arrival. Patient states he vomited last night after supper, a few times overnight and this morning after breakfast. He reports some vague lower abdominal discomfort. Chronically has an indwelling Foley, states it was replaced yesterday, noticed some blood in the tubing yesterday but he has not had any urine output yet today . Physical Exam: Abdomen . Mild tenderness across lower abdomen. ED Course: 100 mL saline flushed through foley easily, but no return of fluid or urine noted. Nursing home did confirm he has had normal urine output, 1200 mL (milliliter) yesterday and 700 drained before he was brought to the ER today . Labs show leukocytosis (elevated white blood cells) with WBC 18.0 . Lactic acid (measures tissue deprived of oxygen in severe illnesses) significantly elevated at 7.5. Patient meeting SIRS (Systemic Inflammatory Response Syndrome [Septic Shock] criteria, no clear source of infection at this time .CT (Cat Scan) with findings concerning for bladder rupture . cystography (bladder imaging) confirms extraperitoneal bladder rupture with contrast extravasation (leakage of x-ray dye) into the anterior extraperitoneal (into the abdomen) space. [Urologist] updated, will consult on patient after transfer (to Regional Medical Center). ABX (antibiotic) coverage broadened to Meropenem 1 g and Vancomycin . We will give loading dose of 2.5 g vancomycin . Assessment: Sepsis, Lactic acidosis, UTI, Bladder rupture . condition at discharge: Fair. CT Abdomen and Pelvis: Marked diffuse bladder wall thickening with diverticulum formation. Extraperitoneal gas and large volume fluid appearing to extend from the anterior superior aspect of the ladder lumen. This is concerning for extraperitoneal rupture. Foley is in the urethra at the level of the prostate apex (entrance of the urethra into the lower part of the prostate) . CT cystogram (Cat scan of the bladder using dye) confirms extraperitoneal bladder rupture from the anterosuperior ladder which contains numerous diverticula (areas of abnormal pouching). Contrast extravasated (leaked) into the extraperitoneal space. During an interview on 7/8/25 at 8:16 a.m., when asked why a progress note detailing R5's condition and catheter change was entered 26 days late, RN S stated, That hall (R5's hall) is hectic. I just forgot that day, and then they called me the next day. I guess I don't know . my boss told me to put a note in . I told him [R5] he was not due to have his catheter changed for two weeks, but we can start with flushing it. I did 60 mls (flush) and I got urine back right away. Then he didn't have much more urine in the bag after that. Then I asked him again what I should do . We laid him down in bed and changed the catheter. The old (catheter) had blood on the tip for about an inch . He had more urine output after the new bag. Filled the bag with 200-300 mls, and it was bloody at the time it started coming out . At dinner he said he didn't feel good again . When asked if she had informed any physician that R5 had blood in his brief, on his penis, in the urine, or decreased urine output, RN S stated, I did not let the doctor know he was having bloody urine and blood on his removed catheter tip. RN S said she had informed Physician P at the time of R5's Physician Visit on 5/27/25 of the large, boggy area on R5's upper left thigh. RN S stated, I told him about it in the room too, and he didn't even look at his thigh. He had his sheet on, and he (Physician P) didn't pull the sheet down to look at his upper thigh. When asked what concern RN S would have with a Lactic Acid level of 7.0, RN S stated, I think inflammation at 7. When asked if sepsis would be a concern, RN S stated, I guess I don't know that. During an interview on 7/8/25 8:13 a.m., RN L reported she had received report on 5/30/25 that R5 had thrown up three times the previous night, and did say RN S had changed R5's catheter on 5/29/25 due to decreased urine output. RN L stated, It (the urine) was pink in the tubing, and pretty dark in the catheter bag, but there was only a very small amount of urine in there. Between 7:10 and 7:20 a.m. I emptied the 100 ccs of urine . I emptied it myself and then was kind of watching . I sent him out by 9:20 a.m., . I don't need a physician order to send him out on an emergency transfer .When I heard his lactic acid was 7, I immediately thought septic . I knew nothing about the blood in the brief and on his penis. RN L stated, The week prior to all of this (with R5) Certified Nurse Aide (CNA) F stomped down to the nurses' station and was so ticked because the night shift had not emptied the (R5's) catheter bag and it was the size of the football . CNA F was fuming about the football sized catheter bag. I know I walked down to [the Nursing Home Administrators (NHA's)] office and reported that to [the NHA] . The [DON] brought me the outputs, and she had pulled the (urine) outputs, but she didn't let me keep them .There was one 35 ml (urine output documentation), and that was 12 hours with only 35 mls! Why was there no bladder scan? RN L said that facility did have a bladder scanner that was available for use in the facility . During a telephone interview on 7/8/25 at 9:55 a.m., when asked if she had any knowledge of R5's Foley catheter bag being found overly full, CNA T stated, Yes, absolutely. I reported it to my nurse several times. I would come in at 7 a.m., at shift (change) and we would go and check the catheters. One time his catheter bag was so full it was the size of a football, and it was leaking. Another time I found it by myself, and it was the size of a football, like 3000 ccs at the beginning of (my) shift. I had to use the graduated cylinder three times to get it emptied. That catheter had not been dumped all night long .The second time I was back in that hall I noticed that there was blood in his catheter, and there was hardly anything in the catheter other than pure blood. It was also reported to us that he had been throwing up during the night . CNA T said she could not remember which nurse she reported it to, but R5's catheter was the only one that she ever remembered being that full, and noted it was the only hall she worked on. When asked when these observations occurred, CNA T stated, May/June - it was recent. During a telephone interview on 7/8/25 at 10:16 a.m., when asked about knowledge of R5's catheter being found overly distended, the NHA stated, I heard that last week, that the catheter had been ballooned, but the NHA was unaware multiple staff had reported the failure of staff in emptying R5's catheter bag. When asked about the very late nursing progress note placed in R5's medical record approximately one month following the provision of care, the NHA stated, That would not be a standard of practice to put in a month later. The NHA said she had not seen the investigation file compiled by the DON. During an interview on 7/8/25 at 11:14 a.m., when asked about R5's medical record documentation and care, RN N stated, I was looking at [R5's] chart and the hospital saying that he had a ruptured bladder. This is a huge concern . (floor staff) were making mention seeing his foley ag being ballooned out like a football . There was no documentation in the Investigation File. When we tried explaining that with the [DON], I felt that she was trying to justify the task for urine output. The numbers were not adding up to accurate numbers. I don't know what kind of follow-through [the DON] did . I feel like there is resistance (to doing the right thing) and hiding of data . One of my bigger frustrations - if something happens here the physician is not being notified . When asked about late progress notes, RN N stated, What about a nurse note entered a month late. It is hard to look back on that and how can you remember what happened a month ago. The [NHA said multiple times this investigation should not have been delayed. I have a big problem with it . I am here to do the right things for the residents . Staff Member (de-identified to prevent retaliation) U said that staff were told not to chart things, (and also) . to chart tasks even if you don't do them . I don't believe any of the numbers that are input on the urine output task. They are not checking before the shift. They are not paying attention to it. During an interview on 7/8/25 at 11:49 a.m., when asked about concerns with distended, over-filled urinary drainage bags, the DON stated, That would be backflowing because it was so full. I think our bags only go to 1000 mls. The DON retrieved a Foley catheter bag, which held 2000 mls, and a graduated cylinder for emptying the urine, which held 1000 mls. The DON provided the following information: 1. Resident care should not be documented if staff have not completed the care. 2. Nursing staff should be documenting nurse notes as soon as the task is completed. The DON agreed there would be the potential for inaccuracy when a note is delayed for approximately one month before being placed in the medical record. 3. The DON said a lactic acid level of 7 would mean a sepsis concern for herself. 4. The DON agreed the physician should be notified of changes in condition immediately. During a telephone interview on 7/8/25 at 12:03 p.m., CNA F was asked if she had observed R5's catheter overly filled with urine. CNA F stated, When I went into [R5's] room after breakfast his foley was like a water balloon, ready to burst open. It took two or maybe 3 graduated cylinders to empty the foley bag completely. The next day it was the same situation, his foley bag was like a water balloon about to burst open. I reported it to the floor nurse, and I reported that it had happened two days in a row. I said this was dangerous because it could back up into the tubing. Breakfast was done about 9:00 a.m., and he did not urinate 2000 ccs between the start of my shift and the end of breakfast. I spoke with [CNA V] (who had worked both night shifts prior to CNA F's day shift) . There was no reason someone could not have gone in and emptied the foley on night shift. During a return telephone call on 7/9/25 at 7:30 p.m., When asked if she had ever been instructed to document the completion of resident tasks, even if she had not performed the task, CNA W stated, I was told to do that, and I was very uncomfortable with it. I did it one night, and I have talked to other nurses about it, and I know that it is illegal to document that I did something when I didn't. I did it because my nurse told me to do that . CNA W provided the name of the nurse, and stated, To be honest I am afraid of her. When asked if she had ever seen R5's foley bag overly filled with urine, CNA W said there was a CNA who had been repeatedly hired and fired and was fired recently for not emptying R5's foley bag overnight. CNA W also provided a staff who were present at the same time when an RN told them to document uncompleted tasks. During a return telephone call on 7/9/25 at 7:56 p.m., when asked if she had ever observed R5's foley bag over-distended, CNA R stated, The night R5's bladder exploded, terminated CNA V was on that hall. Review of R5's Urine Output Task documentation revealed the following, in part: 5/21/25 Night shift (7 p.m. to 7 a.m.) - Blank, no documentation present. 5/22/25 Day shift (7 a.m. to 7 p.m.) - 3000 ml. 5/26/25 Night shift - Blank no documentation present. 5/27/25 Day shift - 1200 mls. 5/29/25 Day shift - 35 mls. Review of R5's Weights documentation following Physician Ps physician progress note of 5/27/25, documenting Lower extremity edema - start furosemide 40 mg daily x 2 weeks, follow weights, leg measurements and urine output ., revealed no weights were documented between 5/27 and 5/31/25. No leg measurements were found within R5's medical record, and urine output values have the potential for inaccuracy, based on staff interviews obtained. Review of the Investigation Timeline, completed by RN N, revealed the following identified concerns by that investigator: 1. Need statement for [Nurse regarding her note from 5/30/25 stating the Cath was changed yesterday and there is blood in urine. 2. Who worked 5/29/25 - need statements. 3. Vital signs ordered to be checked twice daily and report abnormalities to the provider - 6/17/25 - Lack of documentation . 4. Mixed information . notes show he had a low-grade fever, but this is not reflected under the VS (vital sign) tab. 5. May 2025 Treatment Administration Record (TAR) not documented with a catheter change on 5/29/25 or 5/30/25. 6. Need to show we did some type of education with nursing regarding foley care/insertion. Review of Catheter Care policies revealed that no policies were in effect at the time of R5's ruptured bladder, UTI, and septic shock diagnoses following transfer to the local ED. Catheter polices provided by the facility were Implemented by the NHA on 6/23/25. Review of Notification of Changes policy, revised 7/18/24, revealed the following, in part: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include a. Life-threatening conditions, or b. Clinical complications . 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. B. Discontinuation of current treatment due to: i. Adverse consequences. Ii. Acute condition. Iii. Exacerbation of a chronic condition. 4. A transfer or discharge of the resident from the facility .

This deficiency pertains to intake #MI00152671. Based on interview and record review the facility failed to ensure adequate assistance and assistive devices were used to prevent a fall with major injury resulting in harm for one resident (R2), out of three residents reviewed for falls. This deficient practice resulted in hospitalization due to a pelvic fracture. Findings include: Review of R2's 4/19/25 Witnessed Fall Incident report, prepared by Registered Nurse (RN) C, revealed the following information, in part: . CNA (Certified Nurse Aide) was in residents room called out for nurse to help, res (resident [R2]) laying on floor in room on right side next to overbed table. Resident Description: Res states she was getting up to use bathroom and fell during transfer. Was this incident witnessed: N (No). Resident Taken to Hospital? N (No) .Notes: wound to right side of head, c/o (complaint of) right leg discomfort no increased disc (discomfort) with ROM (range of motion) . Statements: No Statements Found. Review of R2's Minimum Data Set (MDS) assessment, dated 1/26/25, revealed R2 was admitted to the facility on [DATE]. R2 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. R2 required partial/moderate assistance with chair/bed-to-chair transfers and toilet transfers, and had active diagnoses that included arthritis, osteoporosis, seizure disorder, non-Alzheimer's dementia, unsteadiness on feet and repeated falls. R2 was noted to be their own decision maker on their Face Sheet. Review of a CNA Incident Report signed and dated by CNA A on 4/19/25, revealed the following Witness Statement Box information: I was helping [R2] into her wheelchair. She started to turn to sit down, her leg stopped, and she fell and hit her head on the bottom of her bed side table. During an interview on 5/7/25 at 11:20 a.m., R2 was asked about any recent falls. R2 said and aide was assisting her during a transfer, and she fell. R2 could not recall if CNA A used a gait belt during the transfer. R2 reported she has a fractured pelvis. Review of R2's 4/19/25 Investigative Summary form revealed the following, in entirety: Resident Name: [R2] . Female . Summary of interview with person(s) reporting the fall .: Helped getting into chair. Slipped out of gripped (sic). Holding her by butt and pants. Doing fine. Launched off of CNA. Between bed and w/c. overbed table. All other areas of the form were blank. R2's ADL care plan, included with the Investigative Summary, had the following Transfer intervention: Transfer limited assist of one to two a gait belt and my FWW (front wheeled walker) for transfers. Date Initiated: 3/6/16. Revision on:1/27/2025. Review of R2's Progress Notes revealed the following, in part: . 4/19/25 01:18 (1:18 a.m.) . CNA (Certified Nurse Aide) requested nurse assistance in residents room, nurse responded right away res (resident) laying on floor next to bed near overbed table, res on right side, bleeding noted from residents head, blood and hair noted on bottom of overbed table, res assessed and assisted to sitting to assess head, bleeding appeared to slow with change in position, dressing applied to res head, res further assessed and assisted to sitting on bed then w/c (wheelchair), see VS (vital signs) then assisted to bathroom, res sitting out at nurses station with staff, denied HA (headache), c/o (complained of) discomfort to right leg, ROM WNL (range of motion within normal limits). No c/o increased discomfort with movement, alert usual self. Author: RN C. . 4/19/25 02:14 (2:14 a.m.) . bleeding slowed to laceration to head, may need sutures, call placed to on call MD and order obtained to send resident to ED (emergency department). Ambulance called for transfer, res c/o pain to right leg with transfer, res to [ED] for eval at 0210 (2:10 a.m.) res did not want family notified of transfer. Author: RN C. . 04/19/2025 04:03 (4:03 a.m.) . Res admitted to [acute care hospital] pelvic fx (fracture). . 04/19/2025 09:25 (9:25 a.m.) . At the time of this fall Resident was being assisted by a CNA (CNA A) from her bed to her wheelchair. Per CNA 'I was helping [R2] turn into her wheelchair, she started to turn to sit down, her leg stopped, and she fell and hit her head on the bottom of her bedside table'. Author: RN/Director of Nursing (DON). Review of R2's Care Plans, retrieved 5/7/25 at 2:19 p.m., revealed the following, in part: Focus: I have an ADL self-care performance deficit r/t (related to) impaired mobility, muscle weakness, Dementia, need for staff assistance with ADL/s. I have a pelvic fracture secondary to a fall on 4/19/2025 . Interventions/Tasks: I am non-ambulatory. Date Initiated: 4.22.2025. Non-Weight Bearing to bilateral lower extremities x 12 weeks. Date Initiated: 4/22/2025. Transferring: I am dependent on staff assist of 2 using a full-body mechanical lift (Hoyer lift). Non-weight bearing on lower extremities x 12 weeks. Date Initiated: 4/25/2025. Review of R2's RESOLVED: I had a fall with major injury care plan, Date Initiated 3/6/2016, Revision/Resolved: 4/23/2025 had the following RESOLVED Intervention, in part: Staff need to use a gait belt and extensive assist when transferring me. I have a gait belt in my bag on my wheelchair. Date Initiated: 3/21/24, Revision/Resolved 4/22/25. The NHA acknowledged the facility had not performed monitoring audits of staff use of gait belts following the incident. Attempts were made to contact CNA A via telephone on 5/7/25 at 10:17 a.m., and on 4/7/25 at 2:30 p.m. Voicemail messages were left requesting a return call from CNA A. No return call was received from CNA A during or following the completion of the survey, therefore she was unable to be interviewed. During an interview on 5/7/25 at 2:33 p.m., the Five-Day Report to the State Agency regarding R2's fall with major injury was reviewed. The Five-Day Report revealed the following, in part: Investigation determined that at the time of the fall [R2's] plan of care was not followed. The NHA said CNA A had not been on the schedule since the incident and would be receiving education on proper use of a gait belt and also receive a written verbal warning upon her return to work. The NHA said she had spoken to CNA A who confirmed she was holding on to the back of R2's pants and her butt, not using the gait belt as an assistive device during the transfer, therefore not following the residents' plan of care. Review of the facility Use of Gait Belt policy, implemented 7/18/2024, revealed the following, in part: Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Policy Explanation and Compliance Guidelines: 1. Each nursing department employee will use the gait belt assigned to each resident. 2. It will be the responsibility of each employee to ensure the use of gait belts . 4. Failure to use gait belt properly may result in disciplinary action up to termination.

Based on observation, interview, and record review, the facility failed to: 1. Consistently complete bed rail assessments to determine resident initial need and continued use for bed rails. 2. Assess all residents with bed rails for risk of entrapment and ensure the absence of bed entrapment zones through consistent and scheduled measurement by facility staff, 3. Ensure compatibility between facility bed frames and bed rails, 4. Follow the manufacturer's recommendations for installation and maintenance of bed rails, 5. Ensure the presence of, and compliance with physician orders for bed rails, and/or 6. Ensure informed consent was obtained prior to installation of bed rails for seven Residents (#1, #19, #22, #31, #33, #34, and #46) of seven residents reviewed for bed rails, resulting in immediate jeopardy (IJ). These deficient practices resulted in the likelihood of entrapment, serious injury or harm, and/or death, for any facility resident using bed rails without assessment of appropriateness for medical condition and safety. Findings include: Resident #46 Review of Resident #46's MDS assessment, dated 08/30/22, revealed Resident #46 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46 required limited one-person assistance with bed mobility, transfers, walking, dressing, and toileting. The BIMS assessment revealed a score of 9 out of 15, which indicated Resident #46 had moderate cognitive impairment. An observation on 09/21/22 at 9:02 a.m. revealed Resident #46 seated sitting upright on the edge of her bed eating breakfast. Her bed had a T-bar bedrail attached to the bedframe on both sides in the middle of her bed. There was no manufacture's labeling or identification observed on the bedrail. The bedrail was older and worn in appearance, with the top horizontal handle square-shaped, sticking out at least 6 on each side beyond the vertical anchor pole at each end. This style appeared would be a hazard if the occupant fell on to the bedrail due to the large prongs sticking out from each side of the bedrail handle. Review of Resident #46's Electronic Medical Record (EMR) revealed no resident-centered bedrail assessment to justify safe use of the bedrail, no informed consent by the resident representative, no physician orders, and no zones of entrapment measurements. During an interview on 09/21/22, Resident #46's Unit Manager, Registered Nurse, RN Y, was asked about the missing documents. RN Y confirmed they were not completed and had earlier made the Nursing Home Administrator (NHA) aware the facility policy/process was not being followed respective to expectations for bedrail standards of practice. During an interview on 09/22/22 at 5:11 p.m., the NHA was asked about the type of bedrail, and safety of this type of bedrail, given the concerns observed. The NHA confirmed they did not have manufacturer's directions for the bedrail, and could not verify when it was installed, or if it was safe for Resident #46. Further review of the EMR showed Resident #46 had three recent falls in her room. The accident and incident report dated 08/21/22 showed Resident #46 was found sitting upright on the floor at her bedside, with her back resting on the bed. Resident #46 reported at that time she was trying to stand up from her bed and slipped onto her bottom. She denied injury and no injury was found by staff. A nursing progress note dated 09/25/22, revealed Resident #46 fell while ambulating to her bed from her bathroom, and was found seated on her buttocks at her bedside, without injury. Two of the three falls staff found Resident #46 by her bed. Review of a document titled, Enabler Bar Documentation, provided by the Environmental Services Director, Staff E, on 09/26/22, dated 06/22/22, revealed the type of device, T-Bar, and four locations on bed/measurement, labeled 1 - 4. Items 1. and 2. were checked. Both showed, Gap in bar between bar and mattress 1/2 (handwritten in). No other zones of entrapment were measured, per standards of practice related to bedrails. There was no additional documentation to show measurements taken for four additional days, per standards of practice and facility policy. During an interview on 09/26/22 at approximately 4:45 p.m., the Environmental Services Director, Staff E, confirmed they would accompany Surveyors to take measurements of the T-bar bedrails, and the measurements of any bedrail gaps, per regulatory and standards of practice guidelines. During an interview on 09/27/22 at 2:57 p.m., the Director of Rehabilitation Services, Physical Therapist (PTA) CC, was asked about Resident #46's safety with the use of the T-bar bedrail, which had since been removed by the facility on 09/26/22. PTA CC reported while Resident #46 had used the T-bar bedrail for bed mobility and transfers, he acknowledged the grab bar style appeared outdated and was a safety concern, given one bar sticking out the bed occupant could possibly catch their neck or arm on the bar. PTA CC reported the enabler bars with the curved edges would be much safer for the bed occupant. PTA CC confirmed Resident #46 was at risk for falls due to an overall medical decline, falls since facility admission, and poor compliance with safety recommendations to ambulate and transfer with assistance. Resident 1 Review of the MDS assessment, dated 6/6/22, showed R1 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) score was 4 out of 15 which reflected severely impaired cognition. R1 had impaired vision and required one staff assistance for toilet use and personal hygiene. Balance during transitions and walking were not steady. R1 was occasionally incontinent of bowel and bladder. During an observation on 9/20/22 at 9:44 a.m., R1 was lying in bed with a T-bar in the upright position to only the left side of the bed. The bed pendant was clipped to the top, left side of the headboard with the control options facing the bed and not the wall. The pendant options contained six, white square buttons which read HEAD, BED, FOOT printed with black triangles indicating the movements for up and down. R1 was wearing dark colored socks without anti-slip grippers to the soles of the feet. The left sock was pulled slightly off the foot. During an observation on 9/26/22 at 10:22 a.m., R1 was lying diagonally on his back, in bed with his head positioned to the right upper corner and his leg/feet positioned to the bottom left portion of the mattress. The bed pendant was wrapped around the T-bar and dangling just above the floor. The call light was also wrapped around the T-bar and dangling directly on the floor just underneath the bed. The call light clip, attached to the white cord, was visible on the floor directly next to the pendant. The overbed table was to the left side of the bed. During an interview on 9/26/22 at 4:15 p.m., Maintenance Director (Staff) E said current beds were purchased around 2000 (making them [AGE] years old). Staff E did not believe the T-bars were specifically geared to the bed frames. Staff E was asked about potential considerations for the use of air mattresses with regards to the T-bar use. Staff E said he did not know. Review of R1's Enabler Bar Documentation dated 6/22/22, identified the type of device as a T-bar and only one measurement was checked and recorded as follows, Top left Gap in bar and mattress 1/2 in. (inch). Review of R1's EMR indicated one Side Rail/Grab bar assessment dated [DATE] was completed by staff. The T-bar physician order was revised on 3/10/22 and read in part, may use a left side TBar/assist bar on his bed .He has difficulty walking, is unsteady on his feet and Alzheimer's disease. Resident 22 Review of the MDS assessment, dated 7/16/22, showed R22 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS reflected moderately impaired cognition. R22 required two staff assistance for bed mobility, toilet use, hygiene, and bathing. The same assessment showed R22 was always incontinent for bowel and bladder. During an observation on 9/19/22 at 3:47 p.m., R22 was observed in bed with the use of bilateral T-bars found in the upright position. The bed pendent was coiled around the left T-bar and assessable to R22. During an observation on 9/22/22 at approximately 10:10 a.m., R22 was lying in bed. The bilateral T-bars were found in the upright position and the bed pendant was clipped to the headboard's left side. During an observation on 9/26/22 at 1:20 p.m., R22 was lying in bed with both T-bars in the upright position and the bed pendant resting directly on the left side of the bed's fitted sheet within reach to R22. Review of the EMR showed R22's bilateral T-bar order was placed on 4/11/22 due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R22 was not reassessed for the T-bar need after recovering from the hip surgery. Review of R22's Enabler Bar Documentation dated 6/22/22 indicated the type of device as T-Bar and only two measurements were obtained for the top right and top left-gap in the bar between bar and mattress were 1/2 in. Resident 31 Review of the MDS assessment, dated 7/23/22, showed R31 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS score reflected severely impaired cognition. R31 required two-person assistance for bed mobility and transfers and one staff assistance for toilet use. The same assessment showed R31 was always incontinent of bowel and bladder. During an observation on 9/20/22 at 9:56 a.m., R31's left side of the bed was pushed against the wall and a T-bar was in the upright position to the right side of the bed. The bed pendant was coiled around the T-bar and assessable to R31. The bed contained an air mattress which was turned on to a firm setting. R31 asked Surveyor if I was able to see the two birds and was pointing towards the foot her bed. No birds were observed. A pressure fall mat was noted to the right side of the bed with the cord extending in the walk path and not secured underneath the bed. During an observation on 9/26/22 at 10:18 a.m., R31 was found in bed with the left side of her head leaning directly against the wall. The breakfast tray remained over her lap on the overbed table. The head of the bed was elevated approximately 45 degrees. The T-bar, on the right side of the bed, was lowered. The fall pressure mat was several feet away from R31's right side of the bed. The bed pendant was not secured to the headboard and was lying loosely over the edge of the mattress on the right side of the bed. On 9/26/22 at 12:19 p.m., R31 remained in the same position as the earlier observation the same day at 10:18 a.m. The head of the bed remained at approximately 45 degrees and R31's head was leaning against the wall. The T-bar, on the right side of the bed, was lowered. The breakfast tray was removed, indicating staff were in the room. A strong urine and feces odor was noted. Review of R31's physician order, dated 3/10/22, read in part, bilateral TBar/assist bars on her bed. The bed rail consent, dated 3/10/22, read in part, I choose to use the following device to assist with bed mobility and security when I am in bed. Device Requested (checked for) Right side and Left side. Consent was obtained via the telephone by R31's durable party of attorney (DPOA) on 3/10/22. Review of R31's, Enabler Bar Documentation dated 6/22/22, showed the type of device was a T-Bar and only one measurement was obtained for the top right-gap in bar between bar and mattress as 3/4 in. No indication was made for the air mattress use. Resident #19 During an observation and interview on 09/21/22 at 10:45 a.m., Resident #19 was found in bed during peri care, with bilateral mobility bed rails (enabler/assist bed rails). Resident #19 verbalized the hallucination of cats being hung by their ears on the telephone line visible outside the room window. No trapeze was present on Resident #19's bed. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 7/5/22, revealed the Resident was admitted to the facility on [DATE], with the most recent re-admission on 4/25/22. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #19's body) and muscle weakness. Resident #19 scored 12 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Resident #19 required extensive two-person assistance with bed mobility, with a resident transfer not performed during the assessment period. The MDS assessment documented A. Bedrail . Used Daily . in Section P0100. Physical Restraints. Review of Resident #19's Enabler Bar Documentation, dated 6/22/22, by maintenance staff, revealed the following bed rail documentation: Enabler bars need to be measured for gaps in bar and between the bar and the mattress every time a device is applied, or if the resident changes beds or mattresses or type of enabler bar used. Documentation will be kept in the Bedrail Book in Maintenance Department. Type of Device: T-Bar (checked) . Location on bed/Measurement: 1. Top right, Gap in bar between bar and mattress, 0 (zero) in (inches). 2. Top left, Gap . 0 inches. Review of Resident #19's Care Plans revealed the following, in part: I have Bilateral T-Bars on my bed to assist me with bed mobility. Date Initiated: 02/15/2022 Created by: [Registered Nurse (RN) X] Review of Resident #19's Resident Bed Rail/Assist Bar/TBar Consent Form, dated and signed 3/10/22, revealed the following, in part: 1. Please initial one of the following statements of your choice for assistive devices. _____The option of bedrails/assist bars has been offered to me and I choose not to have them at this time. _____I choose to use the following device to assist with bed mobility and security when I am in bed. Device Requested ___Right Side ___Left Side ___ TBar ___Assist Bar ___Half Bed Rail . No initials, checks, or notations showed selection of any of the choices presented on Resident #19's Bed Rail Consent form. The bed rail consent form included the following general information: I am responsible for treatment decisions of the above-named resident. I have been advised that I may request that bed rails/assist/tbars be installed on the resident's bed. The risk and alternatives to using bed rails/assist bars/tbars, as they apply to this resident's particular condition and circumstances, have been clearly explained to me. I understand that, in addition to this signed consent form authorizing the use of bed rails for this resident, a written order from the physician, specifying the medical rationale and circumstances for use, must be obtained prior to the installation of this medical treatment device. It is also my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails/assist bars/tbars and that the resident, responsible party, and attending physician will be consulted in this matter. With all the above information in mind, I consent to the installation and utilization of bed rails for the care of the above-named resident, consistent with the written orders of the attending physician . Review of Resident #19's Physician Orders related to bed rails, read as follows: Order Date: 3/10/22 14:50 (2:50 p.m.), Resident may use bilateral TBar/assist bars on her bed along with her trapeze to aide with bed mobility and repositioning. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #19's Bed Rails Clinical Guidance form, dated 4/27/22, revealed the following, in part: Implementation Plan: 1. Have you anticipated and planned for the Resident getting out of bed at night for such things as hunger, thirst, restroom, restlessness/pain, and/or need for skin care/hygiene? NO . 6. Have you considered the use of floor mats for residents that are prone to rolling out of bed? NO . 9. Evaluate and document the effect of these interventions: Resident . has a trapeze on her bed and has requested T-bar/assist bars to help mover (sic) herself about in bed. [Resident #19] is obese has difficulty even with T-bars moving about in bed. Uses Hoyer lift to transfer. Education provided included: 1. Resident issues that often result in bed rail use include memory disorders, impaired mobility, risk for injury, nocturia/incontinence, and sleep disturbances. 4. Strangling, suffocating, other bodily injury, and death can occur when a resident is caught between bed rails or between bed rails and mattress . Implementation: . 5. What steps have you taken to move to lesser restrictive devices? BLANK - no information provided. Signed Date: 4/27/22. Review of the User-Service Manual, copyright 2020, for Resident #19's bed, a [Name Brand, Model Bed], revealed the following, in part: To avoid injury, read user's manual before using . Warning: Possible Injury or Death. If a resident/patient's mental or physical condition could lead to resident/patient entrapment, the mattress support platform should be left in the flat position when unattended. Failure to do so could result in injury or death . Warning: An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of bed system entrapment guidance, including the Clinical Guidance for the Assessment and implementation of Side Rails, published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration . Warning: Possible Injury or Death. Do not use any replacement parts not manufactured, marketed, or provided by [Name Brand] Healthcare on any [Name Brand] bed. Use of unapproved replacement parts may result in injury or death .If using accessories not manufactured, marketed, or provided by [Name Brand] Healthcare . consult with the manufacturer for compatibility and limitations prior to use. Failure to do so may result in injury or death . Entrapment zones involve the relationship of components often directly assembled by the healthcare facility rather than the manufacturer. Therefore, compliance is the responsibility of the facility . While the guidelines apply to all healthcare settings, (hospitals, nursing homes and at home), long-term care facilities have particular exposure since serious entrapment events typically involve frail, elderly, or dementia patients . Resident #33 Review of Resident #33's MDS assessment, dated 7/27/22, revealed Resident #33 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33 scored 11 out of 15 on the BIMS, reflective of moderate cognitive impairment, and was independent in bed mobility and transfers. The Resident had functional limitations in range of motion on one side of the lower extremities and used a wheelchair for mobility. The use of bed rails was not documented on the MDS assessment. During an observation on 9/26/22 at approximately 12:15 p.m., Resident #33's bed was found with bilateral T-bars installed on the left and right sides of the bed. The T-bars in use appeared old, without manufacturer's labeling or information, and were observed as a single chrome finished bar extending upward from the bed frame, with a single chrome finished, square handle (the area where the user holds the bar), approximately 2 inches x 2 inches in width and approximately 12 inches in length, attached perpendicularly to the top of the mounted bar. The square handle had distinct edges on all sides and ends, and allowed potential for injury, with square metal prongs (not rounded) sticking out at each end. The T-bar appeared as the image of a T. No T-bar identification of any similar bed rail was found in multiple internet searches for a similar appearing bed rail. Review of Resident #33's progress notes revealed the following, in part: 8/4/22 12:05 (p.m.), Family Care Conference, Meeting Note: .When resident (#33) has to use the bathroom at night she tries to raise the back of her bed so she can get up. Resident (#33) ends up raising her whole bed in the air. Resident/Family are afraid of a fall. Family tried to cover the buttons that raise the bed up and down . 8/4/22 12:21 (p.m.), Social Service Progress Note . talked with maintenance. They can take the motor out of the controller that moves the bed up and down. The bed will be kept in the lowest position to prevent a fall . 8/5/22 14:26 (2:46 p.m.), Social Services Progress Note . Maintenance was not able to disconnect the controller on the bed resident had. Resident was given a different bed that allowed the up and down controller to be disconnected. Resident is not happy about the new bed - resident does not like the T-bars compared to the other bed (assist bars) . On 9/26/22 at 12:38 p.m., Review of Enabler Bar Documentation completed 6/22/22 by maintenance staff, revealed Resident #33's bed had bilateral Enabler Bars (assist bed rails) on the top right, and top left of the bed, with a Gap in bar between bar and mattress of 3/4 (3/4 inch) on each side. Only one measurement was performed, and other bed entrapment zones were not measured. No resident assessment for bed rails was found in the Electronic Medical Record (EMR), either at the time of admission or at the time she received a different bed with T-bars instead of assist bed rails. No physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #34 Review of Resident #34's MDS assessment, dated 7/30/22, revealed the Resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34 scored 5 of 15 on the BIMS reflective of severe cognitive impairment. Resident #34 required extensive two-person assistance with bed mobility. Bed rail usage was not documented in Section P: Restraints and Alarms on the MDS assessment. During an observation and interview on 9/26/22 at approximately 10:45 a.m., Resident #34's bed was observed with a T-bar bed rail on the right side of the bed. A gap (not measured) was observed and identified between the T-bar and the bed mattress in the presence of Staff E. Review of Enabler Bar Documentation completed 6/22/22 by maintenance staff, revealed Resident #34's bed had one T-bar on the top right of the bed, with a Gap in bar between bar and mattress of 0 (zero inches). Only one measurement was performed, and other bed entrapment zones were not measured. Review of Resident #34's Physician Order Summary for September 2022, revealed the following order, beginning on 3/14/22: Resident may use a TBar/assist bar on the right side of his bed to aide with bed mobility and repositioning due to s/s (signs and symptoms) polyosteoarthritis. Review of Resident #34's Bed Rails Clinical Guidance assessment, dated 4/27/22, and noted as In Progress when retrieved on 9/26/22, revealed the following: 1. Multiple questions were blank, and not completed. 2. The Implementation Plan had questions that were unanswered or answered with NO, including: a. Have you anticipated and planned for the Resident getting out of bed at night for such things as hunger, thirst, restroom, restlessness/pain, and/or need for skin care/hygiene? (unanswered) b. Have you attempted transfer and mobility aides such as a trapeze? (NO) c. Have you considered the use of floor mats for residents that are prone to rolling out of bed? (NO) d. Have you considered a referral to therapy or restorative for exercises/interventions to enhance the resident's ability to stand, transfer, to reposition self safely? (NO) If the answer is no to any of the above items go back and implement. Education documented as provided to the Resident/Legal Representative did NOT include the following items included on the bed rail form: - Residents who are frail, or elderly are at risk for entrapment. - A resident with agitation, [CONDITION(S)], confusion, pain, uncontrolled body movement, [CONDITION(S)], and elimination issues are at risk for entrapment and/or suffering serious injury from a fall. - A resident may try to climb through, under, or over bed rails or footboard which will greatly increase risk for injury. - Ill-fitted mattresses and rails increase the risk for injury to a resident. Review of the EMR list of all Bed Rails Clinical Guidance forms completed by the facility only showed the 4/27/22 In Progress assessment. No other bed rail assessments had been documented. Review of Resident #34's Care Plans revealed the following ADL (activities of daily living) intervention: SIDE RAILS: I have a T bar on the right side of my bed to assist me with bed mobility. Observed for injury or entrapment related to side rail use. Reposition PRN to avoid injury. Date Initiated: 10/20/21 (Date of Admission) . Residents (#1, #22, #31, #33, #34, and #46) all had old [Name Brand] beds with unidentified old T-bars mounted on the beds. The model was the same for all residents. During an interview on 9/26/22 at 10:13 a.m., Environmental Services Manager (Staff E) was asked for documentation of bed measurements related to the use of bed rails and assessment of entrapment zone risks of resident beds. Staff E stated, (There are) no side rails in the building, so T-rail checks (are performed) on an initial install (of the bed rails) . We (Environmental Services staff) just do them (gap measurements) for the initial install, and do not do them for multiple days or times. During a follow up interview that same day at 10:48 a.m., Staff E provided a pink Bedrail Book binder that he said documented Bed Rail Use and Measurements. Staff E stated, I was never aware or informed that T-bars or assist rails were considered bed rails. Staff E said because they were not considered bed rails, the small assist rails on the beds were not measured for multiple days and therefore measurements of the seven bed entrapment zones were not documented on the bed rail assessment form. The T-bars and assist bed rails were measured only one time and he said there were no measurements done for the T-bars because there was no risk of entrapment from those bed rails. Staff E acknowledged the lack of manufacturer's instructions for the T-bars and confirmed he did not know if the T-bar bed rails, and bed frames were compatible or incompatible as mobility support as currently used by facility residents. Staff E said the T-bars had been present in the building for many years. Staff E stated, I don't have any information on the T-bars. Staff E stated, You will see by the dates listed in here (Bedrail Book), that we just started measurements (of the assist and T-bar bed rail's one entrapment zone next to the bed rail) in June of 2022. Staff E acknowledged he was aware of one previous resident death, in another facility, due to entrapment in a bed rail, but because the facility didn't have bed rails (quarter rails, half rails, or full bed rails) Staff E said he was not aware bed entrapment zones had to be measured. During an interview on 9/26/22 at 2:27 p.m., Staff E stated, We don't have any information on the T-bars. We don't have any information at all. Staff E confirmed Environmental Services (Maintenance) (Staff) II and JJ measured all the assist/T-bars (bed rails) on June 22, 2022. Staff E said all the beds currently with T-bars were old [Brand Name] beds, and stated, We don't have information on the beds or the bars (T-bars). Staff E provided a Parts Catalogue for the old [Name Brand] beds, but no instructions for use were available or provided by the facility for either the [Name Brand] bed or the T-bars that were absent manufacturer identification/information. Staff E was asked to provide the bed manufacturer, model, serial number, and type of rail on the bed. Review of the Bed Rails policy, revised 12/20, revealed the following information related to bed rails: Policy: Full and half bed rails will be safely used only as needed to treat a resident's medical symptoms. Policy Explanation and Compliance Guidelines: 1. The IDT (interdisciplinary team) to complete the following items prior to initiating side rail usage. a. Complete the resident bedrails consent form. b. Complete the bedrails clinical guidance assessment. c. Obtain a Physician order that contains statements and determinations regarding medical symptoms and is specific to the circumstances under which bed rails are to be used and time limit for use. d. Initiate a Care Plan. e. Complete the [Facility Name] Side Rail Measurement Monitoring UDA at the time of instillation (sic) and every day for 4 days (to total 5 days of measurement). f. Document corrective action taken if measurements do not meet [State Name] guidelines for gaps. g. Complete the [Facility Name] Side Rail measurement Monitoring UDA every quarter unless resident has any of the following: new/different mattress, new/different side rails, new/different bed frame and/or resident experiences weight loss. 2. Complete the [Facility Name] Bed Rail Clinical guidance assessment quarterly. 3. Prior to the discontinuation of side rails document reasons for the discontinuation in the medical record, to include resident choice and interdisciplinary team recommendations. Review of the Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, Document issued on: March 10, 2006, revealed the following, in part: Potential Zones of Entrapment: This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions . The seven areas in the bed system where there is a potential for entrapment are .: Zone 1: Within the Rail Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support Zone 3: Between the Rail and the Mattress Zone 4: Under the Rail, at the Ends of the Rail Zone 5: Between Split Bed Rails Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board Zone 7: Between the Head or Foot Board and the Mattress End During a telephone interview on 9/27/22 at 12:46 p.m., Customer Service Representative (CSR) DD, from the old [Name Brand] bed corporation, confirmed the serial numbers of the [Name Brand] model beds in question showed the beds were [AGE] years old. CSR DD said the corporation no longer made the bed model or bed rails for the [Name Brand] bed. CSR DD said hospital beds had bed rails made exactly for the model of bed in use. When asked if a different bed rail could be attached to the bed frame, CSR DD stated, For safety reasons, I would not recommend it. CSR DD was able to provide the [Name Brand] bed Owner's Operator and Maintenance Manual, copyright 2003, via email to this Surveyor. Review of the Owner's Operator and Maintenance Manual, copyright 2003, revealed the following, in part: WARNING: DO NOT OPERATE THIS EQUIPMENT WITHOUT FIRST READING AND UNDERSTANDING THIS MANUAL .The side rails when used with a Manual/Electric bed DO NOT fall within any

Based on observation, interview, and record review, the facility failed to 1) perform routine skin assessments, 2) provide aseptic wound care, 3) prevent the development of pressure ulcers, 4) monitor wound healing, 5) ensure licensed staff were competent in wound care, and/or 6) implement interventions to prevent the development and worsening of facility acquired pressure injuries for four Residents (R38, R19, R22 and R31) out of five residents reviewed for pressure injuries resulting in development and or worsening of pressure ulcers. Findings include: Resident #38 A review of R38's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 8/2/22 Minimum Data Set (MDS) assessment revealed he scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. This MDS revealed he was at risk for pressure ulcer development. A review of a 9/6/22 progress note for R38 revealed, Resident has a non-blanchable area on R (right) butt measuring 1&1/2 (centimeters) by 3/4 dark area, has a hard lump within. Repositioned off area, feet elevated off bed as well. Dressing intact. A review of the Wound Assessments for R38 dated 9/6/22, 9/9/22, and 9/15/22 revealed no assessment of this new wound to the R buttock. Further review of the wound assessments for R38 revealed the development of the wounds as follows: 9/4/22 Wound Assessment: Wound #1. New . Left heel. Blister. 2.5(cm) x 2.6 . Suspected Deep Tissue Injury. Comfort foam and heel protector booties applied .Education provided: repositioning, aid (CNA) states she told a nurse on Friday (two days prior) of injury . 9/9/22 Wound Assessment: Wound #1. New. Acquired in-house . Left Heel. Blister. 2.5 x 2.6. (Stage) 2. Instructed CENAs to position foot away from bottom . A second Wound assessment dated [DATE] completed by Wound RN M: Wound #1. (Not marked as new). Right knee. Other (type) 1.6x1.5 . Stage: N/a (not available) . Amount of drainage: c) moderate. Type of Drainage: d) Purulent: thin, thick, opaque, tan/yellow . Education provided: repositioning often and using pillows to keep legs from pressing into each other . Wound #2: . Right elbow. Skin tear . Wound #3: (did not indicate if new or old). Left Heel. Pressure. 2.5 x 2.6. Suspected Deep Tissue Injury . Amount of Drainage: heavy . serosanguineous . Offload heel if possible, reposition resident so he is not on his heel; reposition every 2 hours . 9/15/22 Wound Assessment: Wound #1: Right knee . Wound #2: (does not indicate that it is new) L (left) Plantar pinkie toe. Type: Other. 1.5 x 1.5 . Stage: N/a . Education provided: keep clean & dry .Wound #3: Left heel. Pressure. 8x6. Depth: unknown. Suspected Deep Tissue Injury. Unable to get into wound clinic due to insurance. Amount of drainage: d) heavy . Serosanguineous . On 9/20/22 at 12:00 p.m., Resident (R38) was observed lying in his bed on his back. R38's feet were curled up near his abdomen, and no boots or devices were observed in use to protect his heels from breakdown. R38 appeared very thin and gaunt, and the skin on his face and hands was red, dry, and flaky. During an interview and observation on 9/21/22 at 5:19 p.m., RN M, in the presence of the Director of Nursing (DON), said the last time she had looked at Resident #38 there was no opening (pressure injury) on the coccyx or buttocks. RN M said as of 8/24/22 Resident #38's buttock/coccyx was healed, and as of 9/6/22 (two weeks prior) there was an unblanchable area (on the right buttock) but no openings. When the bed covers were removed, Resident #38's left heel was observed pressing on the bed mattress. The 2 x 2 [MEDICATION(S)] dressing on the right buttock was dated 9/14/22. When asked about the dressing not being changed for seven days, RN M stated, That is about right, we have been doing them (dressing changes) once a week if there is nothing there. The old dressing was removed, and the right buttock area was examined by RN M. RN M stated, It does look like it is open. A layer of skin was observed absent in a circular pattern on Resident #38's right ischial tuberosity (bony prominence on right buttock), with slight peeling of additional skin when the dressing was removed and the wound cleansed with normal saline. RN M removed her dirty gloves and donned new gloves without hand sanitation. RN M was stopped by the DON and this Surveyor with the failure to perform hand hygiene. RN M removed the gloves and placed the dirty gloves onto the clean field (barrier cloth) on the resident's bed. RN M performed hand hygiene, donned clean gloves and opened the wound dressing package that was now dirty from contact with dirty gloves previously placed on the clean field. During this procedure, RN M ran out of clean gloves. The DON retrieved a box of gloves, handed the glove box to RN M, who set it down on Resident #38's dirty bed linens. RN M was directed by the DON to put out a clean barrier cloth by touching the inside of the clean barrier cloth only with new clean gloves. RN M touched her pants pocket with her ungloved right hand. RN M performed hand hygiene with that right hand only and donned clean gloves. RN M measured the right buttock wound as 2.2 cm (centimeters) x 1.2 cm, with no depth. The Stage II pressure injury was on a bony prominence and appeared to be over Resident #38's right ischial tuberosity. RN M did not use a garbage can/container for disposal of dirty wound supplies but continued to place the dirty wound dressings removed from the resident onto the clean barrier cloth. During this observation there were numerous infection control breaches between clean and dirty, with verbal and nonverbal direction provided by the DON and this Surveyor to maintain a clean and appropriate wound change environment throughout the procedure. Next, the DON retrieved additional clean barrier pads. RN M placed the clean barrier pads on top of the glove box sitting on Resident #38's dirty bed linens. RN M said [Resident #38] had a plantar pinkie wound and heel pressure injuries on the left foot. No dates were observed on either the plantar pinkie or left heel dressings. RN M removed the dressing from a circular wound on the left, lateral side of the left foot, near the little (5th) toe. The dressing appeared saturated with exudate prior to removal of the dressing. When the dressing was removed, yellow/brown purulent drainage was present with a foul order. The dressing was saturated with the exudate, and thick, strands of drainage were visible as the dressing was lifted from the wound. When asked about the type of exudate and smell, RN M said the drainage was purulent with an odor. The wound was not measured, as RN M said the left pinkie was considered a plantar wart, not a pressure injury. The wound dressing was removed from the left inside heel, revealing purulent yellow/brown drainage, again with strands of sticky, thick exudate clinging onto the dressing as it was lifted from Resident #38's left heel. The wound had a strong foul odor. When asked about the exudate and smell, RN M confirmed it was again purulent and odorous. Skin was peeling off the left heel wound. The heel wound was measured at 7 cm x 5 cm, with depth undetermined. RN M said there was yellow/brownish eschar in the middle of the wound bed, but the wound appeared to have increased in size and deteriorated. RN M said both left foot wounds would be considered unstageable at this time. Several small, reddened areas were newly identified on Resident #38's feet, and RN M was asked if Resident #38 had foot/heel protectors to reduce pressure on Resident #38's feet. RN M stated, The boots I thought would be a good idea, but it is, do we have any available? I will have to look in the basement and the laundry. RN M stated, I tried to get him into the wound clinic but because of insurance they will not take him. RN M and the DON confirmed they were awaiting a disability determination that would provide additional payment alternatives for the wound clinic. On 9/21/22 the facility provided wound care documentation for R38. An IDT progress note dated 9/21/22 at 2:09 p.m. revealed, Wounds are stable, bottom will be assessed today, heel not better. Discussed reaching out VA for further wound care. Reviewed weights stable, takes ensure TID (660 calories, 27 grams protein) to promote healing, with very good acceptance. No change to treatment plan at this time. Participants: RD, DON, MDS/RN, Wound nurse This note was written prior to the assessment of the right buttock wound, but indicated his wounds were stable despite evidence to show that they were not. No new interventions were discussed or implemented. During an interview on 9/22/22 at 7:25 a.m., the DON was asked about Resident #38's wound care completed by RN M on 9/21/22. When asked about what concerns she identified during observation and the amount of assistance provided during the dressing changes for three separate pressure injury dressings, the DON stated, I spoke with her (RN M) very briefly. I stressed about clean (and) dirty, hand hygiene, don't shake your hands in the air, don't touch your clothes. The lack of the garbage can. I heard [RN M] say 'I will have to see if we have any (protective foot/heel boots)' and I thought 'Oh why did you say that'. I talked to her about saying the wound clinic would not schedule him . I would say both the heel and the left lateral (wounds) were unstageable. During a follow up interview that same day at 10:20 a.m., the DON provided copies of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged there was not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/22/22 at 12:55 p.m., RN M said she had returned to work at the facility in November of 2021 but had only been doing wound care for about a month. RN M acknowledged she had never been given a clear-cut job description, and stated, The previous wound care nurse tried to give me some training, but she was not here long enough to get proper training - so I wing it. My understanding is they let me know about the wounds, I assess them, I do a wound assessment, I get orders to treat, and I go from there. RN M said she had no formal or informal wound care training. During a continued interview that same day at 1:11 p.m., when asked about a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . I told her yesterday there was not an order because I was not aware of the wound on Resident #38's bottom. RN M said she picked the order from the wound dressing protocols available within the EMR. For [Resident #38's] butt I picked the Stage 2 pressure injury with no to moderate drainage. RN M said she normally left the Duoderm dressings on for 2-3 days. When asked why seven days elapsed between the dressing change time for Resident #38's right buttock pressure injury, RN M stated, I don't know. RN M further stated the physicians just signed the wound dressing change orders she requested. RN M said, Normally it is every 2-3 days for most dressings (to be changed). I was in the hot seat yesterday, and I didn't know about the wound, and normally it would be every three days. When asked if she had completed wound assessment documentation for the dressing change on 9/21/22, RN M said she had not. When asked if the physician had been notified of the deterioration of the left heel wound and foul odor of both the pinkie plantar wound and left heel wound, RN M said she had not provided them any notification because there had not been any change. RN M said the purulent drainage and foul odor had been present previously. RN M confirmed she had not written a progress note. When asked about her thoughts on her ability to determine pressure injury wound dressing change orders and provide appropriate care to promote healing of Resident #38's pressure injuries and to prevent the development of further pressure areas, RN M stated, I feel that I am not qualified to take care of him (Resident #38) at this point. I need training and I have been asking for help with him, but I have been running into roadblocks. Even for his knee - I cannot get it to heal, and they said no (to wound care), and they said it could be drained, but the Dr. would have to come in and do that. During an interview on 9/22/22 at 11:45 a.m., RN H was asked about the recent Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN H stated, I would not have done that. I don't know why you would leave a dressing on a wound for seven days. When asked if wound orders were formulated by the physicians, or if the nursing staff created the order and had them signed by the physicians, RN H stated, To be honest our physicians do not know very much about wounds . They will call us from the clinic and ask our nurses what they should do about their wounds. They sign the orders that our nurses send to them. They normally don't tell us what to do. RN H said their facility physicians normally refer them to wound care or sign what we (the nursing staff) suggest. When asked who was competent in wound care in the facility to be able to develop wound care treatment orders, RN H stated, Well [RN M], but I don't know what training [RN M] has. Further review of R38's progress notes revealed the following: 9/23/22 Reached out to Wound Clinic RN, ., related to odor of pressure wound to resident's heel & concern for needing a culture of all current wounds & advice from wound clinic to further treat resident . 9/23/22 Sent resident to ER via non-emergent EMS . sent to have wounds evaluated due to no available physician, L heel wound is progressively deteriorating, possible infection, evaluation required immediately . 9/23/22 Updated . wound clinic RN that resident was sent to ER to have wounds evaluated due to no available physicians until Monday . 9/23/22 Resident has returned from ER evaluation . resident has confirmed pressure ulcer with skin infection. IV [MEDICATION(S)] and oral [MEDICATION(S)] administered in ER. Resident to start new antibiotic in the morning. Cultures were taken of wounds on heel & knee, blood cultures obtained as well as labs . A review of the 9/24/22 wound assessment for R38 revealed, Wound #1: Right knee (front). Type: Other. 1.7 x 1.7 . Stage: N/A . Wound #2: L Plantar Pinkie . 1.8 x 1.5. Unstageable . Wound #3: Left heel. Pressure. 7x5. Depth: Unknown. Unstageable. ER (emergency room ) started on antibiotics. Amount of drainage: heavy . Purulent . Odor after cleansing: a) strong . Offload heels if possible, apply booties, reposition every 2 hours . Wound #6: Right buttock. Pressure. 2x 1.4. Depth 0.1 (cm). Stage: 2 . reposition q2hrs (every 2 hours) . Wound #7: New. Right Trochanter (hip). Blister. 2 x 0.4. (depth and stage were left blank) . reposition . During an interview on 9/27/22 at 2:47 p.m., the DON confirmed no wound assessment was completed by RN M on 9/21/22. The DON agreed the assessment should have been documented in the medical record. The DON confirmed the both the pinkie plantar pressure wound and the left heel wound had a foul odor on 9/21/22 with purulent, thick, yellow-brownish exudate. The DON confirmed the heel wound had greatly increased in size, and the wound dressing, when removed, was saturated with exudate. The DON said she would have telephoned the physician and reported the type and appearance of wound drainage, the worsening of the wound, and the foul smell associated with both wounds. Resident #19 Review of Resident #19's MDS assessment, dated 7/5/22, revealed the Resident was admitted to the facility on [DATE], with the most recent re-admission on 4/25/22. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #19's body) and muscle weakness. Resident #19 scored 12 of 15 on the BIMS reflective of moderate cognitive impairment. Resident #19 required extensive two-person assistance with bed mobility, with a resident transfer not performed during the assessment period. During an observation on 09/20/22 at1:00 p.m., Resident #19 was observed with both bare feet positioned on the bed with bilateral heels in contact with the mattress. LPN P present during the observation, confirmed Resident #19 should have her heels floated (off the bed). During an observation on 09/21/22 at 10:02 a.m., Resident #19's bilateral bare feet were found in contact with the bed/air mattress. CNA GG, present in the room, did not offer or act to float Resident #19's heels off the bed. Review of Resident #19's Skin Integrity Care Plan revealed the following, in part: .I am at risk for impaired skin integrity r/t (related to) risk for moisture d/t (due to) muscle weakness, impaired mobility, [CONDITION(S)], cardiovascular disease, left-sided [CONDITION(S)] and [CONDITION(S)] r/t previous [CONDITION(S)], DM, [CONDITION(S)], risk for decreased activity d/t chairfast, hx (history) of MASD (moisture associated skin damage) and pressure injuries to my buttocks. Date Initiated: 07/28/2021 Protective booties on bilateral feet at all times when in bed. Date Initiated: 05/09/2022 Review of Resident #19's POC (Point of Care) Response History for Resident #19 regarding Task: Float heels as care planned, with protective booties on both feet at all times when I am in bed, for the last 30 days as of 9/20/22, revealed the following: - Two refusals were documented during the 30 days. - No documentation was present for 8/24, 8/26, 8/27, 8/30, 8/31, 9/2, 9/4, 9/6, 9/8, 9/9, 9/12, 9/14, 9/15, and 9/19/22. - Only one shift documented on the following dates:8/25, 8/28, 8/29, 9/3, 9/5, 9/7, 9/10, 9/11, and 9/13/22. During an observation and interview on 9/21/22 at 10:45 a.m., Resident #19 was observed in bed with both bare feet (without protective booties) positioned directly on the bed mattress. When asked about refusal to wear protective booties while in bed, Resident #19 stated, No I don't refuse to wear them, (protective booties) They (facility staff) don't put them on, and I haven't seen them since they were behind the TV which has been awhile now. No protective boots were observed anywhere in the resident room during this interaction. Resident 22 (R22) Review of the MDS assessment, dated 7/16/22, showed R22 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS reflected moderately impaired cognition. R22 required two staff assistance for bed mobility, toilet use, hygiene, and bathing. The same assessment showed R22 was always incontinent for bowel and bladder. R22 was at risk for pressure ulcer development but was identified as having no unhealed pressure ulcers. During an observation on 9/19/22 at 3:47 p.m., R22 was observed lying on her back in bed. The bed was not equipped with an air mattress. On 9/22/22 around 10:15 a.m., R22's skin was observed with the DON and Registered Nurse/Infection Preventionist (IP) H. This Surveyor turned on the overbed light and ceiling light. R22 was lying supine (on back) wearing a hospital gown and a brief. R22's feet were bare and lying directly on the mattress. The linens were soiled of yellow drainage and blood. When IP H was asked about the source of the blood seen on the linens, IP H did not answer. IP H lifted R22's gown and exposed the abdomen. A large hernia was noted to the left side. The right lower abdomen contained a square bandage. When the DON was asked about the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When R22 was asked if the bandage had been wet due to continued leaking, R22 responded, Yes, it has. R22 was turned to the left side (facing the door) to observe the heels. The right outer heel was red and flat when the DON pressed on the location. The right malleolus (ankle) had a circular red pattern noted. The DON was asked to check both areas for blanching. IP H directed the DON on the procedure. The DON confirmed the sites were non- blanchable (the skin did not turn white when touched with a finger indicating Stage 1 or 2 Pressure Injury). No heel protectors were noted within the room. R22 was then repositioned, and the brief lowered. A very thick layer of white, barrier cream was noted to the buttocks, groin, lower abdominal fold, and upper thighs. IP H removed the cream which exposed bright redness, maceration, and pressure ulcers. The right upper thigh contained an area of missing epidermis (indicative of a Stage 2 pressure ulcer) which was the approximate size of a silver dollar. R22 was then turned to the right side, where a larger area of darkened red/purplish skin was noted to the left upper buttocks. Both the DON and IP H confirmed the pressure ulcer was considered unstageable. This Surveyor requested wound measurements when Certified Nurse Aide (CNA) L entered the room and said, I noticed her skin looked worse this morning. I showed (Registered Nurse/Wound Care Nurse M). The DON immediately left the room. After waiting approximately 10 minutes, and the DON had not returned, IP H measured the pressure ulcer to the left upper buttocks as 4.5 centimeters (cm) length by 2.0 cm width with depth 0 cm. IP H after obtaining the measurement proceeded to reapply the same brief. When asked about performing wound care to address the identified wounds, IP H said Wound Care M would later address the wounds. During an interview on 9/22/22 at 12:54 p.m., Wound Care Nurse M said resident skin assessments were to be completed at least weekly or more often if a CNA identifies a skin care concern. Wound Care Nurse M said she had not been invited to participate in Interdisciplinary Team Meetings. When asked how skin concerns were relayed to her, Wound Care Nurse M said, No one told me to review Weekly Skin Sweeps (for potential concerns) .I did not have proper training. When asked about R22's skin, Wound Care Nurse M confirmed CNA L had approached her earlier that morning around 8:30 a.m. with worsening skin concerns. Wound Care Nurse M said R22's groin was red and noted a cluster of open wounds (left buttock) which she covered with Calmoseptime Ointment. When asked about R22's right heel and ankle, Wound Care Nurse M said she had not assessed them. When asked about R22's Care Plan interventions which had not been observed: placement of an air mattress, heel protectors, repositioning with pillows for bony prominences, etc. Wound Care Nurse M said, Yeah, they didn't train me that I needed to review the Care Plan. During an observation on 9/26/22 at 1:20 p.m., two Surveyors and Licensed Practical Nurse (LPN) N observed R22's skin. R22 was lying flat in bed (no air mattress). Lights were turned on in the room. A pillow was found underneath R22's shins but the feet were bare and lying directly on the mattress. R22's left foot crossed over the right foot causing additional pressure points. LPN N said the right heel was spongy and a dry patch was noted. The right ankle contained a circular red patch but determined to be blanchable. R22 was placed on the left side and the brief lowered which revealed bright red/excoriated inner thighs. The top right buttocks had an area of broken skin with a red base which LPN N identified as being a Stage 2 pressure ulcer. The left upper buttocks contained four, separate areas with defined borders of broken skin which LPN N identified as being Stage 2 pressure ulcers. Review of R22's Care Plan, revision on 8/19/22, read in part, I am at risk for impaired skin integrity r/t (related to) pain with movement, incontinence and immobility .Interventions Assist me to position body with pillows/support devices, protect bony prominences .Assist and encourage me to elevate my heels off the bed .I have an air mattress on my bed .I wear bilateral protective booties on my feet daily for pressure prevention . Review of R22's Physician Order, 4/20/22, read in part, Assess resident skin and chart the results of the assessment on the UDA form 'SKIN OBSERVATION TOOL' found in the residents' chart under the assessment tab, every day shift every Thu (Thursday). Review of R22's EMR showed a Weekly Skin Sweep dated 8/25/22, which identified skin discoloration, open area (left gluteal fold), and rash/excoriation. Review of R22's Physician Orders, dated 8/18/22, read in part, Place duoderm (type of dressing) to upper thighs (2x2) & buttocks (4x4) as needed for skin breakdown [MEDICATION(S)] Ointment 0.44-20.625 % (Menthol-[MEDICATION(S)]) Apply to groin topically as needed for raw butt. Resident 31 (R31) Review of the MDS assessment, dated 7/23/22, showed R31 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS score reflected severely impaired cognition. R31 required two-person assistance for bed mobility and transfers and one staff assistance for toilet use. The same assessment showed R31 was always incontinent for bowel and bladder. R31 was at risk for pressure ulcer development but was identified as having no unhealed pressure ulcers. During an observation on 9/20/22 at 9:56 a.m., R31's left side of the bed was pushed against the wall and a T-bar was in the upright position to the right side of the bed. The bed pendant was coiled around the T-bar and accessible to R31. The bed contained an air mattress which was turned on to a firm setting. R31 asked this Surveyor if I was able to see the two birds and was pointing towards the foot of her bed. No birds were observed. A pressure fall mat was noted to the right side of the bed with the cord extending in the walk path and not secured underneath the bed. During an observation on 9/26/22 at 10:18 a.m., R31 was found in bed with the left side of her head leaning directly against the wall. On 9/26/22 at 12:19 p.m., R31 remained in the same position as the earlier observation the same day at 10:18 a.m. The head of the bed remained at approximately 45 degrees and R31's head was leaning against the wall. The breakfast tray was removed, and a strong urine and feces odor was noted. During an observation on 9/26/22 at 1:48 p.m., two Surveyors, Wound Care Nurse M, and CNA L were present to assess R31's skin. A strong odor of urine and feces was still present since 12:19 p.m. R31 was positioned on the left side (same as earlier). Both feet were bare, and the heels were directly on bed. A pillow was under both shins. Once the top linens were removed, a large amount of greenish, liquid stool was noted outside the brief and saturated almost the entire lift pad and second lift pad. CNA L said R31's last brief was changed on night shift (over six hours prior). No disposable incontinence wipes could be located in R31's drawers or bathroom. CNA L removed her gloves and left room (after touching linens, furniture, and oral care supplies) without the performance of hand hygiene. Upon her return, CNA L assisted Wound Care Nurse M to cleanse R31's urine/feces. CNA L gloves were changed twice without hand washing before new gloves applied. Wound Care Nurse M was asked to assess R31's heels where a dry patch was identified to the back of right heel. Wound Care Nurse M confirmed a blister had dried out which was due to pressure. When asked about interventions to prevent pressure ulcers to heels, Wound Care Nurse M said R31's should wear booties and the heels should be elevated when in bed. Wound Care Nurse M during incontinence care changed gloves three times and only washed her hands for one of the three opportunities. Review of the Skin and Pressure Injury Risk Assessment and Prevention policy, revised 7/2021, revealed the following, in part: .Interventions for Prevention and to Promote Healing .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to . i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) . 8. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Wound treatments are documented at the time of each treatment.

Based on interview and record review, the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for one Resident (#1) out of six residents reviewed for quality of care. This deficient practice resulted in actual harm due to Resident #1's delayed hospital transport. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment, 6/28/21, showed an admitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was independent with bed mobility, transfers, ambulation, dressing, eating, and hygiene and was always continent of bowel and bladder. The Brief Interview for Mental Status (BIMS) reflected moderately impaired cognition. The same MDS assessment reported no conditions or chronic disease for Resident #1 that would result in a life expectancy of less than six months. During an interview on 9/20/21 at 12:49 p.m., the Infection Preventionist/Interim Director of Nursing (DON) said Resident #1, who was fully vaccinated for COVID-19 (highly transmissible virus), left the faciity on a Leave of Absence (LOA) between 8/16/21 and 8/19/21. Resident #1 was tested for COVID-19 on 8/25/21 and found to be positive. Review of Resident #1's Medical Treatment Choices dated 3/26/21, reflected the preference for acute care hospital transfer in the event of life threatening medical or surgical emergencies. Review of Resident #1's Progress Notes showed a decline in respiratory condition: On 8/25/21 at 03:44 p.m.- (Physician Q) made aware of resident's confirmed COVID positive results and symptoms of low-grade fever and weakness along with the fall this morning. Currently no new orders. On 8/26/21 at 05:18 a.m.- Having diarrhea earlier .had a drop in O2 (oxygen) sat. (saturation) 88% on room air. O2 initiated at 2 liters per n/c (nasal cannula-medical equipment used to deliver oxygen through the nose). Tired. On 8/27/21 at 06:04 a.m.- .O2 continuously at 2 liters/nasal cannula. Sats (oxygen saturation) read low 78%, O2 increased to 3 liters .Had a fever 102.3 forehead . On 8/27/21 at 11:13 a.m.- (Physician Q) was given an update on resident. He was updated on fever and low oxygen level. Advanced directives were given to MD (physician) that are DNR (do not resuscitate) with hospitalization . He stated no longer able to maintain comfort at facility, send to ER (emergency room ). 8/27/21 at 11:23 a.m.- O2 at 2300 (11 p.m.) was 84% on 2 liters. O2 turned up to 4 liters. The next Nursing Progress Note entry for Resident #1's current condition was made on 8/30/21 at 10:58 a.m. which read, Resident is afebrile but continues with SOB (shortness of breath), occasional cough and weakness. With much coaxing encouraged to take (cough medicine) .no effect observed . been on high flow oxygen via mask but unable to elevate oxygen saturations, currently 78% on 12L (liters). The electronic medical record showed no documentation of any Nurse Progress Notes were made on 8/28/21 and 8/29/21 to indicate Resident #1's current respiratory condition, amount of oxygen use, and overall condition. Resident #1's Nursing Progress Note on 8/30/21 at 10:59 a.m. read, Report called to ER and ambulance notified, awaiting ambulance. A telephone interview with the DON and Nursing Home Administrator (NHA) was made on 9/21/21 at 10:17 a.m. The DON was asked about the lack of nursing documentation for Resident #1 after 8/27/21 until 8/30/21. The DON confirmed the missing documentation and said she would have expected nursing assessments to have been completed and documented every shift during that time period. The DON confirmed, after reviewing Resident's #1's Nursing Progress Notes during the same telephone interview, that Resident #1's condition was worsening when she placed a call to Physician Q on 8/27/21 at 11:23 a.m. and received a verbal physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nursing Progress Note on 9/2/21 at 7:27 p.m. read in part, .readmitted from (hospital) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nurse Progress Note on 9/2/21 at 2:54 p.m. read in part, passed away at 1235 p.m. Review of the facility's policy/procedure Change in Condition revised 7/20, read in part, 1. The organization utilizes an interactive platform in the electronic health record to recognize and manage potential change in condition .c. A need to alter treatment significantly, or d. A decision to transfer.

Based on observation, interview, and record review, the facility failed to implement a complete infection control program. This deficient practice has four noted deficiencies: 1. Failed to timely test an unvaccinated, symptomatic COVID-19 Resident (#17). 2. Failed to perform hand hygiene during water pass observations 3. Failed to adhere to COVID-19 staff screening process to prevent entry into the facility and risk exposure. 4. Failed to use proper Personal Protective Equipment (PPE) for COVID-19 TBP. These deficient practices resulted in the potential for cross-contamination of microorganisms and the potential spread of communicable diseases which had the potential to affect all 40 residents residing in the facility. Findings include: On [DATE] at 5:20 p.m., the Nursing Home Administrator (NHA) confirmed the facility's second COVID-19 outbreak began in [DATE]. Subsequently there were five residents who tested positive for COVID-19 with three confirmed deaths, and ten COVID positive staff. Resident #17 COVID-19 TESTING Review of Resident #17's Electronic Medical Record-diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's admission Progress Note, dated [DATE], read in part, He was admitted to the hospital [DATE] for a fall at home. DX (diagnoses) weakness, [CONDITION(S)], loss of taste and smell. Negative for Covid [DATE] . Review of Resident #17's Physician's Orders, [DATE], read Observe resident for signs and symptoms of COVID-19: Fever, SOB, Cough, Nausea, Diarrhea, Loss of Taste or Smell, Malaise, Muscle weakness. No Physician Order showed COVID-19 vaccination was ordered. During an Infection Control Task interview on [DATE] at 2:01 p.m., Infection Preventionist (Staff) I when asked about the second COVID-19 outbreak said Resident #17 was placed in TBP since admission on [DATE] because he was symptomatic (loss of taste and smell) but confirmed he was not tested until [DATE]. Review of facility's Novel Coronavirus Prevention and Response revised ,d+[DATE], read in part, Testing for COVID-19 will occur for staff or residents with signs and symptoms of COVID19 .Prioritize symptomatic residents [AGE] years of age and older and those with underlying conditions that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, and chronic kidney disease). Hand Hygiene Water Pass During initial tour on [DATE] at 3:38 p.m., Resident Assistant (Staff) T was observed picking up two clean water mugs from the hydration cart, with exposed straws in the cup, by placing each gloved hand (unsanitized) over the top of the mugs, touching the resident straws with the inside of her gloved, unsanitized hands. Two used (considered dirty) mugs were returned from room [ROOM NUMBER] and placed onto bottom shelf of the same cart. No hand hygiene was observed before Staff T picked up two clean water mugs and brought them into room [ROOM NUMBER]. Staff T returned with two dirty water mugs from room [ROOM NUMBER] and placed them on the lower shelf. No glove change or hand hygiene was observed. Staff T then took two mugs into room [ROOM NUMBER], returned dirty mug to lower shelf - with no change of gloves or hand hygiene. Staff T entered room [ROOM NUMBER] with two clean water mugs and returned with two dirty mugs, and placed them on the carts lower shelf. No glove change or hand hygiene was observed. Staff T removed her gloves and sanitized her hands when she had completed the entire 100 Hall. During an interview on [DATE] at approximately 3:55 p.m., Staff T was asked what tasks she completed as a Resident Assistant. staff T stated, I basically help the CNAs (Certified Nurse Aides) - make beds, help with dinner and lunch, and I pass waters, and I help the residents. The kitchen set up the mugs (for the hydration cart). Staff T stated the straws usually were covered with paper, but she usually took the paper off before delivering them. When asked what she had been instructed regarding hand hygiene during water pass, Staff T stated, I usually wear gloves, and if I don't do that I will bring the new cups in (and) take the old cups out and then wash my hands. If I wear gloves I take them off and put new ones on (after each room). When asked about this Surveyor observation of no new gloves, and no hand hygiene between all rooms observed, Staff T confirmed she had only sanitized her hands at the end of the hall. Staff T stated, I . usually I would sanitize my my hands after removing the old gloves - but there were no gloves at the door(s). During an interview on [DATE] at 2:57 p.m., Unit Coordinator/RN I was asked how facility staff should be performing hand hygiene during water pass. RN I confirmed Resident Assistants were passing the water mugs and hand hygiene should be performed when they set things down and when they exit the resident room. RN I said competency had not been assessed for Resident Assistants or CNAs. After description of the above observation with lack of hand hygiene or glove changes,, RN I stated, That never should have happened. Staff Screening and PPE for Transmission Based Precautions During an interview on [DATE] at 2:01 p.m., during the Infection Control interview with RN/Infection Preventionist I, the most recent COVID-19 outbreak in April of 2021 was discussed. IP I said CNA D had punched in for work on the [DATE]th, even though she was feeling ill, and documented in the staff entrance screening that she had more than one symptom consistent with COVID-19. CNA D entered the facility building and went to IP I's office and said she did not feel well, and was tested and found to be positive for COVID-19. During a telephone interview on [DATE] at 2:02 p.m., CNA D confirmed she had filled out the staff screening sheet with symptoms of COVID-19, and felt ill on the day she was to work at the facility. When asked why CNA D had entered the facility after screening positive with COVID-19 symptoms, CNA D stated, Nobody came to the door when I rang (the door bell) - so I went in (and) I told [IP] I that I was not feeling well - and I said nobody answered the door. She tested me and I needed to leave. I thought they would be notified by their phones - that the administration would be coming to the door if we gave a yes response (to COVID-19 symptoms). When asked if IP I was busy donning PPE knowing a staff member had screened with positive symptoms, CNA D said [IP I} was not putting on her PPE (personal protective equipment) - she didn't even know that I answered any of those questions (on the staff screening machine). [IPI] asked me 'Why did you come in?' CNA D said sometimes staff would come in if they were sick, and sometimes they (staff) would get in trouble for coming in . CNA D stated, On Tuesday, starting on ,d+[DATE], I had really bad body aches. I thought it was my [chronic disease], but it kept getting worse Tuesday and Wednesday and on Thursday I felt like dog s##t. I worked on Tuesday and Wednesday. I told them (administration) that I was not feeling well on Tuesday, but they didn't say anything . We would have to work the quarantine unit, the 300 unit, and the 100 unit. (There were) No dedicated staff . Some of the times we don't have everything (PPE) that we need. Sometimes we don't have the right coverings (gowns), and laundry is not there on the weekends. If we didn't have it - then we didn't have gowns to wear it. We would have to put them in dirty laundry . during the weekend - (when) we did not have laundry there we would not wear gowns - because there wasn't any. I think once that happened, for the whole weekend. I have actually had that happen to me . We said something to the nurse but they said laundry was not there. During a telephone interview on [DATE] at 2:18 p.m., CNA S was asked about PPE usage and availability . When asked if there was ever a time staff had to enter quarantine or isolation rooms without full PPE, specifically gowns, CNA S stated, It has happened. They would run low when I was there. When asked where and how CNA S removed PPE upon exit from a quarantine or isolation room, CNA S said all PPE, including N95 face masks were removed inside the quarantine/isolation room. CNA S said the garbage can was right inside of the room. CNA S stated, I did see several nurses - (RN U) would go in there with no gown on - only a mask .There were also CNAs that would go into [positive quarantine resident] room with no gowns. During a telephone interview on [DATE] at 2:57 p.m., RN U confirmed isolation gowns were not always available for use in the facility at all times. RN U said she did have to reuse another staff members gown, when a clean gown was not available. RN U said she had personally seen Administrative Nursing staff walking through the facility with the same gown throughout the facility and had reported her concern. RN U stated, I haven't worked on weekends but I have seen no gowns available on [other days]. During a telephone interview with Resident #17's Family Member (FM) W on [DATE] at 8:16 p.m., the status of Resident #17's health was discussed. FM W said Resident #17 died on [DATE] in an acute care facility from COVID-19 pneumonia. The facility had listed Resident #17 as status unknown. When asked about any concerns with resident care during the recent ([DATE]) COVID-19 outbreak FM W stated, I don't know why they didn't give him a COVID shot (vaccine) [Resident #17] said, 'If I have COVID, why aren't they (staff) wearing gowns and faceshields'. FM W said Resident #17 had communicated with her via telephone and said some staff would come in with their noses uncovered, they wouldn't wear their gowns, and some did not wear their face masks and face shields upon each entrance into the room. FM W said Resident #17 had relayed to them that most staff had no face shield, and their nose wasn't covered by the face mask. During a telephone interview, on [DATE] at approximately 5:00 p.m., the Director of Nursing (DON) was asked if she had ever been informed of any concerns related to lack of PPE and inadequate donning of PPE by facility staff. The DON said she had never heard any concerns related to PPE shortages or inappropriate donning of PPE. Review of the Centers For Disease Control and Prevention (CDC's) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated [DATE], revealed the following, in part: .Reinforce sick leave policies and remind HCP (health care providers) not to report to work when ill. Reinforce adherence to standard IPC (Infection Prevention and Control) measures including hand hygiene and selection and correct use of PPE . Implement Source Control Measures . HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers . Personal Protective Equipment . Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses . Residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection .should be cared for (by) HCP using an N95 or higher-level respirator, eye protection . gloves and gown.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, consistent with professional standards of practice to promote healing and prevent new pressure ulcers from developing for three Residents (#9, #16, and #34) of three residents reviewed for pressure ulcers. This deficient practice resulted in harm to Residents #9 and #16 with the development of two or more new pressure injuries, delayed healing with lack of pressure injury prevention interventions, and increased risk of infection. Findings include: Resident #9 During an interview while conducting initial touch, on 6/7/21 at 3:20 p.m., Resident #9 confirmed he had a sore on his bottom. Resident #9 stated, I had diarrhea and the nurse was supposed to help clean me up, because I could only do so much, and she didn't help me. I have been paying for that ever since then. Review of Resident #9's Minimum Data Set (MDS) assessment, dated 3/21/21, revealed Resident #9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition, was independent with bed mobility, wheelchair locomotion, and toilet use. Resident #9 was documented with two Stage II (two) pressure ulcers on 3/21/21, and noted as having a pressure reducing device for his chair, and pressure ulcer care. Resident #9 was documented as continent of bowel and bladder. During a wound care observation on 6/09/21 at 10:15 a.m., Registered Nurse (RN) B assisted Resident #9 to a standing position, holding the toilet support rail, upon rising from his wheelchair. RN B pulled down Resident #9's pants exposing three 4 x 4 dressings - one on the left buttock, and one dressing each on the left and right inner, upper thigh. RN B looked at the white 4 x 4 dressing on Resident #9's left buttock and stated, That is new. RN B removed the 4 x 4 white dressing to find macerated, grayish-which skin with some peeling/shredding of the skin. The area did blanch and RN B stated, The area (buttock) is always kind of gray, but it does blanch. RN B removed the white 4 x 4 dressing on Resident #9's right back inner thigh. The dressing removal resulted in tearing of Resident #9's skin and frank bleeding on the lower edge of the 4 x 4 dressing, with drops of blood falling onto the bathroom floor. RN B attempted the wipe the area with sterile gauze, and placed the bloody dressing and gauze directly onto the bathroom floor. The clean dressing supplies were in a plastic bag, and tossed into the residents bathroom sink (not cleaned). Resident #9 was asked to sit back in his wheel chair when he stated, Yeah, my legs are starting to give out. An absorbent pad was placed in the wheelchair and Resident #9 was seated while RN B exited the room to find more dressing supplies. RN B did not ask the resident if he would be willing to lay in bed while the wounds were dressed. Upon return RN B asked Resident #9 to again stand with support of the toilet support rail. Frank bleeding was present on the blue pad Resident #9 had been sitting on, with a circle approximately 1 inch in diameter saturated with blood on the pad. RN B cleaned the site with normal saline, and patted dry, applied a Comfort Foam Border Bordered Foam wound Dressing with soft Silicone Adhesive to this wound. This dressing package stated For Partial and Full thickness wounds /Pressure ulcers stages 2-4. The dressing removed was, per RN B a [Name Brand] Composite Adhesive Island Wound Dressing . the package contained the following guidance: General Precautions and Observations - May be used as a waterproof primary or secondary dressing. Should any signs of redness or irritation appear, discontinue use and consult a healthcare professional. RN B did not apply another dressing to the left buttock wound, but left it open to air. RN B removed the tan dressing from Resident #9's left inner thigh. The wound appeared beefy red and rough. RN B removed the tan Comfort Foam Border dressing and reapplied the exact same type of dressing on the left thigh wound. During an interview at this same time, RN B was asked what dressings were removed from Resident #9's skin, as two were white and one was tan. The white dressing on the right back thigh appeared to rip the skin off of Resident #9's skin and resulted in bleeding. RN B stated, That is because they (other nursing staff) applied the wrong dressing. It was supposed to be a gentle silicone dressing, and they didn't put one of those on him. RN B confirmed the dressing applied was not noted with with a signature so she did not know who had applied the previous, incorrect dressing. RN B also provided the packages of the dressings removed, and applied as noted above. RN B said the Dr had been informed of the status of Resident #9's wounds and that the physician had determined HPV (human papilloma virus) was the cause of Resident #9's wounds. During an interview on 6/09/21 at 1:03 p.m., the DON and Regional Clinical Nurse J were asked if they were aware of the condition of Resident #9's wounds. The DON said she had done rounds with Resident #9's physician last month, and at that time under his butt cheek, in the gluteal fold it was kind of bumpy and red. The DON stated, He just had bumps in the right gluteal fold. Neither the DON nor Regional Clinical Nurse J had observed Resident #9's wounds in the last month and were unaware of the condition of Resident #9's skin. All agreed to to observed Resident #9's wounds . with the DON and Clinical Regional Nurse J. The Clinical Regional Nurse J agreed bloody dirty dressings and bloody gauze should not be placed directly on the floor, but should be placed into a different garbage receptacle or on a barrier cloth Following dirty dressing placement onto the floor cleaning staff should have been called to sanitize the floor in the Resident #9's room. Requested all facility documentation related to Resident #9's wounds. During an interview on 6/09/21 at 4:45 p.m., the NHA, Regional Clinical Nurse J, Regional Director K, DON, and Unit Coordinator I were asked for an accurate accounting of the residents with pressure injuries between the Census and Condition (CMS-672) and Resident Roster (CMS-802). The initial Census and Condition form provided identified zero (0) residents with pressure injuries. All agreed to correlate the information and provide it to the survey team tomorrow, 6/10/21. During an interview on 6/10/21 at 10:10 a.m., RN B confirmed she had not provided requested documentation regarding Resident #9's pressure injuries. RN B said she had not prepared any documentation for this Surveyor because she didn't know what I wanted because the Dr. said it was HPV that was causing the wounds. Reviewed requested documentation and RN B said she would get it compiled. Resident #9's wound documentation was provided at 11:45 a.m., on 6/10/21 by RN B. Review of Resident #9's Wound Assessments (multiple pages for multiple wounds) revealed the following wounds are all documented with physician notification on 6/9/21: 1. New, in-house acquired, coccyx, pressure (type of wound), Length 18 centimeters (cm) x Width 9 cm, Depth 0, Suspected Deep Tissue Injury. Physician Notified 6/9/21 at 14:00 (2:00) p.m. 2. New, in-house acquired, right buttock, pressure, 13 cm x 8 cm, x 0, Stage I. 3. New, in-house acquired, right gluteal fold, skin tear, 3 cm x 0.6 x 0.2 cm, surrounding tissue non-blanchable, fragile, dry/flaky. 4. New, in-house acquired, right rear thigh, pressure, 12 cm x 10 cm x 0, Suspected Deep Tissue Injury. 5. New, in-house acquired, left buttock, pressure, 6 cm x 12 cm, Stage I. 6. New, in-house acquired, left rear thigh, pressure, 9 cm x 11 cm, Suspected Deep Tissue Injury. Review of Wound Assessments, dated 3/10/21, revealed the following wounds: 1. Left buttock, Pressure, Stage II, Bottom of left buttock, top of left thigh. measure 1 cm x 1 cm x 0 cm. Review of Wound assessment dated [DATE], revealed the following: 1. Left buttock, Pressure, 2 cm x 4 cm x 0.2 cm., Stage II 2. Right buttock, pressure 0.4 cm x 0.4 cm. x 0.1 cm, Stage II Review of Wound Assessments, dated 3/24/21, revealed: 1. Left gluteal fold, pressure 1 cm x 1 cm x 0/1 cm, Stage II 2. Right gluteal fold, pressure - no measurements or Staging present - area healed. Review of Resident #9's Physician Orders, dated 6/9/21, revealed the following orders specific to wound care: [MEDICATION(S)] Cream 1% (percent), Apply to Left lower gluteal topically in the morning every 3 days for open area. Clean area with normal saline, pat dry and apply Silvadine to wound bed. Cover with Gentle dressing. Change daily and prn. Until healed. No orders were present for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Care Plans found no interventions to prevent skin breakdown specific to Resident #'9's buttock and thigh wounds. During an observation on 6/09/21 at 4:35 p.m., Resident #9's pressure injuries/wounds were observed with Licensed Practical Nurse (LPN) R, the DON, Regional Clinical Nurse J, and Unit Coordinator I. Resident #9's on right and left buttock, and right and left upper, inner, thigh wounds were examined. The dressings were removed by LPN R, using sterile saline to loosen the adhesive edges of the dressings. Multiple small skin openings were present on both the right and left buttocks with bloody drainage. LPN R stated, This (buttock/thigh wounds) was not like this on Sunday. I looked at him on Sunday and there were no openings in his skin, just redness and bumps. All present including LPN R, DON, Clinical Regional Nurse J, and Unit Coordinator I all agreed Resident #9 had multiple pressure injuries to his right and left buttocks. No measurements were taken at this time, but documentation would be collected. Resident had a thick blue cushion in his wheelchair, and reportedly did not sleep in his bed. During this observation the DON and LPN R asked if Resident #9 would be willing to lay in his bed to take the pressure off of his bottom for a few hours after each meal. The Resident agreed. Staff explained the he would develop more pressure injuries and it would be painful and his condition would deteriorate if he continued to sleep in his wheelchair. Regional Clinical Nurse J said they would need to investigate to find out who the nurse was, and who changed the dressing last. All agreed interventions were needed to prevent further worsening of Resident #9's wounds. Resident #34 Observation on 6/09/21 at 07:28 a.m. found Resident #34 still in bed. Resident 34's feet were directly on the bed underneath the covers. No foot cradle was placed on the foot of the bed. Review of Resident #34's MDS assessment, dated 5/23/21, revealed Resident #34 had the following active Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34 scored 4 of 15 on the BIMS, reflecting of severe cognitive impairment, and required extensive, two-person assistance with bed mobility, transfers, and toileting. The 5/23/21 MDS assessment documented 1 unstageable pressure injury, classified as a Suspected Deep Tissue Injury (SDTI). No venous ulcers were present at the time of the MDS assessment. Review of Physician Orders, for June 2021, revealed the following, in part: Foot cradle: Use when resident is in bed to keep sheets/blankets above resident's foot/toes, three times a day for a Dark area on right foot, large toe . Active 4/8/2021 . Observation with LPN R on 6/09/21 at 7:41 a.m., found no foot cradle was on Resident #34's bed. LPN R took the foot cradle from off the counter in the room and told Resident 9, I have to put your foot cradle on your bed. They forgot last night. Observation of Resident #34's big toe on 6/09/21 at 8:01 a.m. with CNAs O and Z. A scabbed area (unstageable) was present on Resident #34's right big toe, and sheering was present on both the right and left buttocks. CNAs O and Z said they were treating the buttock with barrier cream that RN B applied During an interview on 6/09/21 at 8:11 a.m., RN B was asked for intervention in place to promote healing of Resident #34's unstageable right big toe wound. RN B stated, The foot cradle is in place to prevent pressure on the toe because if you don't have it on he wraps his feet up in the blankets on the toe. I have been putting povodone iodine daily BID - it hasn't changed anything. When told the foot cradle had not been positioned on the bed that day, RN B stated, The foot cradle should have been on. During an interview on 6/09/21 at 9:46 a.m., RN/MDS Coordinator H was asked about Resident #34's Care Plan specific to skin care. RN H stated, No he does not have a skin care plan in his care plans. He should have. Asked for any interventions related to prevention/heal pressure injures . RN H said reposition every two hours and free float heels. RN H stated, [Resident #9] does not currently have pressure injuries. He had some pressure injuries on his toes and she (RN B) was treating it. [RN B] said it was healed. I didn't care plan the foot cradle. I missed it. A lot of times the nurses do put interventions in place. I missed it and I forgot to care plan it. Resident #16's face sheet revealed an admitted [DATE], and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/7/21 at approximately 1:00 p.m., Resident #16 was observed laying on her back in her bed, sleeping. On 06/09/21 at 8:12 a.m., Certified Nurse Aide (CNA) C reported Resident #16 had an open area on her buttocks. Interventions to help heal the wound were to turn Resident #16 every two hours and an air mattress. Resident #16 was non-ambulatory and usually got up after breakfast into a wheelchair with a two person assist. An observation of wound care performed by Wound Care Nurse/Registered Nurse (RN) B was made on 06/09/21 at 9:20 a.m. Two separate wounds on Resident #16's coccyx were observed. RN B performed measurements of the wounds. The top wound was 0.2 cm (centimeters) x 0.2 cm. The bottom wound measured 0.2 cm x 0.2 cm. Both of the wounds had a depth of 0.1 cm. The wounds appeared pink with the presence of sloughing (shedding) tissue. Upon completion of wound care, Resident #16 required incontinence care which was performed by CNA C and CNA E. CNA C was observed cleansing Resident #16's bottom to remove stool. CNA C then returned the container of wipes to Resident #16's nightstand without removing her soiled gloves and washing her hands. During a follow up interview on 06/09/21 at 9:41 a.m., CNA C was asked what the process was when touching soiled areas before touching clean areas. CNA C said she had soiled gloves on and touched the wipes, the wipes were then dirty. Then wipes were put in the bedside table which made the drawer dirty as well. CNA C stated she realized she should have washed her hands before handling the wipes. During an interview with Infection preventionist/RN I on 06/09/21 at 10:28 a.m., the findings of the observation during incontinence care were shared. RN I stated the CNA should have washed their hands before touching the wipes. During an interview with RN B on 06/09/21 at 10:48 a.m., it was reported Resident #16's interventions to prevent skin breakdown were to float her heels, reposition her every two hours, use of an air mattress had been implemented, and Resident #16 should receive nutritional supplements. RN B said the CNAs were very good at notifying nurses when skin breakdown occurred, and the nurses were very good at healing pressure ulcers. RN B said staff needed to be better at preventing skin breakdown from taking place. On 6/9/21 at 4:20 p.m. an observation of Resident #16 was made of her sleeping on her back with her heals resting on the bed (not floated). On 6/8/21 at approximately 8:10 a.m. CNA C and CNA E were observed boosting Resident #16 up in bed. Resident #16 had already been previously positioned on her back, with heels which were resting on the bed. On 6/10/21 at 7:58 a.m., Certified Dietary Manager (CDM) A reviewed Resident #16's Electronic Medical Record (EMR) and identified a Weight Change Note written on 5/12/21 at 1527 (3:27 p.m.) by Dietician EE which contained the following information, in part, . Noted new Stage 3 coccyx pressure ulcer, [Name brand nutritional supplement] on order to administer 30 ml [milliliter] TID [Three Times Daily] (300 kcal/45 gm protein per day) for facilitation of wound healing . CDM A reported Resident #16 was not receiving this nutritional supplement because it had to be ordered and had not yet arrived. CDM A was concerned that there had been no nutritional supplement substitutions implemented and Resident #16 had gone almost a month without nutritional supplements. During an interview with the Director of Nursing (DON) and the Regional Clinical Director on 06/10/21 at 9:26 a.m., it was reported the expectation would have been for Resident #16 to receive a substitute nutritional supplement until the one that had been ordered arrived. During a follow up interview on 6/10/21 at 9:52 a.m., Resident #16's EMR was reviewed with RN B. RN B clarified Resident #16's pressure ulcer had never been a stage three and was a stage two. RN B was asked if the interventions which were place were considered effective preventative measures. RN B said the air mattress was implemented after Resident#16's skin breakdown because it had not been considered sooner. RN B said it should have been the first thing she had thought of, not the last. Further review of Resident #16's EMR reveled the following information: A Nursing Progress Note dated 5/30/2021 at 22:56 (10:56 p.m.) contained the following, in part, Resident is noted to have two small open areas to rt [right] of coccyx. Duoderm thin applied and note to [RN B], wound management to follow through with further eval when she returns. Resident #16's care plan (revision date of 4/12/21) contained the following information, in part, I am at risk for skin breakdown, .apply protective cream to bottom after each incontinence episode .free float heels when I am in bed .I need extensive assist from two staff members to turn and reposition in my bed approx. [approximately] q [every] 2 hours and prn [as needed]. A copy of the facility's Skin and Pressure Risk Assessment and Prevention policy (revision date of 12/20) read, in part, .8. The tool [Braden Assessment- a tool used to determine the risk of developing pressure ulcers] will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: i. Impaired/decreased mobility and decreased functional ability:, ii. Co-morbid conditions, such as end stage renal disease, [CONDITION(S)] disease,or diabetes mellitus; .v. Exposure of skin to urinary and fecal incontinence .10. Interventions for Prevention and to Promote Healing b. interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as a repositioning, protecting and/or offloading heels, etc.); iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Maintain or improve nutrition and hydration status, where feasible .

Based on observation, interview, and record review, the facility failed to provide necessary treatment and service to promote healing and prevent the development of pressure ulcers for three Residents (R#1, R#2, and R#3) of three residents reviewed for pressure ulcer care. This deficient practice resulted in harm with the development of multiple Stage II pressure ulcers, suspected deep tissue pressure ulcer, lack of appropriate notification (physician, family, and/or registered dietician), and deterioration of condition. Findings include: Resident #1 Review of Resident #1's Minimum Data Set (MDS) assessment, 12/22/20, showed an admitted [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated moderately impaired cognition and he had limited ability to make concrete decisions. Resident #1 required at least two staff person assistance for bed mobility, transfers, and walking. Resident #1 on the same MDS assessment was identified as being at risk for pressure ulcers and did not have any upon admission. During a telephone interview on 2/11/21 at 3:15 p.m., FM L expressed her disappointment with the care (Resident #1) received while he was admitted to the facility. FM L said she discovered two big open sores on the bottom of (Resident #1's) feet when he was discharged home that weren't there before being admitted to the facility. Review of Resident #1's Skin Observation Tool dated 1/14/21, revealed the following new skin concerns: right heel pressure-3.2 cm (centimeter) by 4.8 cm width-depth 0-suspected deep tissue injury left heel pressure-4 cm length by 4.8 cm width-depth 0.2-Stage II. Review of Resident #1's Progress Notes from 12/22/20 to 1/15/21 (discharge) reflected no pressure ulcer notification to Physician (MD) N, Family Member (FM) L, or to Registered Dietician (RD) O had occurred. Review of MD N's physician visit progress note, dated 1/14/21, showed no reference was made to the presence of Resident #1's bilateral heel pressure ulcers. During a telephone interview on 2/16/21 at 2:01 p.m., Registered Nurse (RN) P said she had assessed Resident #1's skin and found the pressure ulcers where she documented them in the EMR under Skin Assessment Tool on 1/14/21. RN P said she did not notify FM L nor MD N of the new facility acquired pressure ulcers. Review of Resident #1's Discharge Summary dated 1/15/21, did not indicate the presence of the pressure ulcers under the section Summary of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing section which reads, Course of treatment while in facility including complications also does not reference the pressure ulcers found on Resident #1's heels. Resident #2 Review of Resident #2's MDS assessment, dated 1/11/21, showed and admitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was independent for bed mobility and required one staff assistance for transfers. The BIMS score was 10 out of 15 which indicated moderately impaired cognition. Resident #1 on the same MDS assessment was identified as being at risk for pressure ulcers and did not have any upon admission. During Resident #2's wound observation on 2/11/21 at 10:37 a.m., Licensed Practical Nurse (LPN) Q, in the presence of Certified Nurse Aide (CNA) G and CNA H measured the opened coccyx wound (1.5 cm length by 1.0 width and depth 0) and identified the pressure ulcer as a Stage II. Review of Resident #2's Skin Observation Tool dated 1/17/21, identified a new skin concern as a red area to the coccyx. On 2/11/21 at approximately 10:45 a.m., Resident #2's bed and surroundings were observed in the presence of CNA G who was asked why only one pillow was seen that was located at the head of the bed. CNA G said she didn't know and as she looked in the closet. CNA G confirmed Resident #2 required help from staff for repositioning. Review of Resident #2's complete nineteen page Care Plan, last updated 1/18/21, reflected no reference to the Stage II coccyx pressure ulcer identification which would have included interventions for care and measurable goals. Resident #3 Review of Resident #3's MDS assessment, 12/22/20, reflected the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 required two staff assistance with bed mobility and transfers. Resident #3 on the same MDS assessment was identified as being at risk for pressure ulcers and did not have any at the time of the assessment. On 2/11/21 at 10:17 a.m., RN P was asked if Resident #3 had any pressure ulcers. RN P said she thought the one she had (coccyx) was healed but indicated she hadn't assessed her skin yet today. During an observation of Resident #3 immediately following the interview, Resident #3's skin was assessed and wound care provided with the assistance of LPN Q. Resident #3 was found lying flat on her back in bed (no air mattress) with her bilateral heel protecting boots off and heels directly on the mattress. There was no dressing observed to Resident #3's coccyx when she was turned to her right side. RN P cleansed the wound and then measured the wound (0.8 cm -1.0 cm length by 0.3 cm width and depth 0.2 cm) before applying the dressing. RN P confirmed the coccyx wound was now a Stage II. When asked about Resident #3 not having a dressing in place, RN P said, She should have. Review of Resident #3's Skin Observation Tool dated 2/8/21, read in part, no new skin concerns at this time. During a telephone interview on 2/17/21 at 8:50 a.m., FM M said she was aware (Resident #3) had a sore but was told it had healed pretty good. When asked when the facility had last talked with her, FM M indicated approximately two weeks prior. Review of Resident #3's Care Plan, last reviewed 1/6/21, read in part, Notify physician if wound stalls or worsens. Air mattress on bed for added skin protection. During a telephone interview on 2/16/21 at 3:39 p.m., the Director of Nursing (DON) indicated Stage II or greater pressure ulcers required notification to physician, family, RD, and DM. Review of facility's policy Skin and Pressure Injury Risk Assessment and Prevention revised 12/20, read in part, Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care .the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .

Based on observation, interview, and record review, the facility failed to identify an environmental hazard to prevent a thermal burn caused from a radiator for one vulnerable Resident (#1) of four residents reviewed for accidents. This deficient practice resulted in harm with Resident #1 sustaining 2nd degree thermal [CONDITION(S)] involving the right hand and wrist, pain, redness, swelling and blistering. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment, 12/22/20, showed an admitted [DATE], with the following diagnoses: debility of cardiorespiratory conditions, [CONDITION(S)] (blood infection), Alzheimer's disease, chronic obstructive pulmonary disease (COPD), [CONDITION(S)] to right lower limb, open wound to right lower leg, and mastoiditis (ear infection). Resident #1 Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated moderately impaired cognition and he had limited ability to make concrete decisions. Resident #1 required at least two staff person assistance for bed mobility, transfers, and walking. Review of Resident #1's Admission/Readmission Assessment, 12/17/20, read in part, Sensory Perception .has some sensory impairment which limits ability to feel pain or discomfort . Review of Resident #1's Progress Note, 1/1/21 at 05:48 (a.m.) Licensed Practical Nurse (LPN) E wrote, Resident fell asleep with R (right) hand directly on radiator .He has 2-3 blisters of varying sizes and redness along the R knuckles . Review of Licensed Practical Nurse (LPN) E handwritten witness statement, 1/5/21, read, At around 0500 (a.m.) on 1/1/21 CNAs (Certified Nurse Aides) alerted this nurse to (Resident #1's) room. Upon entering room (Resident #1) was noted laying in bed and R (right) hand was red with 2-3 large blisters .denied pain, stated his hand was just 'on fire' . During an interview on 2/11/21 at 9:30 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) said Resident #1's bed was positioned directly next to the radiator on the date of the incident (1/1/21). The NHA and DON indicated Maintenance (Staff) D had checked Resident #1's radiator temperature after the incident on 1/1/21. When queried, the NHA said temperature readings should be below 125.0 (Fahrenheit) to be considered safe in preventing resident [CONDITION(S)]. During an observation on 2/11/21 at 9:36 a.m., the NHA and DON showed this Surveyor Resident #1's previous room (301) to visualize the location of the radiator and location of Resident #1's bed on the date of the incident (1/1/21). The radiator was seen under the window. The NHA explained that Resident #1's entire length (right side) of his bed was against the radiator. The top of the radiator appeared to be at the same height of the unoccupied bed mattress. The radiator vents (heat produced by water heated by the facility's two boilers) was located at the top surface of the radiator. A thermostat to adjust the radiator temperature was noted at the entrance to the room. A cover was placed over the control; however, the bottom screw was missing which easily allowed access to the controls. Review of an untitled log, recorded by Maintenance (Staff) D on 1/1/21 at 2:00 p.m., showed resident radiator room temperatures which included the following at 125 F or higher: Room 305-125 F Room 306-126 F Room 202-125 F Room 204-129 F Room 206-128 F Room 400-125 F Room 104-130 F Room 107-132 F On 2/11/21 at 9:44 a.m., Maintenance Director (Staff) C verified each residents' room contained either one of two thermostats which adjusted each room's radiator temperature. Staff C indicated the highest setting on the thermostat was 85 F. When Staff C was asked why some resident room thermostats contained covers while others did not, Staff C did not answer the question but indicated the system was [AGE] years old and he didn't know if the thermostats were even accurate. Staff C was asked a second time why some thermostats had covers and others did not, but Staff C did not answer the question. On 2/11/21 at 9:56 a.m., Staff C used an infrared (non contact) laser thermometer in room 301 and obtained a radiator temperature of 117.3 F when laser was pointed to at the outside cover (mid height) of the radiator. When asked to obtain a temperature from the top portion of the radiator where the vents were present, Staff C stated the temperature was 137.3 F. On 2/11/21 at 10:11 a.m., Staff C used an infrared (non contact) laser thermometer in room 203 and obtained a radiator temperature of 118.5 F when the laser was pointed at the outside cover (mid height) of the radiator. When asked to obtain a temperature from the top portion of the radiator where vents were present, Staff C stated the temperature was 127.5 F. On 2/16/21 at 10:28 a.m., during a telephone interview, the NHA confirmed two other residents' beds in room 400 and 401 were discovered on 1/1/21 placed directly against radiators. The NHA agreed there was a delay in requesting maintenance to check the boiler and radiator temperatures after Resident #1 sustained his [CONDITION(S)]. Review of an electronic communication from NHA sent on 2/17/21 at 9:36 a.m. verified Staff D clocked into the facility at 12:43 p.m. on 1/1/21. During a telephone interview on 2/16/21 at 1:38 p.m., Housekeeping Director (Staff) B verified the facility did not have a policy and procedure for safe resident furniture placement. When asked if a resident's bed could be next to a radiator, Staff B responded that a nightstand needed to be placed between the radiator and the bed. Review of facility's Timeline of events (Resident #1's) -Burn incident on 1/1/2021 read in part, we (facility) should have a nightstand in place between the bed and the heat register .

Based on observation, interview, and record review, the facility failed to: 1) effectively perform proper staff/visitor entrance screening; 2) perform resident infection line-listing surveillance, mapping, and analysis; 3) complete employee illness monitoring; 4) monitor staff for infection control practices; 5) maintain 6 feet social distancing; 6) separate clean and contaminated space on the COVID Unit; 7) display required Personal Protective Equipment (PPE) signage for the COVID-19 Unit; 8) train and monitor Certified Nurse Aides (CNAs) for housekeeping responsibility on the COVID Unit. This deficient practice resulted in Immediate Jeopardy for the continued spread of COVID-19 throughout the entire facility affecting all 36 residents. The facility's verified COVID-19 data as of 12/2/20 at 11:30 a.m., per the Nursing Home Administrator (NHA) during a telephone interview, indicated the following: Cumulative number of residents infected with COVID-19 was 51. Cumulative number of staff infected with COVID-19 was 26. Cumulative number of deaths related to COVID-19 was 15. Review of the facility-provided COVID-19 laboratory spreadsheets, received onsite on 12/1/20, reflected the first COVID-19 positive test results affected three staff persons in June 2020. One staff was positive in September and then two additional staff were positive in October. Within the first two weeks of November, 11 additional staff had tested positive for COVID-19 before the facility's first resident infection on 11/15/2020. Week one (beginning November 15th) of resident infections affected 33 residents. Week two (beginning November 22nd) affected an additional 18 residents, which accounted for the facility's total census at that time. The Administrator was notified on 12/2/20 of the Immediate Jeopardy, which started on 11/15/20 when the first resident COVID-19 infections were identified. During an interview on 12/1/20 at 11:00 a.m., the NHA and Infection Preventionist designee (Staff) B provided documentation which showed September 2020 Log of Resident Line-Listing Infections was incomplete. Both the NHA and Staff B acknowledged a summary/analysis of September 2020 Resident Infections was not completed along with facility mapping to indicate infection type and room location. When the data for October 2020 and November 2020 was requested, both the NHA and Staff B indicated it had not been completed. Review of the Employee Illness Log showed only one recorded infection on 9/5/20. The NHA and Staff B confirmed additional employees had reported illnesses after 9/5/20 through 11/30/20 but no additional entries were made to the log. The NHA and Staff B were unable to provide records of infection control monitoring, and confirmed it had not been performed for the last three months while their primary Infection Preventionist was on an extended leave. The Immediate Jeopardy concerns continued with multiple observations of staff's lack of social distancing, inadequate signage for required PPE to enter/exit the COVID Unit, and the lack of separation of clean/contaminated spaces on the COVID-19 Unit. The facility submitted an Abatement Plan for the removal of the Immediate Jeopardy, and the plan was approved on 12/2/20 at 3:53 p.m. The facility provided evidence of staff education starting on 12/2/20 which addressed the following concerns: social distancing, hand hygiene, isolation with PPE use, environmental cleaning/disinfecting, and staff/visitor entrance screenings. The evidence was submitted by electronic communication by the NHA on 12/4/20 at 1:49 p.m. The deficient practice continued at widespread level of potential for more than minimal harm until verification of the full plan of correction. Findings include: Visitor/Staff Entrance Screenings On 12/1/20 at 9:35 a.m., during the Visitor COVID-19 Entrance Screening, Staff K took this Surveyor's temperature and then asked, Do you have any COVID symptoms? This Surveyor asked what the symptoms of COVID-19 were. Staff K left the vestibule and returned with a clipboard when she then only asked if I had a cough, sore throat, or shortness of breath. No direction for the performance of hand hygiene nor any education was provided by Staff K. Review of facility's Coronavirus Surveillance date implemented 2/27/20, read in part, 3. Screening for visitors and staff: .b. In the last 14 days, has had contact with someone with a confirmed [DIAGNOSES REDACTED]. c. International travel within the last 14 days .d. Residing in a community where community-based spread of COVID-19 is occurring . Review of Start of Shift Daily Employee Screening Log dated 12/1/20, where this Surveyor's screening was recorded read in part, .please wash your hands or use alcohol-based hand rub (ABHR) on entry and throughout your time in our facility. Please do not shake hands, touch or hug individuals during your visit. Practice Social Distancing (6 FT (feet)) and wear appropriate PPE. During an interview on 12/1/20 at 11:05 a.m., the NHA and Staff B were told of this Surveyor's COVID-19 Entrance Screening concerns. Staff B said the screening form had been changed 8/24/20 which eliminated some of the screening questions. The NHA said he heard Staff K asking screening questions, but this Surveyor clarified the need for prompting to ask the questions. Resident and Staff Infection Surveillance On 12/1/20 at approximately 10:30 a.m., during the Entrance Conference, the NHA and Infection Preventionist designee (Staff) B were asked to provide September, October, and November 2020's Resident Infection Line-Listings (to include COVID-19 tracking), mapping, and analysis, Employee Illness Logs, and COVID-19 lab positives for residents and staff prior to completing the on-site portion of the survey. The NHA said the data was found within a binder and would provide for Surveyor's review shorty. On 12/1/20 at approximately 11:05 a.m., the NHA and Staff B provided surveillance data for review and discussion. Review of September 2020 Resident Line-Listing Log was incomplete (the last two columns- determination of infection criteria met and whether the infection resolved which provides data for monthly analysis and reporting to Quality Assurance). No Resident-Line Listing Logs were provided for October and November 2020 and Staff B confirmed they were not completed. Review of September Employee Illness Log-Infection Monitoring contained one entry on 9/5/20 with symptom of vomiting. The log was incomplete to indicate when/where the employee last work (tracing) and what direction was provided by Infection Preventionist. The NHA and Staff B confirmed additional employees had since called in with illnesses without additional entries made to the log for the Infection Preventionist's review. Staff B was asked to provide resident COVID-19 surveillance data (signs/symptoms, dates placed in quarantine/isolation, room numbers, lab testing dates/results); Staff B confirmed none was completed. On 12/1/20 at approximately 11:20 a.m., CNA G and CNA H were observed wearing face masks, faceshields, and cloth gowns while in room [ROOM NUMBER] while providing cares. No isolation signage was posted outside of the door. When asked why gowns were being worn, CNA G said because (Resident #1) continues to cough with known COVID-19 infection. During a telephone interview on 12/3/20 at 2:11 p.m., Staff V said she had noticed multiple staff, multiple times wearing disposable yellow gowns throughout the facility including inside of the dining room where the food trays were prepared. Staff V said the staff wearing the gowns were coming from the 200 Hall while caring for residents in Quarantine for COVID 19. Staff V expressed concerns with the observation of another staff who lifted his mask to spit into the sink located in the dining room. Staff V was concerned with the lack of staff being monitored for infection control practices and said, It's very upsetting. Review of the facility's Outbreak of Communicable Diseases revised 8/2014, read in part, 1. An outbreak of most communicable diseases can be defined as one of the following: a. One case of an infection that is highly communicable; .c. Occurrence of three (3) or more cases of the same infection over a specified period of time . Review of the facility's Infection Prevention and Control Program date reviewed/revised 12/19, read in part, 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 infection control precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Review of the facility's Coronavirus Surveillance date implemented 2/27/20, read in part, Increase monitoring of resident for development of more severe symptoms or other changes in condition . Social Distancing On 12/1/20 at 9:28 a.m., six staff (one group of four and one group of two) were observed clustered together (less than 6 feet from one another) behind the facility without wearing face masks and smoking. On 12/1/20 at approximately 11:05 a.m., the NHA said smoking was not permitted on nursing home property. When told about the earlier observation of the six staff smoking at the back of the building, the NHA said he was unaware staff were smoking on the property. On 12/1/20 at 11:23 a.m., Resident #2 and an unidentified female resident were watching TV together in a common area and not separated by at least six feet within the COVID Unit. Neither resident was wearing a face mask and a face mask was observed hanging off the right side of Resident #2's four-wheeled walker. Review of facility's, Novel Coronavirus Prevention and Response reviewed/revised 3/21/20, read in part, What is currently known is that it (COVID-19) is spread person-to-person, mainly between people who are within 6 feet of one another through respiratory droplets . COVID-19 Unit-Signage for PPE Use On 12/1/20 at 10:35 a.m., across from the nurses' station, the outside of the COVID Unit contained a polyethylene plastic sheeting across the entire right side of the facility encapsulating the 200 and 300 halls. No signage was observed to indicate the type of isolation was in place and what types of PPE were required to enter. On 12/1/20 at 10:36 a.m., the NHA said entry to the COVID Unit, across from the nurses' desk, was accessed by staff for meal deliveries. The NHA explained nurses and CNAs enter and exit from the 200 hall's stairwell. Concerns were relayed for the lack of signage to indicate the type of isolation, required PPE use, and expected staff traffic flow to prevent cross-contamination. The NHA said he'll have the proper signage put up immediately. On 12/1/20 at around 12:00 p.m., after exiting the COVID-19 Unit through the 200 hall's stairwell, no isolation signage was observed on the outside of the door to indicate it was a COVID-19 Unit, type of PPE required to enter, and expected staff traffic flow. Separation of Clean/Contaminated and Fan Use On 12/1/20 at approximately 11:30 a.m., while on the COVID-19 Unit, the empty resident's room (room [ROOM NUMBER]) designated as a breakroom for staff was entered. A yellow floor fan was plugged in and turned on immediately upon entering the room. On the left side of the room, on top of a built-in dresser, piles of medical supplies were found (wound care tape, medication paper cups, packaged N95 masks, ostomy supplies, and saline vials) directly intermingled with magazines, newspapers, 3-ringed binders used by staff, colored pencils, two trays of chocolate-sprinkled cupcakes, Styrofoam cups, and an opened box of tissues. Hanging directly over the same dresser, a face shield (PPE) was observed along with a red winter coat hanging to the left side of the faceshield. Two overbed tables were pushed together which contained many food/drink items and a grossly soiled surface. A black winter coat was observed on one of the two chairs in front of the overbed tables. A medium sized white cardboard box was seen on the floor which contained medical and electronic supplies. The room did not contain any visual signage to indicate areas which were considered clean and/or contaminated. During a telephone interview on 12/3/20 at 10:05 a.m., Maintenance (Staff) R confirmed no knowledge of the use of a fan on the COVID Unit. When asked if it posed an infection control concern, Staff R said no fans should be used throughout the building during this (COVID-19) outbreak. When asked why, Staff R said, because you don't want to blow [MEDICAL CONDITION] around . During a telephone interview on 12/3/20 at 1:20 p.m., CNA M confirmed working on the COVID Unit. When asked about the breakroom, CNA M said there was definitely a mixing of medical and personal supplies without having a defined space. When asked about taking breaks in regard to PPE use, CNA M said staff only removed their gloves before entering the breakroom; therefore, the same contaminated cloth gown was worn inside of the breakroom. When asked about dedicated space for the removal, cleaning, and storage of faceshields and masks to eat/drink, CNA M said there wasn't any staff education and defined space. Housekeeping Concerns of COVID Unit and Hand Hygiene During the COVID Unit tour on 12/1/20 at approximately 11:30 a.m., several pieces of medical equipment (electronic vital sign machine and transfer equipment) was observed in the hallway. None of the equipment contained any disposable cleaning and disinfection wipes within the storage compartments. On 12/1/20 at approximately 11:40 a.m., Licensed Practical Nurse (LPN) O confirmed cleaning and disinfection wipes were not observed with the medical equipment in the hallway. LPN O said the wipes were stored in the clean utility room located down the 200 hall on the other side of another polyethylene plastic barrier. When asked why they weren't readily available, LPN O said because Resident #4, who was observed in the hallway seated in a wheelchair), was a retired housekeeper from the facility and would take them due to her dementia. Review of facility's Isolation Precautions reviewed/revised 6/10/2015, read in part, Resident care equipment . If use of common equipment is unavoidable, then adequately clean and disinfect them before removing from the isolation room .' On 12/1/20 at approximately 11:55 a.m., this Surveyor exited the 200 hall by the stairwell located at the end of the hall. LPN O entered the passcode and opened the door. LPN O pointed to a trash bin and said that's where PPE needed to be discarded. The white, weaved garbage can was absent of a lid or cover. Soiled PPE was visible near the top of the black garbage bag contained within. A cardboard box bumping up against the same garbage can which contained a light grey jacket on top of additional clothing. Two large plastic garbage bags were observed directly on the floor with one of the bags touching medical evacuation equipment. No hand hygiene supplies were found after the removal of this Surveyor's contaminated PPE. On the top landing and continuing down the stairwell to the ground level, a rust-colored spill was noted to the left side of the stairs. On the ground level, a pink high back chair was noted which contained a cloth yellow disposable gown and a black winter jacket. A grey pair of sneakers with pink shoelaces was found to the right side of the chair sitting directly on the floor. Review of facility's Hand Washing/Hand Hygiene revised 4/8/19, read in part, Hand washing/hand sanitizing is a necessity for control of infection. Hands should be cleaned: .h. After removal of soiled gloves or other personal protective equipment . During a telephone interview, on 12/3/20 at 1:24 p.m., CNA M was asked about the delegation of housekeeping duties while working on the COVID Unit. CNA M explained CNAs were expected to perform resident cares, assist the nurse, assist with resident activities, provide meal assistance, plus perform all the housekeeping duties. CNA M confirmed no formal training nor competency review was completed by any housekeeping staff. CNA M confirmed a cleaning/disinfection checklist was never provided. When asked, CNA M was unable to identify what was considered a high-touch area within a resident's room which would have required regular and increased cleaning/disinfection to prevent cross-contamination. During a telephone interview on 12/3/20 at 12:44 p.m., Housekeeping Supervisor (Staff) D said the NHA did not want any of the facility's three housekeeping staff to enter the COVID Unit; and therefore, delegated the CNAs working on the COVID Unit to perform all the housekeeping duties in addition for performing resident cares. Staff D confirmed CNAs assigned to the COVID Unit had not received any formal training, checklists, explanation of the cleaning and disinfections solutions, nor any competency checks by any of the three-housekeeping staff. When concerns regarding the COVID Unit observations was communicated to Staff D, Staff D said, I completely understand what you are saying . On 12/4/20 at 8:29 a.m., during a telephone interview, CNA L confirmed she has worked on the COVID Unit and was delegated housekeeping duties. CNA L said she received some verbal instruction once from housekeeping. When asked for some specifics, CNA L said she was told what products she could and could not use. CNA L confirmed no checklist nor competency review was provided. When asked how resident rooms' high-touched areas were addressed, CNA L did not provide a response. Review of facility's Novel Coronavirus Prevention and Response reviewed/revised 3/21/20, read in part, Perform routine and terminal cleaning using disinfectants known to be effective against emerging [MEDICAL CONDITION] pathogens or novel coronavirus .

This citation pertains to intake #MI 089. Based on interview and record review, the facility failed to ensure proper training and demonstrations of competency by nursing staff involving two Residents (#1 and #4) of four sampled residents reviewed for nursing services. This deficient practice resulted in harm for staff not performing consistent assessments, evaluations, and prompt responses to residents' needs leading to hospitalization for further treatments, pain, distress, and the potential for further clinical compromise. Findings include: Resident #1 According to Resident #1's Minimum Data Set (MDS) assessment, dated [DATE], showed an admitted [DATE], with the following major Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) reflected severe impaired cognition with inattention and disorganized thinking. Resident #1 required one staff physical assist with bed mobility, transfers, and ambulation. Review of Resident #1's Progress Notes, dated [DATE], read, At 1530 (3:30 p.m.) res (resident) fell in his bathroom and hit his head. He developed a hematoma (bleeding the blood vessels) on the back of his head . BP (blood pressure) ,d+[DATE], Pulse 117, Resp (respirations) 24, O2 (oxygen saturation) 92%. Resident's wife came in after being notified of the fall. At 1630 (4:30 p.m.) (Family Member (FM) B) asked me (Licensed Practical Nurse (LPN) A) to check on (R#1) as he was sweaty and panicked. O2 sat dropped to 66% .At 1730 (5:30 p.m.) the ambulance transported . Review of Resident #1's Medical Treatment Choices dated [DATE], indicated Yes for Cardiopulmonary Resuscitation (CPR) and hospitalization . Review of hospital record for Resident #1, dated [DATE], read, History of Present Illness .suffered a fall striking the back of his head. A hematoma was noted .He was also noted to have low oxygen sats during the day, and per family had appeared to be dealing with increased dyspnea (difficulty breathing) and more audible breath sounds. He has known fibrosis and scarring of the lungs. They (family) were concerned about him all week as he seemed to be deteriorating . Review of Resident #1's Progress Note, dated [DATE] as 12:50 (p.m.) read in part, nonproductive cough .is irritable. (FM B) stated that 'He always gets angry when he gets sick . During an interview on [DATE] at 10:35 a.m., the Director of Nursing (DON) confirmed neither the physician nor the Nurse Manager were immediately notified after Resident #1 sustained a significant injury after an unwitnessed fall. (No Registered Nurse was in the building at the time of the fall.) After review of Resident #1's vital signs (V/S) since admission, the DON confirmed the V/S taken after the fall were considered abnormal and out of range for Resident #1. Review of facility's Evaluation of Falls and Risk of Falls policy/procedure, revised [DATE], read in part, 'TREATMENT AND EVALUATION OF FALLS: .The attending physician will be notified immediately if significant injury occurs . Review of facility's Fall Checklist (undated) read in part, 7. Major injuries such as a Subdural Hematoma, .that you notify the Nurse Manager on call . During an interview on [DATE] at 11:03 a.m., the DON confirmed LPN A recorded only one set of vital signs which were considered abnormal and one physical assessment for Resident #1 after his fall on [DATE]. Both the DON and Nursing Home Administer (NHA) said LPN A should have completed more frequent vital signs and physical assessments. When asked how often, the DON responded at least every fifteen minutes for the first hour. During a telephone interview on [DATE] at 12:15 p.m., LPN A confirmed it was reported in (day to afternoon) shift report that Resident #1 had not been feeling well, which was prior to his fall. When asked why more frequent vital signs and assessments were not completed after Resident #1 sustained the fall, LPN A stated the (electronic medical record) only prompted the need for hourly vital signs and assessments. LPN A then stated, I've been trained though that they should have been every fifteen minutes . When asked what Resident #1's code status was at the time, LPN A responded, full code. Review of hospital chest x-ray, dated [DATE] at 18:59 (6:59 p.m.) read in part, IMPRESSION: [CONDITION(S)] with pulmonary vascular congestion, cardiomegaly (enlarged heart), and pleural effusions . Review of Resident #1's electronic medical record, vital sign history, showed one complete set of vital signs (temperature, pulse, respiratory rate, blood pressure, and oxygen saturation) were taken on [DATE]. The only previous complete set of vital signs were taken on [DATE] even though Resident #1 had not been feeling well for a few days. The vitals signs for [DATE] were B/P ,d+[DATE], P 82, RR 20, O2 97%, T 97.6 F. Resident #4 Review of Resident #4's MDS assessment, dated [DATE], showed an admitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS score was ,d+[DATE] which reflected severe cognitive impairment. Resident #4 required two staff person assistance for bed mobility, transfers, and toilet use. A suprapubic catheter was in place since admission. Review of Resident #4's Progress Note, dated [DATE] at 07:30 (a.m) by LPN A, read, Resident complained of pain around 0400 (4:00 a.m.) this morning in the lower back .Resident slept through most of the night but appeared uncomfortable. At 0600 (6:00 a.m.) it was noted that resident had no output from suprapubic catheter. Bladder scan (ultrasound medical equipment) showed ,d+[DATE] mL (millimeter). Review of Resident #4's Progress Note, dated [DATE] at 9:49 a.m., by Registered Nurse (RN) E read, Physicians office contacted and updated regarding poor urine output, c/o (complaint of) discomfort and pain with palpation to abdomen During an interview on [DATE] at 2:08 p.m., RN E confirmed no urine outputs had been monitored for Resident #4 since admission. RN E stated, They (Intakes and Outputs) should have been ordered with [CONDITION(S)] (diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN E said the physician should have been contacted immediately when no urine output was observed during the night shift. Review of Resident #4's catheter care plan interventions, dated [DATE], read, Monitor of s/sx (signs and symptoms) of discomfort, on urination and frequency. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD for s/sx UTI: pain, .no output, increased pulse, increased temperature, .urinary frequency, . During an interview on [DATE] at 2:31 p.m., Human Resource Manager (Staff) C confirmed LPN A was hired on [DATE] (11 months of employment) whose probationary period ended on [DATE]. LPN A had not completed any facility required nursing skill competencies nor any facility provided on-line training. Staff C identified a second nurse (LPN D) who was working as a newly licensed nurse as of [DATE]. During an interview on [DATE] at 2:43 p.m., the DON confirmed, neither LPN A nor LPN D had completed nursing skill competencies nor required (on-line training) which included some of the the following: Abuse & Neglect, Bloodborne Pathogens, Hand Hygiene, Fire Safety, Hazardous Chemicals, Infection Control and Prevention, Pain Assessment and Management, Understanding Alzheimer's Disease and Dementia, Preventing, Recognizing, and Preventing Abuse, and Medication Administration: Avoiding Common Errors. Review of facility's Licensed Practical Nurse Job Description (undated) read in part, QUALIFICATIONS: Demonstrates .clinical competence, .POSITION DUTIES: ESSENTIAL Follows established standards of nursing practice and implements facility policies and procedures .Demonstrates increased clinical competence by providing direct resident care. Participates in continuing education programs and interest in advancing nursing technical skills .

Based on observation, interview and record review, the facility failed to provide adequate supervision, per plan of care, to prevent a fall with major injury, resulting in harm, for one Resident (#1) of three residents reviewed for falls, out of a total sample of three residents. This deficient practice resulted in a fracture of Resident #1's left hip. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment, dated 3/21/18, revealed Resident #1 was [AGE] years old, admitted to the facility on [DATE], with current active [DIAGNOSES REDACTED]. Resident #1 was noted to have severe cognitive impairment on the same MDS assessment, and required extensive, two-person assistance with transfers, dressing, and toileting. Review of the facility's 3/8/2018 Un-Witnessed Incident reported revealed Resident #1 was found laying on her left side with her head against the wall in front of her toilet. She was noted to be holding her walker when she was found. The walker was found laying on its side in front of resident .PROM (passive range of motion) was attempted after getting resident in a supine position. Due to her voicing pain in the left hip area staff was unable to fully assess .Left foot is noted to be rotated externally. Call placed to .ER (emergency room ) with N. O. (new order) to send resident to ER for eval (evaluation) and treat (treatment) . Review of Progress Notes revealed the following: 3/8/18, 22:10 (10:10 p.m.), Received report from .ER, resident has left hip fx (fracture) and is being transported to (other acute care hospital) for further treatment . Review of the facilities 5 Day Investigation Report, regarding Resident #1's fall with fracture on 3/8/18 at 1815 (6:15 p.m.), read, in part: On the evening of 3/7/18 the Physical Therapist sent an email updating the Nursing Management Team that (Resident #1) should be mostly w/c (wheelchair) bound from now on and can do a walking program with CNA's to keep her strength up. This email was reviewed and changes to the care sheet completed on 3/8/18. The changes to the Plan of Care were highlighted and placed in the Here's The Scoop book for nursing staff to review and take note that a change had been made .Staff is to review the book at the start of their shift to be aware of changes. On 3/8/18 (CNA A), failed to review the Here's the Scoop book when he came onto his 3-11 (p.m.) shift that day. Thus (CNA A) was unaware of changes that had been made that very day on 7-3 shift. The changes were: . 2. Ambulate with 1 assist with walker prn (as needed), 3. Wheelchair for locomotion .(Resident #1's) Care Plan states that she will attempt to get up indep (independently) (due to her dementia) and walk with her walker but staff should intervene when she is noted to be doing this. The failure was for the CNA to stay with the resident during HS (hour of sleep) care in the bathroom as she was using her walker . Review of CNA's A's typed post-fall interview, completed by the Director of Nursing (DON), on 3/8/18, read, in part: (CNA A) confirmed that he had assisted resident into her pajamas and then to the bathroom to use the toilet and brush her teeth .he left her in there as he has always done at HS .she had her walker with her. He added that he had just checked careplan after she was found on the floor and noted that it was changed today to have assist of one. He states he was not aware of the change today, and he confirmed that he had not read the Here's The Scoop book yet today . Review of Resident #1's roommate's witness statement (interview), completed by the DON, on 3/8/18, read, in part: .roommate is alert and oriented. (Roommate) saw (CNA A) assist (Resident #1) to the bathroom and then leave the room .confirmed .nobody else had come in their room between (CNA A) leaving and (Resident #1) calling for help. Review of a Disciplinary Action Notice, dated 3/8/18, for CNA A revealed the following, in part: Work Rule Violation(s): (CNA A) did not follow residents careplan and did not check the here's the Scoop book for changes to careplans. Explanation of the Incident: (CNA A) left resident (Resident #1) in the bathroom unattended. She is to ambulate with assist of 1 or use a walker or wheelchair according to careplan changed earlier today. Resident (#1) fell while in bathroom . Review of the Resident Status Sheets for Resident #1 revealed two separate sheets dated 3/8/18. Both Resident Status Sheets read, in part: .If seen walking, ensure safety and provide wheelchair .Locomotion: Amb (ambulation) 1 Asst. (assist), Wheel Chair .Transfer: Will attempt Independent (highlighted, but unchecked), Assist of 1 (checked and highlighted). Resident #1 was observed on 3/28/18 at 2:20 p.m. sleeping on her left side/back in bed. On 3/28/18 at 2:50 p.m. Resident #1 was repositioned, onto her right side by CNA D and Licensed Practical Nurse (LPN) O. Review of Resident #1's active (3/29/18) Resident Status Sheet, present in the Here's the Scoop book, and inside Resident #1's closet, revealed Resident #2 required Assist of 2 for toileting, transfers, and bed mobility, reposition every hour, and hip precautions with rolling side to side. Interviews with Unit Coordinator/Registered Nurse (RN) B and Quality Achievement/RN C on 3/29/18 at 10:45 a.m. confirmed both of Resident #1's Resident Status Sheets (plan of care), dated 3/8/18 had been completed prior to Resident #1's fall at 6:15 p.m. RN C confirmed Resident #1 was an Assist of 1 transfer status, and stated, We didn't want (Resident #1) toileting herself. Both RN B and RN C agreed If seen walking, ensure safety and provide wheelchair was added on 3/8/18 during day shift with changes highlighted and placed in the Here's the Scoop book for staff review. On 3/29/18 at 3:50 p.m. the Nursing Home Administrator (NHA) confirmed CNA A had left Resident #1 standing alone in the bathroom to perform HS oral care. The NHA stated, If he (CNA A) had known she (Resident #1) was standing brushing her teeth, he should have stayed with her . The NHA confirmed Resident #1's Resident Status Sheet had been updated on day shift, on 3/8/18, and CNA A had not followed the updated plan of care.

Based on observation, interview and record review, the facility failed to supervise and prevent the elopement of one (#103) of three cognitively impaired mobile residents with dementia reviewed for safety awareness from a total sample of 4 residents. This deficient practice resulted in Resident #103 being outside in inclement weather, with area temperature of 15 °F (degrees Fahrenheit), and ambulating without assistance or supervision during the evening hours of 1/19/16, placing Resident #103 in immediate jeopardy to her health and safety, and at high risk for injury, serious harm or death. The Immediate Jeopardy began on 1/19/16 at approximately 7:14 p.m., when the facility was notified via another resident (#102) who reported to Registered Nurse (RN) F that Resident #103 was outside the building. According to the facility report, Resident #103 eloped from the facility on the early evening of 1/19/16 by going through a hallway door, which did alarm, but failed to continue alarming, and was assumed by the staff to be the fire alarm (under maintenance at the time). Resident #103 then propelled herself in her wheelchair to the employee exit, where she exited the building without her wheelchair, descended 18 steps, while wearing no outer winter coat or boots/shoes, which placed her in immediate jeopardy to her health and safety. The Administrator was notified of the Immediate Jeopardy on 1/21/16 at 3:30 p.m The Immediate Jeopardy was removed on 1/21/16 at 5:42 p.m., when the Administrator and Director of Nursing completed the following, confirmed by this Surveyor by observation and record review: 1.) an immediate head count following the discovery of Resident #103's elopement. 2.) Immediate inservice to all employees on duty 1/19/16 on the 3-11 shift. 3.) Written education was posted at the time clock, with required signature before any other staff could come on duty. All employees were notified of mandatory education before their next shift. 4.) The Code Red (fire drill) policy was reviewed and updated. 5.) The Code Red Drill Checklist was updated to include a signature for each door that needs monitoring. 6.) The Maintenance personnel were educated that if unable to re-set the alarms system post drill that all charge nurses are to be informed so that staff members remain on their assigned hall monitoring the exits. 7.) The care plans for all residents considered an elopement risk were reviewed to ensure an elopement care plan was in place and up to date. 8.) All residents with Code Alert devices had their device placement checked and function verified. 9.) All facility residents were re-assessed for elopement risks. No other residents were identified to have a change in their elopement risk with a need for a code alert device. 10.) A fire drill was conducted on 1/21/16 at 13:35 (1:35 p.m.) to ensure all staff responded correctly to the education presented and the check list was completed appropriately. 11.) The second alarm at the exits (red magnetic boxes) had all the batteries replaced on 1/12/16 at 15:15 (3:15 p.m.). Batteries will be routinely changed(every 6 months, unless it is determined more frequent changing is needed) by maintenance personnel and this will be documented on the weekly check list for the door surveillance. During the weekly exit door surveillance maintenance personnel will test this second alarm to ensure it alarms continuously until it is reset with a key. Although the Immediate Jeopardy was removed, the facility's noncompliance with F323 continued at an isolated level with the potential for more than minimal harm pending: 1.) The Administer and the Director of Nursing will be present for the next 3 fire drills to ensure the maintenance personnel and all other staff members follow the protocol for monitoring door exits. 2.) The Nurse Educator will provide an in-house inservice within the next 3 months for all staff to review the fire drill procedures once again. 3.) The Administer or designee will review the weekly exit door surveillance to ensure that testing is being completed and test the doors personally x 4 weeks to ensure compliance. 4.) The Administer or designee will review the exit door surveillance to ensure that batteries are changed timely. 5.) The results from the audits will be brought to the monthly QA meeting. 6.) The Administer is responsible for compliance. All the above corrections will be verified by the State Agency before the facility is deemed in compliance. Findings include: According to the face sheet, dated 1/20/16, Resident #103 is an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment, dated 11/8/15, Resident #103 scored a 9 on her Brief Interview of Mental Status (BIMS), reflecting moderately impaired cognition. Resident #103 needed one person assist for transfers, non-ambulatory in her room and one person assist in the hallway. A wheel chair was coded as her primary mode of locomotion. Her balance score revealed her walking ability and turning around were not steady, only able to stabilize with staff assist. On 1/21/16 at 9:00 a.m., the Administrator and Director of Nursing (DON) produced the following timeline of events for 1/19/16, including photos from the camera near the doors from which Resident #103 eloped: 18:43 (6:43 p.m.) A facility wide fire drill was conducted. Post fire drill the facility experienced difficulty resetting the system because of a faulty smoke detector over the nurses station. Multiple times in the next 45 minutes the alarms sounded and the fire doors shut and the exit doors would disengage. 19:20 (7:20 p.m.) (Resident #103) Observed on camera at employee exit door. Fully dressed. Long sleeve shirt, long pants, socks. 19:21 (7:21 p.m.) Observed on camera exiting through the door. 19:23 (7:23 p.m.) No longer able to be seen standing at the exit door. 19:27 (7:27 p.m.) Observed on camera being assisted back into the building by maintenance (Staff H). 19:30 (7:30 p.m.) Assessment began of resident (#103). Blankets applied and warm packs to abdomen and armpits. Vitals, oxygen sat(uration), glucose obtained. No injury noted On 1/21/16 at approximately 1:00 p.m., the Administrator, DON and Registered Nurse (RN) I conducted a re-enactment of the elopement by Resident #103. The Administrator was in a wheelchair and waited for the door alarm (15 Seconds) to elapse (this was not an issue for the original elopement as the fire alarm continually disengaged the 15 seconds of alarm), allowing the door to be opened when pushed, and proceeded out the 200 hall way door. On the top left hand side of the door was a red magnetic alarm box, the alarm rang for approximately 10 seconds or less. This alarm failed to continually sound when the 200 hallway door was open. The Administrator confirmed the alarm should have continued to sound till the door shut, or a staff member used a key to disengage it. The Administrator, DON and RN I tested the 300 hallway door. After the 15 seconds of alarm the door released, the red magnetic alarm initially sounded, approximately 10 seconds or less, and then failed to continue alarming while the 300 hallway door was open. An interview was conducted on 1/21/16 at 4:01 p.m. with Certified Nurse Aide (CNA) E. CNA E verified he was working the afternoon shift of 1/19/16 when the fire drill and elopement took place. He stated that the fire alarms were ringing what seemed to be over a half hour. CNA E stated he would open up the double fire doors and then they would shut again, I would look out into the hallway to see what was going on. I didn't really see (Resident #103) in the hallway but there was so much commotion going on. I was right in room 208 (room next to exit door) and I never heard any alarm except the fire alarm going on and off. To me the Red Box alarm sounds exactly the same as the fire drill alarm. CNA E was told the results of the Red Box alarm test and failure of the alarm to continuously ring when the door was open. He stated Well no wonder I didn't hear it go off. During an interview with RN F via phone on 1/21/16 at 4:44 p.m., she stated she was alerted to the elopement by Resident #102, who reported she saw a resident outside the building who was trying to get back in. RN F stated she and Maintenance staff H exited two different doors to search for the resident, and RN F was the first to reach Resident #103. Regarding Resident #103's location, RN F stated she was found on hands and knees in the snow. ( )