Every finding on record at Beaver Dam Health Care Center

Based on interviews, record review, and policy review, the facility failed to ensure quality of care for 2 residents (R1 and R6) reviewed for timely care and services out of a total sample of 10 residents. The facility failed to ensure R1 and R6 received timely follow-up assessments and treatment related to a potential change in conditions after a reported injury for R1 and reported fall for R6. Findings include: Review of the facility's policy titled, Acute Condition Changes-Clinical Protocol last revised March 2026 indicated, The physician will help identify individuals with a significant risk for having acute changes of condition during their stay. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status.The nursing staff will contact the physician based on the urgency of the situation.The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status.The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. If necessary, the physician will order diagnostic tests and evaluate the patient directly.The physician will help identify and authorize appropriate treatments .If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, Emergency room, or another appropriate setting.The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized.The physician will make interim visits as needed to assess the situation. 1. Review of R1's admission Record located under the Profile tab of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy, chronic obstructive pulmonary disease, epilepsy, and vascular dementia. Review of R1's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/26, indicated a Brief Interview for Mental Status (BIMS) score of fourteen out of 15, which indicated R1 had no cognitive impairment. The MDS documented that R1 had not rejected care. R1 required partial/moderate assistance to roll left and right, and substantial/maximum assistance for sit to lying and lying to sitting on side of bed. Review of R1's Care Plan initiated on 04/02/26 in the EMR under the Care Plan tab indicated, the resident .sometimes have behaviors which include refusing medications and treatments.I am sensitive to being moved and can perceive cares to be rough. Interventions:.Explain all procedures to the resident before starting and allow resident to adjust to changes.give resident personal space.make sure I am not in pain or uncomfortable. Revised on 05/26/26, interventions included to Notify resident that you are about to move a part of his body before moving them. Explain all cares prior to doing the cares. Cares in pairs. Review of the documentation reported to the State Agency on 05/24/26 revealed, R1 had reported, .on May 24, 2026, at approximately 8:38 PM that during the NOC (night shift) beginning May 23, 2026, and ending May 24, 2026, a CNA (Certified Nursing Aide) handled him in a rough manner while providing repositioning care in his room. The resident reported right shoulder discomfort associated with the interaction.The resident was subsequently evaluated at the hospital, where the clinical finding was a contusion. Review of the facility's investigation revealed, The facility cannot confirm that the CNA intentionally handled (R1) in a rough manner. However, there may have been a lack of communication that did not allow (R1) adequate time to prepare for the cares he was going to receive. The investigation contained a written statement from CNA1, dated 05/24/26, that read .as we were changing him he said his arm hurt, I rolled him as (CNA2) put the brief under him because he was hard to roll. The investigation contained a written statement from CNA2, dated 05/25/26, that read, We changed him, (CNA1) was not rough or unsafe with the roll.(R1) didn't express a lot of pain, just an ow as he was turned. (CNA1) and I changed him once more after that. He told me his arm hurt after he was turned the last time. (CNA1) came in, we changed him again and he said ow again. I did not witness anything unsafe, rough, or aggressive from (CNA1)'s turn. I told (Licensed Practical Nurse (LPN3)).arm hurt. The investigation contained a written statement from R1, dated 05/24/26, that read, Nurse asked resident at 4:22 PM why his right shoulder hurt, resident stated an old injury nothing new. Resident has been complaining of right shoulder pain throughout the shift. Nurse went into resident's room to do his nighttime medication, now resident is stating.there was a guy and female that was repositioning resident, girl didn't do anything but the guy was rough with me on purpose due to them having a disagreement. Record review revealed a Progress Note located in the Progress Note of the EMR, dated 05/24/26 at 5:54 PM, that Nurse gave resident morphine due to pain in his shoulder. Stated it is not new pain. Record review revealed an eINTERACT SBAR (Situation, Background, Assessment, and Recommendation) Summary for Providers dated 05/24/26 at 9:51 PM, that indicated a change in condition with increase L (left) shoulder pain. Primary Care Provider Feedback revealed that the Nurse Practitioner (NP) did not have any documented follow-up response to the SBAR. Record review of the Vitals and Pain Only Evaluation located in the Assmnts tab of the EMR, dated 05/24/26 at 10:04 PM, revealed R1's pain at 9:47 PM was a 6 out of 10, that this pain was a New Issue to the right anterior shoulder, was moderate and constant. No Clinical Suggestions documented. Record review revealed R1 was admitted to Hospice on 04/29/26 due to congestive heart failure. Record review revealed a Hospice Progress Note located in the Misc tab of the EMR, dated 05/27/26 at 9:08 AM, under the Comprehensive Pain Assessment, it was documented there was New onset of pain since last visit that was aching, shooting, intermittent and intensified with movement. The Hospice Registered Nurse (HRN) documented that .has right shoulder pain with movement, no pain while holding arm still. He reports that this happened one night when they came in to change him, the aid pulled on his arm. Facility NP ordered an Xray.NP wanted to send (R1) to ER for pain control, but facility said he is on hospice so not going to ER. Has not used any PRN (as needed) morphine for pain control, continues to use Tylenol and he reports that this is helpful. He does have full range of motion in his shoulder, does wince with movement, but continues to move it during visit. Review of an Xray report dated 05/27/26, revealed, Dissociation of the acromioclavicular joint (shoulder separation). Record review revealed a Progress Note located in the Progress Note of the EMR, dated 05/27/26 at 10:15 AM, that Xray report sent to NP and hospice team. NNO (no new order) at this time. Hospice to treat any pain with Morphine that is ordered and contact them if concerns. Record review revealed a Progress Note located in the Progress Note of the EMR, dated 05/28/26 at 12:53 PM, that .hospice saw resident this morning as resident requesting to disenroll. Record review revealed a Progress Note located in the Progress Note of the EMR, dated 05/28/26 at 1:08 PM, that Resident agreed to be sent out to the ER following discussion with NP about right shoulder x-ray results. Review of the Physician Progress Note, dated 05/28/26, read as R1 had .expresses desire to discontinue hospice care and seek emergency evaluation for right shoulder dislocation.right shoulder dislocation causing pain and limited movement. Record review revealed a Hospital Discharge Summary, located in the Misc tab of the EMR, dated 05/28/26, that documented Patient complaints of right shoulder pain that started this morning. No known injury. SNF (skilled nursing facility) states that they had an Xray done this morning and it was dislocated.Reported by nursing staff pain started today when rolling him but patient reports that has been going on for a number of days.There was conflicting reports where patient stated that somebody had injured him however staff reported that they tried rolling him and injured it then. We repeated x-rays and showed just some degenerative changes with no evidence of dislocation. Record review revealed that R1 complained of increased pain after repositioning was provided during the morning hours of 05/24/26. The facility reported and investigated the allegation. Although there was a change in condition with the resident's level of pain as identified in the written staff statements, the 05/24/26 SBAR and the 05/24/26 Vitals and Pain Only Evaluation, the facility was unable to determine a direct correlation with poor care and services provided by CNA1 or CNA2. The facility failed to address a change in condition timely, to inform the NP of a change in pain level and movement, and to follow their recommendation until an Xray result was returned three days later indicating a possible shoulder dislocation. Hospital documentation also revealed that the facility informed the hospital that the resident had not been complaining of a change in pain until the day of admission to the ER, when the resident record identified this change of condition on 05/24/26. During an interview on 08/11/26 at 5:18 PM, CNA1 said that he had worked the third shift with CNA2 and had gone into R1's room to change him. CNA1 said that when they were done they asked R1 if he needed anything and that was when he told them that his shoulder hurt. CNA1 said he only recalled the resident telling him his shoulder hurt after care was provided, and that normally he didn't complain of pain during repositioning. CNA1 said the resident was not a two person reposition at that time, but CNA2 was helping that night, so they did it together. CNA1 said that they told the nurse. He said it had been the last reposition for that shift. He said he was told that the resident had filed a complaint just against him, so he went home so they could investigate. CNA1 said he received education to ensure R1 was awake and understood what care was being provided to him, and that we would always have two people assist him. During an interview on 08/11/26 at 5:36 PM, CNA2 said that she recalled R1 was harder to roll, so she went in to assist in providing care. CNA2 said that she did not recall R1 saying anything at the time. She stated that about two hours later he said his shoulder was hurting, and asked for Tylenol, so that was when she told the nurse. CNA2 said that she was not usually working on that unit and did not know the resident well. She said she is aware that he requires two people to assist with his care now, to make sure he is ok. During an interview on 08/12/26 at 8:00 AM, R1 said that there were two CNAs in his room providing care, and he felt CNA1 was too rough with him. He could not recall if he told the CNAs that it was hurting more or not when they repositioned him, or if his level of pain had changed after the incident. R1 said he remember that he informed the facility later that same day that had happened. R1 confirmed that he had to wait multiple days for an Xray and follow-up, and he did not know why there was such a long delay. He said he had wanted the Xray to be done much sooner than it had been. R1 said he still had some aches in his arm but had no current concerns with care provided by the staff. During an interview on 08/12/26 at 10:45 AM, HRN (Hospice Registered Nurse) said that she had worked with R1 while he was on hospice. HRN said the resident had pain in his shoulders for years. She confirmed that he had said something about his shoulder after the incident but could not recall the story. HRN said that if there is a possible change in condition, normally they would call hospice first, and in-house staff. She confirmed that the NP had wanted R1 to go to the ER, so HRN came and assessed the resident before they sent him out. She said that was when he wanted off hospice, so they discontinued his hospice care. HRN confirmed that the day he was disenrolled from hospice was the day he went to the hospital. During an interview on 08/12/26 at 1:53 PM, the NP said that she had gone to R1's room and he complained of his shoulder being sore and that a CNA had been too rough. He could not recall who, just that it happened. NP said that she ordered an Xray and it was believed that it was dislocated. The ER got another Xray and found no dislocation. It was very sore. The NP stated that what got him off of hospice services was because she wanted him to go to the hospital to be seen for his pain. She said she had to be stern with everyone. The NP confirmed that she had not been told about the resident's shoulder pain because hospice had said he was fine. She restated that a resident could have palliative care for pain. She stated that the day she found out was the day he disenrolled and she had him go to the hospital. During a concurrent interview on 08/12/26 at 5:39 PM, the Administrator and Director of Nursing (DON) confirmed that they had received a call that R1 had stated that CNA1 had been a little rough with him during care. They stated that they suspended CNA1 during the investigation. The Director of Nursing said that they had reached out to HRN to see if they knew anything, and they were told that HRN had stated that his pains were not new. The investigation revealed that it was possible CNA1 had touched R1's already painful shoulder but had not been neglectful. They confirmed that staff were educated to make sure they were extra gentle about what care was being done, and to communicate better. They could not find any indication of noncompliance with care for R1. The Director of Nursing said that the HRN did not want R1 to go to the hospital since he had stated in the past he had not wanted to go again, so they did the Xray at the facility. He said that they did request it immediately. They confirmed that if there was a change in condition, they wanted to see that documented the same shift. 2. Review of the facility's policy titled, Falls-Clinical Protocol last revised March 2026 indicated, The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the event.Falls should also be identified as witnessed or unwitnessed events.For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Review of R6's admission Record located under the Profile tab of the EMR revealed that R6 was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy, chronic obstructive pulmonary disease, and fibromyalgia. Review of R6's admission MDS with an ARD of 08/03/26 indicated a BIMS score of 11 out of 15, which indicated R6 had moderate cognitive impairment. The MDS documented that R6 had not rejected care. R6 required partial/moderate assistance for toileting hygiene and toileting transfer. R6 required supervision/touching assistance to roll left and right, to sit to lying, and lying to sitting on side of bed. Review of R6's Care Plan initiated on 07/27/26 in the EMR under the Care Plan tab indicated, the resident was At risk for falls related to weakness, unsteady gait, other physical limitations, and need for staff assistance. Interventions:.Keep personal items within reach. Nonskid socks/slippers. Keep environment well-lit and free of clutter. Call light and personal items available and in easy reach. Encourage participation in activities to improve strength or balance. Encourage rest periods if feeling fatigued. Record review revealed a Post Fall Evaluation, located in the Assmnts tab in the EMR, dated 07/30/26 at 2:04 PM, stated R6 had an unwitnessed fall on 07/29/26 at 3:30 AM, walking to the bathroom. The reason for the fall was due to dark lighting. The resident was noted, fall and leg pain and the NP was notified on 07/31/26. The form documented that a fall was triggered on 07/28/26 due to an Incident (Fall: Ambulating) with no additional follow-up. This Post Fall Evaluation was initially incomplete, with the recorded details added on 08/10/26 at 3:07 PM by the Director of Nursing. Record review revealed a Progress Note, located in the Progress Note tab in the EMR, dated 07/30/26 at 2:38 PM, that Resident reporting that she had a fall 2 days ago at around 3:30 AM. Resident stated that she was walking to the bathroom and lost her footing causing her to fall. Resident stated that she hit her leg when she fell. Denies hitting her head. Denies any other pain. Able to move extremities at baseline. Resident Right lower leg had a pinpoint scab. No redness bruising or deformities noted. NP notified. X-ray ordered for right lower extremity. Resident notified and agreed. Record review revealed an eINTERACT SBAR Summary for Providers located in the Assmnts tab in the EMR, with an effective date of 07/31/26 at 2:03 PM. The document stated, The Change in Condition/s reported on this CIC (Change in Condition) Evaluation are/were: Falls. The document stated that the provider was notified on 07/30/26 at 2:00 PM. The document's created date was 08/10/26 at 2:37 PM by the Director of Nursing. Record review revealed a Progress Note, located in the Progress Note tab in the EMR dated 07/30/26 at 7:06 PM from a physician visit that failed to document any follow-up regarding the identified fall, nor that a physician order had been placed for an X-Ray. Record review revealed a Progress Note, located in the Progress Note tab in the EMR dated 07/30/26 at 9:43 PM, that No issues with fall from 2 days ago, up and around with walker, neuros wnl (within normal limit). Record review revealed a Progress Note, located in the Progress Note tab in the EMR dated 07/31/26 at 2:00 PM, that .Give PRN (as needed) Percocet, as requested. Effective.Xray completed as ordered. Awaiting report. Record review revealed a 07/31/26 X-ray of the Right Tibia and Fibula which revealed, No evidence of fracture or dislocation. Record review revealed a Progress Note, located in the Progress Note tab in the EMR dated 08/05/26 at 9:32 AM that, Xray results sent to the provider and NNO (no new order) at this time. Record review of R6's documentation revealed on the Post Fall Evaluation that an Incident (Fall: Ambulating) was noted on 07/28/26, and the Progress Note on 07/30/26 at 9:43 PM, also documented that the fall had occurred two days prior on 07/28/26. However, the facility documented that the NP was not notified until 07/30/26 on the eINTERACT SBAR, and the form was not completed until 07/31/26. The Post Fall Evaluation also documented that the NP was not notified until 07/31/26. These discrepancies, including the delay in the completion of the X-ray on 07/31/26 (with no dated physician order found) and the follow-up not provided to the physician until 08/05/26, revealed a delay in response to a change in condition related to R6's unwitnessed fall. Review of a facility document titled, Three Step Employee Memorandum, dated 07/31/26, revealed that, On 07/29/26, (R6) had a fall which she got herself up and told staff about the fall later. (LPN1) did not document fall, notify provider, or assess. During an interview on 08/11/26 at 9:25 AM, the Administrator confirmed that LPN1 had failed to report the fall timely. During an interview on 08/12/26 at 1:10 PM, R6 stated that she had fallen on the night shift after she had been admitted , in the early hours of 07/28/26. She said the nurse had gone into her room to provide her with a nebulizer treatment earlier in the shift, and a little later the resident said she had gotten up and had fallen. R6 said she had told the nurse on that same shift that she had fallen, and the nurse had told her that she was fine and should go back to bed since it was still early morning. R6 stated that it was days later when anyone addressed the problem or did an Xray. She said no one came to talk to her about it, and she had a bruise and her leg hurt enough for the Xray. The resident lifted her leg and displayed the small red scab and slight bruise to the right shin that was still visible. She said she had never been told the results of the Xray, but figured that since they never said anything, it must have been ok. R6 said that she was frustrated that no one had come to talk to her about it for many days. During an interview on 08/12/26 at 1:53 PM, the NP confirmed that she had received a call a few days after R6 had fallen. The NP stated that the information had not been relayed to her. She said that once she had been made aware of it, she had ordered a Xray. There were no fractures or major concerns found. The NP said that the resident did have a scab on her shin and had told her that it was sore. The NP said that if a resident had a fall after 5:00 PM or weekends, the after-hours group would get notified. The NP confirmed that there was not a good way to communicate with the outside/off-hours physician group. She said that when she was not on call, the charting was so important for the physicians and NP, or they would not really know what happened. She said that when she returns on Mondays, she talks to the nurses to get updates and relied on those conversations. The NP said that it was hard to find out what the outside/off-hours physician group did on the weekends. During an interview on 08/12/26 at 2:17 PM, Licensed Practical Nurse (LPN) 3 said that if a resident had a fall, it was important to assess for injury, start neurological assessments, to notify the physician or NP, do a change in condition form, a risk management form, and complete a fall intervention form. LPN3 said it was important to report immediately, and document it in the EMR. On the weekends and on weekdays after 5:00 PM, they used an off-hours agency, and would inform them and the Director of Nursing, not the physician or NP. LPN3 said that at the beginning of the week the NP and physician could go into the EMR and see the off-hour agency's notes and get informed by the managers. LPN3 said she assumed the managers would give the NP and physician the footnotes. During a concurrent interview on 08/12/26 at 5:39 PM, the Administrator and Director of Nursing (DON) said that after there is a resident fall, they wanted to see resident vitals taken, for the provider to be notified, and for any orders to be input into the EMR. The Director of Nursing said that he wanted to be made aware and they should contact him. He confirmed that he wanted to see the incident documented as soon as it was reported. They confirmed that with R6's fall, there had been a delay in documentation and the follow-through with the investigation.

Based on observation, interview and record review, the facility did not ensure that they established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and conduct an annual review of its IPCP and update their program, as necessary, this has the potential to affect the census of 75. The facility does not have the IP (Infection Preventionist) on their Water Management Team. The facility has not reviewed all their infection control Policies and Procedures annually. Nurse did not clean the rubber cap of the insulin pen with alcohol before attaching the needle when administering insulin to R36. The facility failed to follow standards of practice during wound care for R1. This is evidenced by: Example 1 In reviewing the facility's Water Management Program, the Team documented as of August of 2025 is the NHA (Nursing Home Administrator) and the Director of Maintenance. On 5/14/26 at 4:01 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C if she is part of the Water Management Program team, ADON/IP C stated, I am not at this point. On 5/14/26 at 4:58 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if he would expect the IP to be part of the Water Management Program team, DON B said yes. Example 2 In reviewing the facility's Infection Control Policies, their Legionella Surveillance Policy and Procedure is dated 10/1/19 and their Hand Hygiene/Handwashing Policy is dated 2023. On 5/14/26 at 4:01 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C how often their infection control policies are reviewed, ADON/IP C said annually. Surveyor asked ADON/IP C if these should have been reviewed, ADON/IP C said yes. On 5/14/26 at 4:58 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if all infection control policies should be reviewed annually, DON B replied yes. Surveyor asked DON B if there is documentation of the Hand Hygiene/Handwashing and/or Legionella Surveillance policies reviewed in the facilities QA (Quality Assurance) Program, DON B said no, I don't think so. Example 3 LPN M (Licensed Practical Nurse) failed to clean the rubber cap of an insulin pen before attaching the needle when administering insulin to R36 during observation of the medication administration task. Surveyor requested a facility policy for insulin administration. The facility provided a policy titled Injectable Medication Administration, effective 10/25/14. The policy does not provide detailed instructions for insulin pens. Instructions for administering insulin using a NovoLog FlexPen, according to the company's website, are as follows: Step 1. Getting NovoLog FlexPen Ready: Start by washing your hands with soap and water. Then, pull off the pen cap and wipe the rubber stopper with an alcohol swab. Step 2. Attaching the NovoFine 32G Tip Needle: Take a new disposable needle and remove the protective tab. Screw the needle tightly onto your NovoLog FlexPen. (https://www.novolog.com/taking-novolog.html). R36 admitted to the facility on [DATE]. R36's physician orders included the following, in part: NovoLog FlexPen Subcutaneous Solution Pen Injector 100 unit/mL (Insulin Aspart) Inject 22 unit[s] subcutaneously in the afternoon related to type 2 diabetes mellitus with diabetic neuropathy.with lunch (Order Date: 1/5/26). On 5/18/26 at 11:23 AM, Surveyor observed LPN M preparing R36's insulin for administration. LPN M completed hand hygiene, checked the expiration date on the insulin pen, removed the cap from the insulin pen, and attached the needle to the rubber stopper of the pen. After LPN M had completed R36's insulin administration, Surveyor asked LPN M if she typically cleans the end of the insulin pen before attaching the needle. LPN M indicated she was never taught to do that, but she is willing to learn if she did something wrong. On 5/19/26 at 2:15 PM, Surveyor discussed the missed insulin pen cleaning during medication administration with DON B (Director of Nursing). DON B agreed that the insulin pen should have been cleaned with an alcohol swab before the needle was attached. Example 4 The facility policy titled Wound Care, with last revision date of April 2026, indicates in part: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote wound healing. Steps in the Procedure:. 4. Establish clean field on resident's overbed table. 5. Place all items to be used during procedure on the clean field. On 5/19/26 at 8:27 AM, Surveyor observed wound care for R1 with ADON D (Assistant Director of Nursing) and WP L (Wound Physician). Surveyor observed ADON D prepare to clean the wound by propping R1's foot up on a pillow. Surveyor observed ADON D remove a piece of wet gauze from a cup and drop it onto the pillowcase. Surveyor observed ADON D pick the wet gauze up from the pillowcase and use it to clean R1's wound. After the wound care was completed, ADON D removed the pillowcase and returned the pillow to R1's bed. ADON D provided education to R1 on reducing smoking to promote wound healing and the importance of keeping his feet elevated. On 5/19/25 at 12:51 PM, Surveyor interviewed ADON D. Surveyor asked ADON D about R1's wound care observation earlier today. ADON D stated that she put the pillow under R1's foot because the foot rests on his wheelchair are metal and she didn't want to cause discomfort so she put the pillow under his foot. ADON D stated that she had taken the pillow off R1's bed. Surveyor asked about sterile and clean fields during wound care. ADON D stated that no wound care in the facility would be sterile but that it's all performed in a clean field. Surveyor asked ADON D if the wet gauze being dropped on the pillow taken from R1's bed and then used to clean his wound could be considered cross contamination. ADON D indicated yes, it could be. On 5/19/26 at 3:52 PM, Surveyor interviewed DON B (Director of Nursing) about R1's wound care. Surveyor asked DON B if he would expect staff to perform wound care in a clean field. DON B indicated yes, that is his expectation.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 75 residents who reside in the facility.Items in the refrigerator were improperly dated.Findings includeOn 5/13/2026 at 9:49 AM, Surveyor observed the following in the facility's main kitchen refrigerator:*9 nutritional shakes with dating that states thawed 4/28/26, use by 5/12/26. Of note, these nutritional supplements are stored in the freezer manufacturer recommendations printed on the shakes states the supplement is to be used within 14 days of thawing.*48 chocolate milks (8oz) with sell by date of 5/12/26.DM Q (Dietary Manager) stated at this time that she uses the sell by date as the use by date and stated they would be removed along with the nutritional supplements.

Based on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 4 of 5 residents (R6, R7, R4 and R8) reviewed for unnecessary medications. R6 is receiving Trazodone for insomnia, depression, and anxiety related to depression and did not have a sleep assessment/tracking completed for the insomnia diagnosis. R7 is receiving Melatonin for insomnia and did not have a sleep assessment/tracking completed. R4 is receiving antipsychotic medication and did not have a tardive dyskinesia (a neurological disorder characterized by uncontrollable, repetitive body movements) assessment completed. R8 is receiving antipsychotic medication and did not have a tardive dyskinesia assessment completed. Findings Include: The undated facility policy, Sleep Medication/Hypnotic Medication Monitoring Policy, indicates, in part: .Procedure.2. A sleep log will be initiated and completed for a minimum of three (3) consecutive days to monitor sleep patterns, frequency of awakenings, behaviors impacting sleep, daytime fatigue or lethargy, and effectiveness of interventions. The facility's policy Tardive Dyskinesia Monitoring Policy, dated 1/26, includes; The facility will monitor residents receiving antipsychotic medications and other medications associated with movement disorders for signs and symptoms of tardive dyskinesia to ensure early identification, timely intervention, and resident safety in accordance with CMS (Centers for Medicare and Medicaid Services) regulations and accepted standards of practice. 1. Residents receiving antipsychotic medications or other medications associated with tardive dyskinesia will be monitored for abnormal involuntary movements. 2. Monitoring will include completion of an AIMS (Abnormal Involuntary Movement Scale) assessment or other approved assessment tool at least every six (6) months and as needed. Example 1 R6 was admitted to the facility on [DATE] with diagnoses that include, in part: Insomnia, Major Depressive Disorder, and Generalized Anxiety Disorder. R6's physician orders include, in part: Trazadone 50mg oral tablet. Give 1.5 tablets by mouth at bedtime for Insomnia, depression, anxiety related to depression. Start date: 1/30/26. R6 did not have sleep assessment completed related to trazadone use. Example 2 R7 was admitted to the facility on [DATE] with diagnoses that include, in part: Insomnia. R7's physician orders include, in part: Melatonin 3mg tablet. Give 2 tablets by mouth one time a day for Insomnia. Start date: 3/3/26. On 5/19/26 at 2:48PM, Surveyors interviewed DON B (Director of Nursing). During the interview DON B indicated usually they would complete a sleep pattern form that is either for one night or three, he will have to review this to be sure of the length. DON B indicated that if they are admitted to the facility on a sleep medication the sleep assessment should be completed right when they come in. If a new order is placed for a current resident, it should be completed when it is started. DON B indicated that anyone that has a medication that says it is for sleep should have an assessment. DON B indicated he would expect that sleep assessments were completed for R6 and R7 and they are still working on finding them. On 5/19/2026 at 4:58PM, DON B informed surveyors they do not have the sleep assessments for the residents requested. Example 3 R4 was admitted to the facility on [DATE] with diagnoses including mood affective disorder, and severe agitation. R4 has a physician order, dated 4/19/26, quetiapine fumarate (an antipsychotic medication) oral tablet 100 mg, give 2 tablet by mouth three times a day. R4 does not have a tardive dyskinesia assessment completed. On 5/19/26 at 2:48 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated tardive dyskinesia assessments should be completed on admission and every 6 months after and at the start of an antipsychotic or any dose changes. DON B indicated R4 should have had a tardive dyskinesia assessment completed and did not. Example 4 R8 was admitted to the facility on [DATE] with diagnoses including panic disorder, persistent mood affective disorder, psychotic disorder with delusions, and psychotic disorder with hallucinations. R8 has the following physician orders:Quetiapine fumarate 100 mg, give 1 tablet at bedtime, start 12/12/25.Quetiapine fumarate 25 mg, give 1 tablet by mouth one time a day QAM (Every AM), start 1/13/26.Quetiapine fumarate 25 mg, give 2 tablet by mouth in the afternoon, start 5/15/26. R8 does not have a tardive dyskinesia assessment completed. On 5/19/26 at 2:48 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated tardive dyskinesia assessments should be completed on admission and every 6 months after and at the start of an antipsychotic or any dose changes. DON B indicated R8 should have had a tardive dyskinesia assessment completed and did not.

Based on interview and record review the facility failed to ensure each resident had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 of 22 sampled residents (R53) and 1 of 1 supplement Residents (R9) reviewed for advance directives. The facility did not have guardianship paperwork on file for R9.The facility did not have a Do Not Resuscitate (DNR) form on file for R53 to match his wishes.This is evidenced by:The facility policy, titled Residents' Rights Regarding Treatment and Advance Directives, dated [DATE], states, in part: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.Policy Explanation and Compliance Guidelines:. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on [sic] the chart as well as communicated to the staff.7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.Example 1R9 admitted to the facility on [DATE] enrolled in hospice care with diagnoses that include, in part: cerebral palsy (brain condition that affects muscle control, movement, and coordination), quadriplegia (paralysis of all four limbs), and epilepsy (neurological condition with frequent, uncontrolled seizures). R9's face sheet indicated he had two activated guardians. Surveyor reviewed R9's advance directive information on file and noted he had an active DNR order signed by one of his guardians and his physician. No guardianship paperwork was located in his file. On [DATE] at 3:00 PM, Surveyor asked MR N (Medical Records) if she was able to locate any POA (Power of Attorney) or guardianship paperwork in R9's chart. MR N searched and was unable to locate any POA or guardianship documents on file for R9. MR N directed Surveyor to speak with Admissions O. MR N indicated Admissions O works with new admissions and handles POA documents. These documents are given to MR N and she scans them into the resident's medical record and keeps a paper copy as well.On [DATE] at 4:22 PM, Surveyor spoke with Admissions O. Admissions O indicated the facility's process is to request POA or guardianship documents immediately upon admission. Surveyor asked about R9. Admissions O indicated R9's guardianship documents should be in his file. Admissions O said she would check R9's file and would request these documents from his hospice agency if the facility did not have them. On [DATE], Surveyor reviewed R9's file and confirmed R9's hospice agency had faxed his guardianship paperwork to the facility, and the facility had uploaded it to his medical record. On [DATE] at 2:15 PM, Surveyor discussed the facility's issue with advance directives with DON B (Director of Nursing). DON B indicated he had been made aware of the issue. Example 2 R53 admitted to the facility on [DATE]. R53's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], shows R53 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R53 has moderate cognitive impairment. R53's face sheet indicated he did not have an activated HCPOA (Health Care Power of Attorney) or guardian. On [DATE], the banner on top of R53's Electronic Health Record (EHR) stated Do Not Resuscitate (DNR) with a DNR physician's order dated [DATE]. R53 did not have a copy of a signed Emergency Care Do Not Resuscitate Order (DNR) on file. R53 had a cardiopulmonary resuscitation (CPR) directive on file signed by R53 and a witness on [DATE] and a physician on [DATE]. There were no notes in R53's electronic file indicating that he had wished to change his advance directive order from full code to DNR. On [DATE] at 11:57 AM, Surveyor interviewed LPN M (Licensed Practical Nurse) and asked where she would look to find a resident's code status. LPN M indicated she would look in the miscellaneous tab in a resident's file to find his or her signed advance directive. LPN M indicated she would occasionally look at the banner on the front page of a resident's EHR to find the code status. LPN M looked at R53's banner and indicated his code status was DNR. LPN M pulled up R53's CPR form in the miscellaneous tab of his file and indicated that full code was checked. LPN M said she completed that form with R53 when he was admitted to the facility. LPN M indicated, That's a problem that they don't match. On [DATE] at 12:51 PM, Surveyor interviewed ADON E (Assistant Director of Nursing) regarding R53's code status. ADON E indicated staff can look at a resident's banner to determine a code status quickly. ADON E pulled up R53's EHR and indicated his code status was DNR. ADON E pulled up R53's CPR form dated [DATE] and indicated that form didn't match his DNR order on [DATE]. ADON E indicated he should have a signed DNR form. ADON E indicated R53's HCPOA must have changed his code status. Surveyor asked if R53 had POA paperwork on file. ADON E could not find this paperwork and directed surveyor to MR N (Medical Records) to find R53's DNR form and POA paperwork. On [DATE] at 2:05 PM, Surveyor spoke with R53. R53 indicated he elected to be a full code when he first admitted to the facility but changed his mind and would like his code status to be DNR now. On [DATE] at 2:13 PM, Surveyor spoke with MR N. MR N indicated the facility does not have DNR paperwork filled out for R53. MR N indicated the facility has POA paperwork for R53 and it is not activated. On [DATE] at 3:15 PM, Surveyor spoke with ADON E. ADON E indicated she now remembered speaking with R53 previously about changing his code status from full code to DNR. ADON E said she informed the NP (Nurse Practitioner) who put the DNR order in, but ADON E forgot to have R53 complete the DNR election form. ADON E indicated this form should have been completed. ADON E indicated the facility just changed R53's code status to full code while they are working on completing his DNR paperwork. On [DATE] at 4:08 PM, Surveyor verified that R53's completed DNR form had been uploaded into his EHR. R53's physician order on file still indicated he was a full code.On [DATE] at 4:20 PM, ADON E indicated R53's code status order had been changed to DNR.On [DATE] at 4:22 PM, Surveyor spoke with Admissions O and asked about the facility's process for advance directive paperwork. Admissions O indicated the CPR or DNR form is completed by a nurse who admits the resident, but she is unsure of the process after that. Admissions O indicated she requested that she will work with the resident or POA to get the paperwork completed as soon as the resident is admitted to ensure the process is completed correctly, as it is important to get these documents in order.On [DATE] at 4:30 PM, Surveyor checked R53's physician order and it still said full code. At 4:32 PM, Surveyor interviewed MDS RN P (Minimum Data Set Registered Nurse). MDS RN P indicated he forgot to change R53's order, but he would do it now. At 4:41 PM, Surveyor verified that R53's physician order for his code status was DNR. On [DATE] at 2:15 PM, Surveyor discussed the facility's issue with advance directives with DON B (Director of Nursing). DON B indicated he had been made aware of the issue.

Based on interview and record review, the facility failed to ensure a resident (R11) is free from sexual abuse, from another Resident (R3). R3 was found performing sexual acts on R11. At the time of the event, the facility was unaware whether these two individuals had the capacity to consent to a sexual relationship.Findings includeThe facility's Abuse/Neglect/Exploitation policy states, in part, The facility's Abuse/Neglect/Exploitation policy states, in part, Sexual abuse is non-consensual sexual contact of any type with a resident.The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation or resident property, and exploitation that achieves.Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.Additionally, the facility's abuse policy states, Investigation of alleged abuse, neglect and exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.written procedures for investigations include: Identifying staff responsible for the investigation; Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigationR3 was admitted to the facility on [DATE] and has diagnoses of schizophrenia, mild cognitive impairment and bipolar disorder. Her most recent MDS (Minimum Data Set), dated 2/18/26, includes a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment.R11 was admitted to the facility on [DATE] and has diagnoses of vascular dementia. His most recent MDS (Minimum Data Set), dated 4/3/26, includes a BIMS (Brief Interview for Mental Status) score of 8 indicating moderate cognitive impairment.A facility incident report dated 3/27/2026 at 12:55 AM states Resident (R3) was found engaging in oral sex with another resident (R11). Nurse was looking for resident (R3) during rounding and found resident in another room. When door was opened, residents separated and both were cooperative with no signs of distress or injury. Residents were interviewed separately and stated that the acts were consensual and risks were discussed with both residents.Of note: The facility was unable to provide any documentation that R3 and R11 were assessed for capacity to consent to sexual relations before 3/27/26. The incident was not reported to the State Agency. The facility did not interview any other residents or staff other than the 3 that were working the night shift at the time of the incident. On 5/14/26, Surveyor interviewed RA W (Resident Assistant) at 9:52 AM, LPN M (Licensed Practical Nurse) at 9:30 AM, CNA Z (Certified Nursing Assistant) at 9:32 AM, CNA AA at 9:27 AM, LPN J at 11:31 AM and LPN X at 11:37 AM. All stated they were unaware that R3 and R11 had been in a sexual relationship, were unaware if they could consent and did not believe either should be in each other's rooms. On 5/14/26 at 11:12 AM, CNA S stated that she was working the night of the sexual encounter between R3 and R11. CNA S stated that she had heard that R3 could not be found but was not sure if there was a sexual encounter and she was never instructed on anything regarding the relationship between R3 and R11, and was unaware if they could consent to a sexual relationship. Additionally, CNA S indicated that staff are to follow the guidelines on their CNA Kardex (care plan) for guidance of resident cares. On 5/14/26 at 11:40 AM, CNA F stated she was aware of R3 and R11 having had a sexual encounter but she didn't ask for any details and was unsure what to do if they wanted to engage in sexual activity again.On 5/14/26 at 11:42 AM. CNA K stated that R3 and R11 are very close and she heard that R3 had been having oral sex with R11 in his (R11's) room. CNA K stated it was only talked about once and she was concerned if they could do this again, but DON B (Director of Nursing) stated that they (R3 and R11) are 2 consenting adults and staff need to give them privacy. CNA K stated there was no guidance on how to monitor or accommodate this.On 5/14/26 at 12:20 PM. CNA Y stated there was one incident when R3 went into R11's room and performed oral sex on him (R11). CNA Y stated that staff are just supposed to keep the door open and keep the room in view. R3 can go in R11's room but the door needs to stay open and they are not to engage in anything. CNA Y stated that she can not remember who gave her this guidance. It should be noted that neither R3's nor R11's Kardex (CNA care plan) indicated any approach, monitoring, or guidance for sexual relations. On 5/19/2026 at 9:13 AM, Surveyor interviewed DON B who stated that the facility did not have any other documentation on the incident of 3/27/26, nor did he interview other staff on other shifts regarding any other sexual incidents or activity between R3 and R11, or any other residents. DON B indicated they did not interview any other residents. DON B also stated they did not assess R3 or R11 for capacity to consent prior to 3/27/26. The facility was unaware if R3 or R11 could consent to a sexual relationship as they did not assess them for this capacity and therefore did not have a plan in place to accommodate their privacy for such a relationship or protect them from potential abuse. The facility did not put measures into place after the event to ensure continued monitoring or appropriate approaches for the relationship.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 2 incidents involving 3 residents (R3, R11, and R42). R3 was found performing sexual acts on R11 and the facility did not report the event to the State Agency. During a PM shift on 5/1/26, CNA S (Certified Nursing Assistant) and CNA T (Certified Nursing Assistant) reported to LPN U (Licensed Practical Nurse) that R42 has a black eye, an IUO (Injury of Unknown Origin). LPN U states CNA S and CNA T did not report R42's black eye. However, LPN U administered medication twice to R42 during her shift and did not note his black eye. LPN U failed to report and observe R42's black eye during her shift. Findings include: The facility's Abuse/Neglect/Exploitation policy states, in part, Sexual abuse is non-consensual sexual contact of any type with a resident.The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation or resident property, and exploitation that achieves.Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Additionally, the policy states, The facility will have written procedures that include: reporting of all alleged violations to the administrator, state agency, adult Protective Services and to all other required agencies within specified timeframes: immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve use or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. Example 1: R3 was admitted to the facility on [DATE] and has diagnoses of schizophrenia, mild cognitive impairment and bipolar disorder. Her most recent MDS (Minimum Data Set), dated 2/18/26, includes a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. R11 was admitted to the facility on [DATE] and has diagnoses of vascular dementia. His most recent MDS (Minimum Data Set), dated 4/3/26, includes a BIMS (Brief Interview for Mental Status) score of 8 indicating moderate cognitive impairment. A facility note, dated 3/26/26 for both residents states, Writer received a call from staff stating that Resident was engaging in consensual sexual intimacy with another resident. Residents separated when staff opened the door. Per staff, both residents appeared calm and were cooperative with no signs of injury, distress, or coercion. Additionally, a progress note in both R3's and R11's chart states, Writer and SS [name] at bedside with resident in regard to resident having oral sex with another resident. Resident alert and oriented at this time. Resident stating that sexual acts were consensual. Writer discussed risks of sexual acts including potential STD or infections. Resident stating she is aware of the potential risks involved. Also discussed with resident the risk of emotional distress if the resident who she was having sexual relations with decided to start having a relationship with someone else or another resident. Resident denies any concerns at this point. It should be noted that the facility did not have any assessments or knowledge of either resident's capacity to consent prior to 3/26/26. On 5/19/2026 9:13 AM, Surveyor interviewed DON B (Director of Nursing) who stated that the facility did not have any capacity to consent assessments before the 3/26 incident for either R3 or R11 and were unaware about their ability to consent. DON B also stated that they did not report the incident due to privacy reasons. Example 2: The facility's policy, Abuse/Neglect/Exploitation, states, in part, as follows: Reporting/Response: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury. The State Operations Manual under F600 states in part; 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 483.12(a) The facility must- 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. R42's Minimum Data Set (MDS) dated [DATE], indicates R42 scored 3/15 on his Brief Interview for Mental Status (BIMS) indicating he is severely cognitively impaired. R42 requires assistance of 1 for transferring, dressing, toileting, and hygiene. R42 was admitted to the facility 4/7/26 with diagnoses including, but not limited to, dementia with behaviors (a group of thinking and social symptoms that interferes with daily functioning; symptoms may include aggression, wandering, anxiety or delusions) and amnesia (the inability to recall past experiences). On 5/1/26 PM shift, the following three (3) staff were working together on the unit: CNA S (Certified Nursing Assistant), CNA T (Certified Nursing Assistant-Agency), and LPN U (Licensed Practical Nurse-Agency). CNA S and CNA T reported to LPN U that R42 has a black eye. LPN U did not report this potential allegation of abuse to the management team or any RN (Registered Nurse) for follow up. Furthermore, there is no documentation regarding R42's black eye on this date. On 5/2/26 AM shift, CNA K and CNA V observe the bruise to R42's eye. CNA K and CNA V report to ADON/IP C (Assistance Director of Nursing). ADON/IP C assessed R42 and passed the information along to the oncoming RN (Registered Nurse). On 5/2/26 at 10:46 AM, The RN (Registered Nurse) on duty documented, in part, the following Change in Condition assessment: Nursing observations, evaluation, and recommendations are: Resident (R42) has a bruise to left eye (black eye), skin intact (Note, based on staff statement R42's skin is not intact). ADON/IP C reported to DON B (Director of Nursing). DON B immediately initiated the reporting process to the State Agency and began investigating. DON B (Director of Nursing) documented the following typed statement for CNA S (Certified Nursing Assistant): I (CNA S) came on the unit around 4:00 PM and noticed that the resident (R42) had bruising on his face. I reported to the nurse (LPN U-Licensed practical Nurse) when I saw. DON B (Director of Nursing) documented the following typed statement for CNA T (Certified Nursing Assistant): I (CNA T) came onto the unit at 3:00 – 3:30 PM and noticed that the resident (R42) had bruising on his face. Resident (R42) stated that he was rubbing his eye. I reported to the nurse (LPN U-Licensed Practical Nurse) who stated that she was aware and resident (R42) stated he was rubbing and scratching his eye. DON B (Director of Nursing) documented the following typed statement for LPN U (Licensed Practical Nurse): I (LPN U) was the nurse on the unit on 5/1. I did not notice resident (R42) having a black eye. I was taking care of resident (R42) however resident (R42) was sleeping most of the day. Last saw the resident (R42) around 9:00 PM on 5/1. I did not get a good look at his face as when I was in his room helping him he was facing the other way. On 5/2/26 AM shift, the following three (3) people were working together on the floor: CNA K (Certified Nursing Assistant), CNA V (Certified Nursing Assistant) and ADON/IP C (Assistant Director of Nursing/Infection Preventionist). CNA K (Certified Nursing Assistant) documented the following handwritten statement: Today 5/2/26 me (CNA K) and CNA V (Certified Nursing Assistant) went into R42 and his roommate's room to get R42's roommate up for breakfast around 8:00 AM when we saw R42's huge black eye we asked R42 if he was okay and he seemed to be fine so we asked to changed [sic] his sheets because they [sic] were blood everywhere. He was hesitant but he agreed and stood on his walker. We told the nurse (ADON/IP C – Assistant Director of Nursing/Infection Preventionist) immediately because we thought it was a fall that has not yet been reported by [sic] R42 said otherwise. It was because of him rubbing it (his eye) too much it says. CNA V (Certified Nursing Assistant) documented the following handwritten statement: Today May 2, me (CNA V) and CNA K went into R42's room to get his roommate ready for breakfast around 8:00 AM when we noticed that R42 had a huge black eye and blood on his sheets. We asked him what happened he said nothing. He said he was okay. I (CNA V) asked to change his (R42's) sheets he hesitated because he said he wanted to keep sleeping but eventually he agreed. We immediately reported it to the nurse (ADON/IP C – Assistant Director of Nursing/Infection Preventionist) in case it hadn't been reported or seen. He stated that the bruise was from rubbing his eye. On 5/14/26 at 9:45 AM, Surveyor spoke with R42. Surveyor observed R42's left eye was still black and blue. R42 stated he thinks a fall may have caused his black eye (this is inconsistent with R42's earlier recollection of events). R42 stated, It's no big deal. R42 stated he feels safe at the facility. On 5/18/26 at 1:57 PM and 5/19/26 at 2:30 PM, Surveyor spoke with LPN U (Licensed Practical Nurse). Surveyor asked LPN U, during your shift on 5/1/26 did any staff report that R42 has a black eye. LPN U stated, No, I didn't' hear anything or see it when passing meds. LPN U stated, I didn't see anything on my shift, I gave him (R42) his medicine twice that shift and didn't see any black eye. Surveyor asked LPN U, did you receive a write up from the facility regarding this incident. LPN U stated, yes, she must tell management when she observes residents with bruises or anything happens. LPN U stated, I have to report it. Surveyor asked LPN U when you administered medication to R42 were the lights on. LPN U stated, yes. LPN U stated, R42 sat up partially in bed twice during her shift to take medication. On 5/19/26 at 9:20 AM, Surveyor spoke with CNA S (Certified Nursing Assistant). CNA S stated, when she arrived at the unit she saw R42's face. CNA S stated, that she and CNA T told LPN U (Licensed Practical Nurse) about the bruise to R42's face. CNA S stated, she might have even sworn she is not sure. CNA S added, we were so alarmed. CNA S stated, LPN U told her I don't know and left it at that when she asked what happened to R42's face. CNA S stated that R42's face was severely bruised. CNA S added, R42's face did not look swollen but it was badly bruised. Surveyor asked CNA S was R42 able to tell you what happened. CNA S stated, no, a lot of times R42 does not want to talk with us. CNA S stated, for example when we bring his meal tray he will tell us to get out. CNA S stated, R42 told her nothing happened. CNA S stated, that is when we went to LPN U (Licensed Practical Nurse). CNA S asked LPN U what happened to R42's face, he has a black eye. CNA S stated, LPN U told her, I don't know I haven't seen it. Surveyor asked CNA S if she wrote a statement following this incident. CNA S stated, yes, she provided the facility with a handwritten statement. CNA S stated, facility staff interviewed her. CNA S added, we (staff) don't type our statements. On 5/19/26 at 11:05 AM, Surveyor spoke with NHA A (Nursing Home Administrator). NHA A stated he is unable to locate the handwritten staff statements for this investigation. NHA A stated, the handwritten statements must have made it into the Shred-it box. On 5/19/26 at 3:43 PM, Surveyor spoke with CNA T (Certified Nursing Assistant). CNA T stated she and CNA S (Certified Nursing Assistant) entered R42's room on 5/1/26 PM shift to find R42 with a black eye. CNA T stated she and CNA S reported R42's black eye to LPN U (Licensed Practical Nurse). CNA T stated that LPN U did not respond to their concern. CNA T stated they (staff) do not care. On 5/19/26 at 11:55 AM, Surveyor spoke with ADON/IP C (Assistant Director of Nursing/Infection Preventionist). ADON/IP C stated, on 5/2/26 she worked from 6:00 AM-11:00 AM. ADON/IP C stated, on 5/2/26 around 9:00 AM CNA K (Certified Nursing Assistant) reported to her that R42 has a black eye and stated she was unsure how he (R42) got it. ADON/IP C stated it was close to the end of her shift. ADON/IP C stated, she reported to the oncoming staff. ADON/IP C stated it is not fun to transfer all that information to the next staff. ADON/IP C stated she went to check it out and talk with R42. ADON/IP C stated, R42 told her it was from rubbing his eye, his eyes are dry and he was rubbing it frequently. Surveyor asked ADON/IP C, to describe the bruising. ADON/IP C stated the bruise was from the inside of R42's left eye around the top and up to his forehead. Surveyor asked ADON/IP C if R42 falls is he able to get himself up off the floor. ADON/IP C stated, she has never seen him get up off the floor but she thinks he is capable of getting himself off the floor. ADON/IP C stated, we all thought this was a new IUO (injury of unknown origin). ADON/IP C stated, she reported this new IUO to DON B (Director of Nursing) and he went through the steps of reporting and forwarding the information to the oncoming nurse. On 5/19/26 at 1:45 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated, the bruising to R42's face was reported to him on 5/2/26 between 9:00-9:30 AM. DON B stated, CNA K (Certified Nursing Assistant) reported the bruising to ADON/IP C on the morning of 5/2/26. DON B stated, on 5/2/26 at 9:35 AM he called LPN U (Licensed Practical Nurse). LPN U stated to DON B that R42 was sleeping most of the PM shift on 5/1/26 and the last time LPN U saw R42 was around 9:00 PM. DON B stated, LPN U asked DON B if something happened. Surveyor asked DON B, did LPN U deny CNA S (Certified Nursing Assistant) and CNA T (Certified Nursing Assistant) reported R42's black eye to her. DON B stated, he is not going to lie he cannot recall. Surveyor provided DON B with a copy of the typed statement for LPN U. DON B reviewed the typed statement for LPN U. In the typed statement LPN U denied any knowledge. Surveyor asked DON B, when LPN U administered medication to R42 twice during the PM shift on 5/1/26 would you expect her to have observed R42's black eye. DON B stated, yes. DON B stated, when obtaining statements from staff we noted that staff were not looking at residents' faces. Surveyor asked DON B, was the facility looking at R42's IUO as potential abuse. DON B stated, absolutely, R42 stated it was from scratching his eye. DON B stated, he wants to make sure the facility is doing their due diligence. The facility contacted police regarding this IUO (injury of unknown origin). On 5/2/26 at 10:52 AM, a police officer documented in part, as follows: .Staff noticed the R42 had a black eye this morning. They did not know how this injury occurred. I (Officer) met with R42. He had a black left eye (discoloration of skin that was black and blue), and a quarter or so in size bruise to the left side of his head near his forehead that is also black and blue. R42 did not even realize this. R42 advised that he believed it was from itching his eye. It is not from that. LPN U (Licensed Practical Nurse) failed to report an IUO (Injury of Unknown Origin) to management. LPN U is required to report an IUO (Injury of Unknown Origin) immediately, but not later than 2 hours after the allegation is made, as the events that caused the allegation may have involved abuse or resulted in serious bodily injury.

Based on interview and record review the facility failed to have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. and failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 2 incidents involving 2 residents (R3 and R11). R3 and R11 were observed engaging in a sexual act and the facility did not conduct a thorough investigation.Findings includeThe facility's Abuse/Neglect/Exploitation policy states, in part, The facility's Abuse/Neglect/Exploitation policy states, in part, Sexual abuse is non-consensual sexual contact of any type with a resident.The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation or resident property, and exploitation that achieves.Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.Additionally, the facility's abuse policy states, Investigation of alleged abuse, neglect and exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.written procedures for investigations include: Identifying staff responsible for the investigation; Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigationR3 was admitted to the facility on [DATE] and has diagnoses of schizophrenia, mild cognitive impairment and bipolar disorder. Her most recent MDS (Minimum Data Set), dated 2/18/26, includes a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment.R11 was admitted to the facility on [DATE] and has a diagnosis of vascular dementia. His most recent MDS (Minimum Data Set), dated 4/3/26, includes a BIMS (Brief Interview for Mental Status) score of 8 indicating moderate cognitive impairment.A facility incident report dated 3/27/2026 at 12:55 AM states Resident (R3) was found engaging in oral sex with another resident (R11). Nurse was looking for resident (R3) during rounding and found resident in another room. When door was opened, residents separated, and both were cooperative with no signs of distress or injury. Residents were interviewed separately and stated that the acts were consensual. Risks were discussed with both residents.Of note: The facility was unable to provide any documentation that R3 and R11 were assessed for capacity to consent to sexual relations before 3/27/26. The facility did not interview any other residents or staff other than the 3 that were working the night shift at the time of the incident. On 5/14/26, Surveyor interviewed RA W (Resident Assistant) at 9:52 AM, LPN M (Licensed Practical Nurse) at 9:30 AM, CNA Z (Certified Nursing Assistant) at 9:32 AM, CNA AA at 9:27 AM, LPN J at 11:31 AM and LPN X at 11:37 AM. All stated they were unaware that R3 and R11 had been in a sexual relationship, were unaware if they could consent and did not believe either should be in each other's rooms. Additional interviews on 5/14/26:*At 11:12 AM CNA S stated that she was working the night of the sexual encounter between R3 and R11. CNA S stated that she had heard that R3 could not be found but was not sure if there was a sexual encounter and she was never instructed on anything regarding the relationship between R3 and R11 and was unaware if they could consent to a sexual relationship. Additionally, CNA S indicated that staff are to follow the guidelines on their CNA Kardex (care plan) for guidance of resident cares. *At 11:40 AM, CNA F stated she was aware of R3 and R11 having had a sexual encounter, but she didn't ask for any details and was unsure what to do if they wanted to engage in sexual activity again.*At 11:42 AM, CNA K stated that R3 and R11 are very close, and she heard that R3 had been having oral sex with R11 in his (R11's) room. CNA K stated it was only talked about once and she was concerned if they could do this again, but DON B (Director of Nursing) stated that they (R3 and R11) are 2 consenting adults and staff need to give them privacy. CNA K stated there was no guidance on how to monitor or accommodate this.*At 12:20 PM CNA Y stated there was one incident when R3 went into R11's room and performed oral sex on him (R11). CNA Y stated that staff are just supposed to keep the door open, and keep the room in view. R3 can go in R11's room but the door needs to stay open and they are not to engage in anything. CNA Y stated that she cannot remember who gave her this guidance. It should be noted that neither R3's nor R11's Kardex (CNA care plan) indicated any approach, monitoring or guidance for sexual relations. On 5/19/2026 at 9:13 AM, Surveyor interviewed DON B who stated that the facility did not have any other documentation on the incident of 3/27/26, nor did he interview other staff on other shifts regarding any other sexual incidents or activity between R3 and R11, or any other residents. DON B indicated they did not interview any other residents. DON B also stated they did not assess R3 or R11 for capacity to consent prior to 3/27/26. The facility was unaware if R3 or R11 could consent to a sexual relationship as they did not assess them for this capacity. When R3 and R11 were found engaging in sexual activity on 3/27/26, the facility did not conduct a thorough investigation that included interviews of staff and residents, and they did not put a plan in place to monitor the continued relationship that they had deemed consensual. Most staff were unaware that sexual activity had occurred and others were unaware of how to accommodate a potential sexual relationship between R3 and R11.

Based on interview and record review, the facility did not develop, current up-to-date policies and procedures to ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized, this affects 1 of 5 residents (R8) reviewed for immunizations. The facilities Pneumococcal Vaccine (Series) dated 3/1/19 does not have the current up-to-date standard of practice involving an adults age. R8 has consent given for pneumococcal vaccine, the facility does not have documentation that the vaccine was offered or administered. This is evidenced by: Example 1The facilities Pneumococcal Vaccine (Series) dated 3/1/19, documents in part: .7. A series of vaccines will be offered to immunocompetent *adults > (greater than or equal to) 65, depending on current vaccination status and practitioner recommendation. The current Standard of Practice from the CDC (Center for Disease Control and Prevention) dated 10/24 is: Pneumococcal Vaccine Timing for Adults, Adults > (greater than or equal to) [AGE] years old. On 5/14/26 at 4:01 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C if this Pneumococcal Vaccine (Series) dated 3/1/19 is the most up-to-date, ADON/IP C stated, yes this is the up to date one. On 5/14/26 at 4:58 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if he would expect the Pneumococcal Policy and Procedure to be up-to-date, DON B said yes. Example 2The facilities Infection Prevention and Control Program Policy and Procedure dated 10/1/25, documents in part: .9. Influenza and Pneumococcal Immunization.b. Residents will be offered the pneumococcal vaccines recommended by the CDC (Centers for Disease Control and Prevention) upon admission, unless contraindicated or received the vaccines elsewhere.d. Residents will have the opportunity to refuse the immunizations. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunization. The facilities Pneumococcal Vaccine (Series) dated 3/1/19, documents in part: .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. R8's Immunization Consent or Declination marks yes for Pneumococcal vaccine, with verbal consent documented as obtained by POA (Power of Attorney) 11/4/25. R8's medical record does not reflect that she received a pneumococcal vaccine nor that she refused it at the time of injection. On 5/14/26 at 4:50 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C if she has documentation of R8 receiving a pneumococcal vaccine, ADON/IP C replied no. On 5/14/26 at 4:58 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if he would expect R8 to have been offered or administered a pneumococcal vaccine after consent was obtained, DON B stated yes.

Based on interview and record review, the facility did not ensure each resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for experiences and preferences in order to eliminate or mitigate triggers that may care re-traumatization for 1 of 2 residents (R79) reviewed for PTSD (Post-Traumatic Stress Disorder).R79 admitted to the facility with a diagnosis of PTSD. The facility failed to include PTSD on R79's comprehensive plan of care, nor were staff aware of any of R79's PTSD triggers. Evidenced by:The facility policy, Trauma Informed Care, dated [DATE], states, in part: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Policy Explanation and Compliance Guidelines:. 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event. 4. The facility will collaborate with resident trauma survivors. to develop and implement individualized care plan interventions. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan.R79 was admitted to the facility on [DATE] with diagnoses that include, in part: Post-Traumatic Stress Disorder.R79's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicates R79 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R79 is cognitively intact. Section I6100 of R79's MDS states yes for PTSD.R79's most recent Comprehensive Care Plan states, in part:Focus: Resident is at risk for malnutrition related to multiple medical diagnoses including DM (Diabetes Mellitus). PTSD. need for therapeutic diet, and need for skilled nursing care. Date Initiated: [DATE].Of note, there is no other mention of PTSD in R79's care plan, including no PTSD focus, goal, or interventions.A review of R79's progress notes included in the EHR (Electronic Health Record) include the following:A psychiatry evaluation note on [DATE] states the following, in part: Chief Complaint: PTSD. Mood: Some depression and anxiety. Patient reports having some ongoing depression and anxiety due to his history of PTSD and personal issues. Discussed medication options to improve his mood, but patient declined medications. He stated, I don't believe in taking psychiatric medications for your mood. Sleep: OK. Patient reports having some ongoing trouble sleeping at night. He reports his sleep is off and on. Discussed sleep aid options, but patient declined medications. He stated, I don't want to take a sleep medication. Social history: Reports trauma from past police officer job. He reports that my police partner was shot while with me and he died in 1983. He reports that he had also been shot while on duty. Discussed psychotherapy would be beneficial for past trauma, but patient declined therapy at this time.On [DATE] at 7:14 PM: RN (Registered Nurse) spoke with resident at 0500 (5:00 AM) and he stated that he wanted to know if we still had his room. RN informed him that we did, and he stated that he would be coming back. He stated that he had some health issues with his PTSD (post-traumatic stress disorder) at church.On [DATE] at 8:04 AM: Went to talk to [Resident Name] regarding his absence from the facility for a couple days. [Resident Name] in his room sitting on his bed and eating breakfast. I asked him how he was doing and where did he go. He responded that he was depressed. Has PTSD and needed money. Feeling very depressed. Asked him if he had any medical appointments coming up. He stated I'm canceling them. I haven't eaten in 3 days and need to eat. I told him to finish eating and I would come back to talk to him a little later.On [DATE] a NP (Nurse Practitioner) note states, in part: Patient presented for evaluation due to change in condition following recent two-day out of facility pass, including increased depression and abnormal mouth movements. Reports increased depressive symptoms and history of PTSD.On [DATE] at 6:38 AM: Resident was very restless throughout the night. He was turning in the bed, making the mattress come partially off the frame. CNA (Certified Nursing Assistant) fixed this. Resident was heard crying, talking, hollering, all of this was in his sleep. RN continued to check on resident for safety.On [DATE] at 1:02 PM, Surveyor interviewed R79, who stated he had PTSD from being shot on duty when he was a police officer. R79 stated that his partner was also shot and died in his arms. R79 stated that when he hears other residents yelling for help in the hallway it triggers his PTSD. R79 stated that he knows it is not the other resident's fault, and that the staff are doing the best that they can, but that he was getting more depressed with his wife passing away recently and his issues with his PTSD. Surveyor asked R79 if he was receiving any behavioral health services at the facility. R79 stated that they offered for him to see a counselor but that he chose not to at this time.On [DATE] at 2:24 PM, Surveyor interviewed CNA F (Certified Nursing Assistant) and asked if any of the residents on that hall had a PTSD diagnosis. CNA F stated none that she knew of. Surveyor asked CNA F where she would find that information. CNA F indicated that it should be in their chart, on their care plan and Kardex. Surveyor asked CNA F how she would provide care differently for a resident who had PTSD. CNA F stated that it would depend on what their triggers were, but that she would try to stay calm and understanding when providing care. Surveyor asked CNA F what monitoring was being done for R79. CNA F stated none that she knew of.On [DATE] at 2:37 PM, Surveyor interviewed LPN G (Licensed Practical Nurse) and asked if any of the residents on that hall had a PTSD diagnosis. LPN G stated that R79 and two other residents on that hall had PTSD. Surveyor asked LPN G how he would provide care differently for a resident who had PTSD. LPN G indicated he would approach them calmly, give them time to collect their thoughts, and provide positive affirmation, but that mostly care would be specific to their triggers. Surveyor asked LPN G if he knew what R79's triggers were. LPN G stated that they would be in his care plan.On [DATE] at 3:06 PM, Surveyor interviewed CNA H and asked if any of the residents on that hall had a PTSD diagnosis. CNA H stated that R79 and one other resident on that hall had PTSD. Surveyor asked CNA H how she would provide care differently for a resident who had PTSD. CNA H stated that she would try to give them space, be calm, and validate their feelings. CNA H indicated that it is important to know the resident and their specific triggers. Surveyor asked CNA H if she knew what R79's triggers were. CNA H stated that she doesn't normally work that half of the hall, but that it should be on his care plan.On [DATE] at 9:12 AM, Surveyor interviewed LPN J and asked her if any of the residents on the hall had PTSD. LPN J stated that R79 and two other residents had PTSD. Surveyor asked LPN J if she knew what R79's triggers were. LPN J stated that they would be on his care plan.On [DATE] at 11:26 AM, Surveyor interviewed CNA I and asked if any of the residents on that hall had PTSD. CNA I stated not that she knew of. Surveyor asked CNA I how she would provide care differently for a resident who had PTSD. CNA I stated that that information would be on their care plan.On [DATE] at 1:28 PM, Surveyor interviewed CNA R via telephone and asked her if any of the residents on that hall had a PTSD diagnosis. CNA R stated that she wasn't sure, but that she would find that information in the resident's chart.On [DATE] at 1:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) and asked about R79's PTSD. DON B stated that R79 had shared with him some of his stories about being a police officer and his PTSD, and that R79 had also talked to the psych NP (Nurse Practitioner) about it. Surveyor asked if R79's PTSD with specific interventions and triggers should have been added to R79's care plan. DON B stated yes, it should have been added to the care plan so that staff know what to monitor R79 for. The facility failed to include PTSD or R79's PTSD triggers in his comprehensive care plan, despite R79 having a diagnosis of PTSD prior to admission, PTSD being included on his facility diagnosis list, and PTSD indicated on his MDS. While some staff were aware of R79's PTSD diagnosis, none of staff were aware of R79's specific triggers or how to effectively monitor and prevent re-traumatization.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision and safety to prevent accidents and hazards for 1 of 5 residents (R79) reviewed for accidents and hazards.On 4/26/26, R79 left the faciity on leave, and upon returning to the facility the following day, admitted to staff that he had used cocaine while he was out of the building. The facility failed to implement any ongoing monitoring for R79's substance use.Evidenced by:The facility policy, Substance Use Disorder, dated 2001, with a last revision date of November, 2022, states, in part: . Policy Explanation and Compliance Guidelines:. 4. The resident's history of substance use disorder and risk for using substances which could lead to an overdose while in the facility are identified to the extent possible and documented in the medical record. 6. Care plan interventions are directed at maintaining the safety of the resident, staff and other residents. Examples of appropriate care interventions for a resident with SUD (Substance Use Disorder) include: a. monitoring the resident for signs and symptoms of substance use. and overdose, especially after returning from a leave of absence or during/after visitation; b. increasing supervision of the resident.R79 was admitted to the facility on [DATE] with diagnoses that include, in part: Alcohol abuse, uncomplicated.R79's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/26 indicates R79 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R79 is cognitively intact.R79's most recent Comprehensive Care Plan states, in part:Focus: Risk for depression r/t (related to) statements made post his return from being away from the facility for a day related to his wife's death, financial concerns and medical issues at this time. Date Initiated: 4/28/26. Intervention: Hx (history) of cocaine use and had urine test after return to facility. Urine test did test positive for cocaine. Date Initiated: 4/30/26.A review of R79's progress notes included in the EHR (Electronic Health Record) include the following:On 4/27/26 at 1:31 PM: Resident is out of unit. RN (Registered Nurse) attempted to contacted (sic) resident and emergency contact without success. Both phone numbers went to an unidentified voicemail.On 4/28/26 at 7:14 PM: RN spoke with resident at 0500 (5:00 AM) and he stated that he wanted to know if we still had his room. RN informed him that we did, and he stated that he would be coming back. He stated that he had some health issues with his PTSD (post-traumatic stress disorder) at church.On 4/28/26 at 8:04 AM: Went to talk to [Resident Name] regarding his absence from the facility for a couple days. [Resident Name] in his room sitting on his bed and eating breakfast. I asked him how he was doing and where did he go. He responded that he was depressed. Has PTSD and needed money. Feeling very depressed. Asked him if he had any medical appointments coming up. He stated I'm canceling them. I haven't eaten in 3 days and need to eat. I told him to finish eating and I would come back to talk to him a little later.On 4/28/26 at 9:42 PM: urine sample collected and sent to the lab. awaiting the resultsOn 4/28/26 a rapid urine test was completed on R79. The results of the test came back on 4/29/26, which indicated positive for cocaine use.On 4/28/26 a NP (Nurse Practitioner) note states, in part: Patient presented for evaluation due to change in condition following recent two-day out of facility pass, including increased depression and abnormal mouth movements. Reports increased depressive symptoms and history of PTSD. Subjective: Patient reported increased depressive symptoms and difficulty holding conversation. Nursing staff noted patient more depressed than normal and exhibiting tardive dyskinesia movements of his mouth. History includes alcohol abuse, substance abuse. PTSD. Patient appears altered during the visit. Assessment: Increased depressive symptoms. Tardive dyskinesia movements of mouth. Possible cognitive impairment or altered mental status.Plan: Urine drug screen ordered to evaluate possible substance involvement. Monitor symptoms closely, especially cognition and fall risk.On 5/1/26 at 10:12 PM: Resident LOA (Leave of Absence) without medications. Resident did not notify staff how long he would be leaving for. No acute concerns.On 5/4/26 at 4:09 PM: Resident on LOA and has not returned. Several calls to phone number on file with no answer, message left. Call placed to local hospital and law enforcement, no hospitalizations or arrest. APS (Adult Protective Services) call as a precaution. Provider notified. Resident alert and oriented and physically capable of self-care. Resident recently voiced having a significant other and daughter he was trying to visit. Resident did not sign out, reported to staff on unit he was leaving for a while. Resident chooses not to sign out when leaving the facility despite education given in the past.On 5/7/26 an NP note states, in part: Reason for visit [Resident Name] is seen for a follow-up visit at the skilled nursing facility related to acute care management. He reports having knee replacement surgery scheduled for tomorrow and general concerns regarding his overall health and recent illicit drug use findings. Subjective: Recently tested positive for cocaine use, stated as a one-time event. Denies ongoing illicit drug use . Plan: . Tramadol discontinued due to recent illicit drug use. Continue to observe for changes in physical and mental status. On 5/13/26 at 1:02 PM, Surveyor interviewed R79, who stated he had really bad pain from his knee replacement surgery, and PTSD from being a police officer. R79 stated that his wife passed away recently and that he was working on coping with that. R79 indicated that he was seeing a psychiatrist, who was helping him deal with his issues in a healthy manner. R79 indicated that he had a history of using alcohol, but that he had only used drugs one time, which he told staff about. R79 stated that he doesn't really have any family in the area now, and that some of the facility staff feel like they have become his family.On 5/18/26 at 2:24 PM, Surveyor interviewed CNA F (Certified Nursing Assistant) about illegal drug use. Surveyor asked CNA F what type of monitoring she would be doing for someone who had used illegal drugs. CNA F stated she would report to management anything that she observed if a resident were acting differently from their norm. Surveyor asked CNA F what monitoring was being done for R79. CNA F stated none that she knew of.On 5/18/26 at 2:37 PM, Surveyor interviewed LPN G (Licensed Practical Nurse) about illegal drug use. Surveyor asked LPN G what type of monitoring he would be doing for someone who had used illegal drugs. LPN G stated he would report it to management, initiate the protocol, check their vital signs and do assessments. Surveyor asked LPN G what monitoring was being done for R79. LPN G stated that based on his drug use, he would look to see if he was shaky, rapid heart rate, or in any way not acting his normal self.On 5/18/26 at 3:06 PM, Surveyor interviewed CNA H about illegal drug use. Surveyor asked CNA H what type of monitoring she would be doing for someone who had used illegal drugs. CNA H stated she would report it to the nurse so that they could take action such as holding their medications. CNA H stated that if anyone was acting funny or she smelled something like if they had been drinking, she would report that to the nurse right away. Surveyor asked CNA H what monitoring was being done for R79. CNA H stated she normally doesn't work that end of the hall, so she wasn't sure, but that she knew he had PTSD. CNA H also stated that R79 had left the building for several days at a time, and that had happened at least a few different times. On 5/18/26 R79's care plan was updated to include the following: Focus: I have a history/active substance use disorder. I had a one time cocaine substance use episode while oop (out on pass). Date Initiated: 5/18/26. Goal: I will not engage in illicit drugs or alcohol use through the next review. Date Initiated: 5/18/26. Interventions: Administer medication as tolerated. Date Initiated: 5/18/26. Monitor for signs/symptoms of withdrawal and notify MD (Medical Director) appropriately. Date Initiated: 5/18/26. Offer emotional support as needed. Date Initiated: 5/18/26. Offer substance abuse treatment if desired. Date Initiated: 5/18/26. Psychiatry/Psychology consult and treat as ordered. Date Initiated: 5/18/26.On 5/19/26 at 11:26 AM, Surveyor interviewed CNA I about illegal drug use. Surveyor asked CNA I what type of monitoring she would be doing for someone who had used illegal drugs. CNA I stated anytime someone appears like they might be high, like agitated or anxious, and that is not normal for them, she would report it to the nurse. Surveyor asked CNA I what monitoring was being done for R79. CNA I stated that she wasn't sure, but that it should be on his care plan.On 5/19/26 at 12:40 PM, Surveyor interviewed ADON E (Assistant Director of Nursing) about R79's illegal drug use. ADON E stated that R79 had left the facility for a day or two, and when he came back, he slept a lot and was not as perky as he normally was. ADON E stated that R79 told her that he had done some not so good things while he was out, so she reported that to the NP, and it was the NP who decided to run the drug test. ADON E stated that R79 told her that the drug screen would come back dirty. ADON E stated that she didn't think that R79 acted impaired in any way. ADON E stated that she did not see the results of the drug test, but that due to his history of drug use, she decided to put the depression and drug use on his care plan so that the people taking care of him would know about it. Surveyor asked ADON E if she would expect the care plan to have specific interventions that include what staff should be monitoring for someone with a history of drug use. ADON E states yes, she would expect that to be on R79's care plan. Surveyor asked ADON E if R79 had left the facility since this incident. ADON E stated not that she knew of.On 5/19/26 at 1:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) and asked about R79's illegal drug use. DON B stated that there was only the one incident when R79 went out on pass and used cocaine. DON B stated he added it to R79's care plan just yesterday. Surveyor asked if this should have been added to R79's care plan two weeks ago when it happened. DON B stated yes, it should have been added to the care plan earlier. Surveyor asked DON B if the care plan interventions should include what staff should be monitoring for such as signs of a drug overdose. DON B stated yes, that should have been added to the care plan. Surveyor asked if R79 had been out of the facility on pass since this incident. NHA A stated yes, that R79 had also left the faciity on 5/1/26.The facility failed to implement adequate interventions and monitoring after R79 returned from being out on leave and used illegal drugs.

Based on interview and record review, the facility did not ensure 1 of 5 residents (R5) reviewed for hospitalizations was provided a bed hold and transfer notice. R5 was hospitalized on [DATE], 5/7/26, and 5/14/26 without a bed hold or transfer notice provided.This is evidenced by: The facility's policy, titled Transfer and Discharge (Including AMA (Against Medical Advice)), dated 10/1/25, states, in part: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances.Policy Explanation and Compliance Guidelines:.12. Emergency Transfers/Discharge - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated.R5 admitted to the facility on [DATE] following a left leg below-knee amputation. R5's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/2926, shows R5 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R5 was cognitively intact. R5's face sheet indicated he did not have an activate HCPOA (Health Care Power of Attorney) or guardian.Review of R5's Progress Notes from 4/22/26 to 5/19/26 indicate he was admitted to the hospital on the following dates:-5/6/26 at 12:45 PM: Resident has large amount of drainage found from incision from left lower knee amputation.NP (Nurse Practitioner) gave orders to send resident out to the ER (Emergency Room) nonemergent to be seen. 11:21 PM: Resident was sent out to the hospital at 1440 (2:40 PM). He cam [sic] back at 1916 (7:16 PM).-5/7/26 at 8:30 AM: Change of Condition: .Edema (new or worsening) shortness of breath. Recommendations: Send to ER for evaluation.- 5/09/26 at 3:24 PM: Resident arrived back to facility around 3:00 PM.-05/14/26 at 7:11 AM: During morning cares @ 0640 (at 6:40 AM) cna alerted nurse that resident was not responding to verbal stimuli. Floor nurse went to resident and checked blood sugar, blood sugar at that time was 39.911 arrived at facility @ 0710 (at 7:10 AM) to transfer resident to ER.(Of note: there were no progress notes indicating R5 had received a bed hold or transfer notice during any of his transfers to the hospital.)R5 did not return to the facility following his hospitalization on 5/14/26. On 5/19/26 at 2:00 PM, Surveyor noted R5's electronic health record was moved from Current residents to discharged .On 5/19/26 at 3:00 PM, Surveyor asked ADON D (Assistant Director of Nursing) who handles bed holds notices for residents being sent out to the hospital. ADON D indicated the nurse on the unit who is handling the discharge works on the bed hold and it is either verbal or signed. Signed bed holds should be uploaded to the resident's file. Verbal bed hold notices should be in the progress notes. ADON C was also in the room and indicated it would be difficult to find the bed hold documentation.On 5/19/26 at 3:05 PM, Surveyor requested a bed hold and transfer notice for R5 from DON B (Director of Nursing).On 5/19/26 at 3:38 PM, Surveyor followed up with DON B and NHA A (Nursing Home Administrator) and asked if they were able to find any of the bed hold or transfer notifications for R5. DON B indicated they were not able to locate them. NHA A indicated R5 had discharged from the facility as of today and his family had picked up his belongings, so he did not need a bed hold form. Surveyor noted R5 should have received a bed hold and transfer notice each time he was sent to the hospital, as it was presumed that he would return to the facility. Surveyor asked if the resident and/or his family should have been given bed hold and transfer paperwork when he left the facility. DON B said yes.

Based on interview and record review, the facility did not ensure that each resident is offered a COVID-19 immunization, unless the immunization is medically contraindicated or the resident has already been immunized, this affects 1 of 5 residents (R8) reviewed for immunizations. R8 has consent given for COVID-19 vaccine, the facility does not have documentation that the vaccine was offered or administered. This is evidenced by: The facilities Infection Prevention and Control Program Policy and Procedure dated 10/1/25, documents in part: .10. COVID-19 Immunization: a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. R8's Immunization Consent or Declination marks yes for COVID-19 vaccine, with verbal consent documented as obtained by POA (Power of Attorney) 11/4/25. R8's medical record does not reflect that she received a COVID-19 vaccine nor that she refused it at the time of injection. On 5/14/26 at 4:50 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C if she has documentation of R8 receiving a COVID-19 vaccine, ADON/IP C said no. On 5/14/26 at 4:58 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if he would expect R8 to have been offered or administered a COVID-19 vaccine after consent was obtained, DON B stated yes.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents and hazards for 1 of 3 residents (R1) reviewed for safety.On 2/27/26, a resident (R1) who smokes started a fire in her room using a lighter that she was deemed safe to have in her possession. R1 was not reassessed for safety after igniting material in her room and continued to have smoking materials in her possession without safety interventions being put in place to ensure she does not start another fire within the building. Residents in rooms next to R1 use oxygen.The facility's failure to reassess R1 after she started a fire with smoking materials, and the failure to implement proper safety interventions to prevent accidents created a finding of immediate jeopardy that began on 2/27/26. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CRN C (Corporate Registered Nurse) of the immediate jeopardy on 3/5/36 at 4:50 PM The immediate jeopardy was removed on 3/6/26; however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan.Evidenced by:The facility policy, Resident Smoking, dated 2/4/26, states, in part: .Purpose: To provide a safe and healthy environment for residents, staff, visitors, and contractors by maintaining a smoke-free campus. This policy promotes resident safety, reduces fire risk, and supports public health initiatives.Smoking safety assessments will be completed quarterly and as needed with any change in condition or functional abilities.Cigarettes, cigars, lighters, matches, vaping devices, and all tobacco products must be turned in to the nurse for secure storage.Smoking materials are not permitted in resident rooms, on their person, or in their belongings while on facility property.smoking materials may not be shared with other residents at any time.Residents who choose not to provide the facility with their smoking materials must safeguard these items in a locked, secure container.failure to comply with this requirement may result in a 30-day discharge notice.R1 was admitted to the facility on [DATE] with diagnoses that include alcohol use, chronic pain, generalized anxiety disorder, insomnia, cocaine abuse, major depressive disorder, persistent mood disorder, post-traumatic stress disorder, and restlessness and agitation.R1's most recent Minimum Data Set (MDS) dated [DATE], indicates R1 has a Brief Interview for Mental Status (BIMS) of 15 indicating R1 is cognitively intact. R1 is her own person.R1's current care plan states in part:.initiated: 11/6/25, I sometimes have behaviors which include accusations, manipulation, inappropriately recording and calling the police inappropriately.I have behaviors which include going into staff only work spaces.I sometimes have behaviors which include being verbally aggressive with staff. Initiated: 12/24/25, I sometimes have hoarding behaviors which include excessive accumulation of items in resident room.Initiated: 1/16/26 I have made threats to staff that I will [NAME] them if they wake me up.Initiated: 1/25/26, I choose to safe keep my own smoking materials in my room. Resident will adhere to the tobacco/smoking policies of the facility.Conduct smoking safety evaluation on admission and PRN (as needed.) Educate resident/responsible party on the facility's tobacco/smoking policy. I will safe guard my smoking materials, I understand my smoking materials cannot be left out unattended to ensure the safety of my peers. If my smoking materials are left unattended, give the materials to the nurse for safe keeping. Offered smoking cessation, resident declined. Reviewed benefits but resident continues to decline at this time. R1's Smoking and Safety Assessment states in part: dated 1/25/26, Supervision, designated smoking location, and smoking times are determined by facility policy. This evaluation will be utilized for the resident's smoking care plan on admission and as indicated.Which of the following products does the resident use? Tobacco. Does the resident display any of the following? .Follows the facility's policy on location and time of smoking. Care Planning.Resident will adhere to the tobacco/smoking policies of the facility. Conduct smoking safety evaluation on admission and PRN. Educate resident/responsible party on the facility's tobacco/smoking policy.It is important to note the facility did not complete an updated Smoking and Safety Assessment after the incident on 2/27/26 when R1 started a fire in her bedroom.R1's nursing progress notes state in part:.2/27/26 12:37.@925 (9:25 am) writer was pushing another resident down the hall and smelt smoke. Writer asked CNA (Certified Nursing Assistant) to check area where smoke was smelt. CNA altered [sic] writer to resident's room, upon entering room writer noted that resident had cut up an ace wrap and sheet and had started the material on fire. Material on floor was wet. Resident stated she put fire out. When asked why she started the fire, resident replied I don't know. I am not in my right mind. Administrator was updated. Staffed with resident until resident left facility.note written by LPN D (Licensed Practical Nurse).LATE ENTRY 2/27/26 12:13 (12:13 PM) .Staff notified NHA that resident ignited a small item in her room using a personal lighter. NHA immediately met with resident to assess the situation. Resident stated she used her lighter to burn something small near her shoe. Nursing staff reported the resident was observed burning additional small items and described the behavior as related to being all over the place. No injuries noted at time of assessment. Room checked for safety. Lighter removed from resident's possession. Given the discrepancy in reports and safety concern, social services to review resident's mental status with NP (Nurse Practitioner) and reassess cognition, including review of most recent BIMS. Resident placed on 15-minute safety checks. Ongoing monitoring initiated.note written by NHA A (Nursing Home Administrator)).R1's care plan indicated on 2/27/26, I sometimes have behaviors which include attempting to start a fire with my lighter. My behavior will stop with staff intervention. Administer meds as ordered. Monitor and document for side effects and effectiveness. Contact local law enforcement/NHA if behavior occurs. Discuss resident's behavior, explain/reinforce/educate why behavior is inappropriate/unacceptable. Give resident personal space. Intervene as necessary to maintain safety of resident or others. Monitor/document/report any signs of resident posing danger to self or others. Psychology/psychiatry consult as ordered.On 3/4/26 at 9:20 AM, Surveyor interviewed LPN D (Licensed Practical Nurse) and LPN H. LPN D indicated she was the nurse that was working down R1's hallway on 2/27/26. LPN D indicated it was around 9:00 AM on 2/27/26 when she smelled smoke. LPN D indicated she was walking with another resident and could smell smoke when they came out of the hallway. LPN D indicated it was a nice day and a window was open, so she thought maybe it was someone burning something outside. LPN D asked the two CNAs down the hallway to search all the bedrooms as she finished assisting the resident she was with. LPN D indicated the two CNAs started searching rooms. LPN D indicated one of the CNAs yelled down the hallway, R1 lit a fire in her room! LPN D indicated she observed the pile in R1's bedroom; it was a pile of ace wrap and pieces of a sheet. The pile was on the floor, burnt, and wet. LPN D reported R1 had put out the pile so it was wet. LPN D indicated management did not come down. LPN D indicated R1 told them she wasn't in her right state of mind and wasn't sure why she started the fire. LPN D indicated R1 was not in her bedroom, but was down the hallway, and went with the CNA to the Nursing Home Administrator's office. LPN D indicated the pile of burned up ace wrap and sheets was still in the same spot on R1's bedroom floor when LPN D came back to work on Monday morning. LPN D indicated R1 has a backpack full of medications, [NAME], and a knife. LPN D indicated the police were not called and staff were told to keep an eye on R1. LPN D indicated R1 still has smoking materials and has been going in and out smoking all morning. LPN D indicated after the incident they took her lighter, but currently she has her smoking material and manages it on her own. LPN D indicated the last two days they have been receiving education on the smoking policy and procedures. LPN D indicated shortly after the incident R1 left the facility and did not return until later that night. LPN D indicated it is R1's norm to leave the facility for the entire day. LPN D indicated she asked the Director of Nursing why the police were not called and he told her he would have to ask about that since he wasn't at the facility at the time of the incident. LPN H indicated agreement that R1 still has her smoking materials on hand and has been going in and out smoking. LPN H indicated this is their (nurse's) license on the line and they spend so much time trying to watch over some of the residents with challenging behaviors.On 3/4/26 at 12:40 PM, CNA K indicated she was the staff that was working down R1's hallway on 2/27/26. CNA K indicated it was around 9:00 AM and she had just been in R1's bedroom and asked R1 if she could help her organize her room. CNA K indicated R1 had her items all over the bedroom and was asking for boxes to pack up all of her items. CNA K asked R1 if she could help her clean up and R1 told her later. CNA K indicated she was standing by the nurses' station and LPN D said that she smelled something burning down the hallway. CNA K and CNA O started searching bedrooms. CNA K indicated she and the other CNA started going from room to room starting at the front of the hallway, and when they entered R1's room, which is at the end of the hallway, they could see the burnt pile and smelled smoke. CNA K indicated that R1 was not in her bedroom. CNA K indicated the pile was 3-5 steps in front of her sink in the bedroom, and the pile was ace wrap and something else all burnt up. CNA K stated it was covered in water and looked like it was just put out. CNA K indicated she and CNA O yelled down the hallway and then immediately went to the NHA's office. CNA K indicated R1 was down the hallway and followed them to the office. CNA K indicated they asked R1 if she started a fire in her room and she said that she did and it was on purpose. CNA K indicated R1 stated, We are all going to die anyways. CNA K indicated they found a knife, [NAME], and medications in R1's bedroom. CNA K indicated she gave the knife, [NAME], and lighter to the NHA. CNA K indicated it was a scary situation because you don't know exactly what R1 has in her bag and she was coming towards the CNAs with her hands in her pockets. CNA K indicated her top concern was everyone's safety and it was so much going on at that moment. CNA K indicated she reported all of this immediately to the NHA. CNA K indicated she received education and NHA talked to her about not taking items out of a resident's bedroom. CNA K indicated she got talked to because she took the knife and [NAME] out of R1's bedroom. CNA K indicated she took the items out of the bedroom because she needed to keep everyone safe. CNA K indicated it was a very stressful situation, and she didn't know what R1 was going to do next.On 3/4/26 at 2:40 PM, CNA O indicated she was the other CNA that was working down R1's hallway on 2/27/26. CNA O indicated LPN D asked if she smelled something burning and CNA O and CNA K searched bedrooms. CNA O indicated they found the pile of something burned on R1's floor and it was wet like it had been put out. CNA O indicated R1 wasn't in her room at the time and that they found her in the hallway. CNA O indicated they asked her if she started the fire and she said yes. CNA O indicated they asked her if she did it on purpose and she said yes. CNA O indicated they gave the knife and [NAME] to the administrator and reported everything immediately. CNA O indicated she hasn't worked at the facility since the 2/27/26 incident, but she has received education on the smoking policy multiple times.On 3/4/26 at 9:45 AM, NHA A (Nursing Home Administrator) indicated he immediately started education after the incident on 2/27/26 with R1. NHA A indicated he started education on the smoking policy/procedures, oxygen use, and all the education that was previously done. NHA A indicated they added smoking material on the Angel Rounds form as well and started a sweep to ensure the residents that do have their smoking materials are appropriately safeguarding them. NHA A indicated R1 left the building right after the incident, returned around 8:30 PM and was placed on 15-minute checks until R1 met with psych on 2/28/26. Surveyor asked NHA A for all documentation, education, assessments, 15-minute check forms, psych notes, and sweeps that were started after the incident on 2/27/26 to current. NHA A indicated understanding.On 3/4/26 at 9:00 AM, LPN E indicated she was working on 2/27/26 and co-workers down R1's hallway were searching for what smelled like smoke. LPN E indicated she heard that staff found items in R1's bedroom such as [NAME] and medications. LPN E indicated she watches to make sure R1 swallows her medications when she gives them to her because of medication concerns. LPN E indicated just this morning LPN E was offering pain medications to a different resident and R1 said, Oh, I'll take their pain medications. LPN E indicated she provided R1 education at that time.On 3/4/26 at 9:05 AM, CNA F indicated she heard about R1 starting a fire in her bedroom. CNA F indicated R1 had to turn in her lighter after the incident on 2/27/26. CNA F indicated she received education yesterday regarding smoking policy and procedures. CNA F indicated she is not sure if R1 can have smoking materials in her room at this time but knows she has a lock box in her room.On 3/4/26 at 9:10 AM, CNA G indicated she heard about R1 starting a fire in her bedroom. CNA G indicated she received education on Monday and Tuesday regarding smoking policy, oxygen, and procedures. CNA G indicated R1 was on 15- minute checks after the incident. CNA G indicated R1 is very independent and has been at the facility for a few months now.On 3/4/26 at 12:20 PM, LPN I indicated she worked Sunday first shift. LPN I indicated R1 is very protective over her backpack and will not allow staff to go in it. LPN I indicated she remembers R1 going in and out of the building, doesn't know if R1 can have her smoking materials now after the incident, and that LPN I didn't go in R1's bedroom at all on her Sunday shift. LPN I indicated she has received education on the smoking policy recently. LPN I indicated she heard about the fire that R1 started in her bedroom but was not working that day.On 3/4/26 at 12:30 PM, CNA J indicated she has recently received education on the smoking policy after the incident on 2/27/26. CNA J indicated she was not down R1's hallway on 2/27/26, but CNA K and CNA O were working down the hallway.On 3/4/26 at 1:20 PM, CNA L indicated she was working the morning of 2/27/26. CNA L indicated she could smell smoke and observed the pile of burned ace wrap on R1's bedroom floor. CNA L indicated the pile was burned and was wet. CNA L indicated staff reported it to management and that was as much as she knew. CNA L indicated she went back to her daily tasks after it had been reported. CNA L indicated after the incident management reviewed the smoking policy and procedures with staff. CNA L indicated she also received the education on Monday when she worked.On 3/4/26 at 1:30 PM, CNA M indicated she received education on the smoking policy, oxygen, what to do if you see someone smoking/fire, and notifications on Monday. CNA M indicated she was working at the facility on 2/27/26 in the morning. CNA M indicated you could smell the smoke, and she went down the hallway and assisted in looking for the fire. CNA M indicated R1 had said something about starting a fire and CNA M observed ace wrap and a burnt pile on R1's floor. CNA M indicated the pile was wet and no active flames. CNA M indicated it had been reported, and she went back to her assigned hallway and tasks. CNA M indicated as far as she knows R1 still has her smoking materials.On 3/4/26 at 1:50 PM, Receptionist N indicated she is responsible for the lock box with resident smoking materials when she is working. Receptionist N indicated the Nursing Home Administrator tells her whose smoking materials she has to keep in the lock box. Receptionist N indicated she works Monday-Friday and there is a part time front desk person as well who works on the weekends and a couple evenings a week. Receptionist N indicated that when there isn't a front desk person working, the lock box stays in the nurses' station. Receptionist N indicated she has never been told by anyone to hold R1's smoking materials or ask for it when she comes inside from smoking. Receptionist N indicated R1 has always been and continues to be able to safely handle and hold her smoking materials. Receptionist N indicated R1 has a lock box in her room where she keeps smoking materials. Receptionist N indicated she observed R1 handing her smoking materials on her own yesterday morning.On 3/4/26 at 3:40 PM, Med Tech P indicated she was not working on 2/27/26 and has not heard about R1 starting the fire. Med Tech P indicated she has received education recently on the smoking policy and oxygen.On 3/4/26 at 3:45 PM, CNA Q indicated she has received education on the smoking policy and does not usually work down R1's hallway.On 3/4/26 at 4:00 PM, RN R (Registered Nurse) indicated she is familiar with working down R1's hallway and that she is the evening supervisor for the facility. RN R indicated R1 is able to safely safeguard smoking materials and keeps items in the lock box in her room. RN R indicated she is aware of the incident with R1 starting a fire in her bedroom. RN R indicated she has observed R1 going outside to smoke holding a cigarette over the weekend. RN R indicated RN R stayed late last night to educate the 3rd shift staff on the smoking policy, procedure, and oxygen.On 3/4/26 at 2:08 PM, NHA A indicated on 2/27/26 around 10:00 AM, he was notified of the situation with R1 from staff. NHA A indicated staff told him that everything was put out. NHA A indicated he interviewed R1 immediately. NHA A indicated R1 told him that she burned a piece of string off her shoe. NHA A indicated R1 came to his office. NHA A indicated R1 gave him the lighter and then he provided education to her. NHA A indicated he went over the smoking policy with R1. NHA A indicated his concern was not actual smoking, but about the smoking material. NHA A indicated R1 left the facility right after the incident and did not return until 8:30PM. NHA A indicated once she returned to the facility, she was placed on 15-minute checks. NHA A indicated he immediately started staff education and completed a sweep of all residents who smoke and have their smoking materials in their rooms. The sweep is being completed daily, and it is to ensure residents who smoke and have their materials on person are keeping items in their lock boxes in their bedrooms. NHA A indicated they did update R1's care plan to include starting the fire and care planned it as a behavior. NHA A indicated they kept R1 on 15-minute checks until she talked with psych the next day, on 2/28/26. Surveyor asked NHA A if he looked in R1's bedroom and he indicated that he did assess her room for any damage. NHA A indicated he did not see anything concerning when he went to R1's room. NHA A indicated when he interviewed R1 it seemed like she understood she didn't make a good decision and that she had let herself down. NHA A indicated that R1 understood the seriousness of the situation and that he had tried to call R1 after she left the building. NHA A indicated they did not redo the smoking assessment because it was not a concern with smoking, but rather the smoking materials. NHA A indicated he did get the knife and [NAME] from R1. R1 told NHA A that she uses these items for protection. NHA A indicated he has not seen R1 with smoking materials currently, if she has something he does not have control over if she brings items back in when she is out in the community. NHA A indicated the police were not called because R1 has not directly threatened other residents at the facility. NHA A indicated the facility is working on issuing R1 a 30-day discharge notice due to not following the smoking policy. Surveyor asked NHA A if R1 can safely have smoking materials on hand and in her lock box. NHA A indicated no, she cannot have these items. Surveyor shared with NHA A that per R1's care plan and staff interviews it appears R1 is able to have these items on person. NHA A indicated R1 is able to have smoking materials on person because the concern was R1's mental health and not if she can safely smoke. NHA A indicated R1 was on 15-minute checks until psych services met with her on 2/28/26.On 3/4/26 at 3:30 PM, NHA A indicated the facility did complete a Smoking Assessment for R1 since Surveyor recommended it. NHA A indicated they continue to do the sweep of the facility and did not find any smoking materials in R1's bedroom today. NHA A indicated they do not have control over if she brings something in from her car or community. NHA A indicated staff should be asking her for the smoking materials when she comes back. Surveyor asked NHA A who should be asking for smoking materials? NHA A indicated it depends on what time R1 returns to the facility.It is important to note that staff interviews and R1's care plan do not corroborate NHA A's statement about asking R1 for materials when she returns back to the facility.R1's Smoking and Safety Assessment completed on 3/4/26, states in part: .Does the Resident display any of the following? .10. Burned skin, clothing, furniture or other (NOT CHECKED).No concerns with being able to smoke outside building safely.It is important to note the Smoking and Safety Assessment was completed after Surveyor was asking why an assessment wasn't completed after the incident. It is also important to note it does not mention the resident started a fire in her bedroom.R1's Guardian Angel Rounds forms state in part:.3/1, 3/2, 3/3, 3/4.cigarettes secured in lockbox (if applicable) .all checked YES.(Of note: these checks do not indicate if R1 has access to a lighter or ignition material)Surveyor reviewed R1's 15-minute check documentation which was started when R1 returned to the facility on 2/27/26 and ended after she met with psych services on 2/28/26. R1's psych notes state, in part:.2/28/26 45 minute phone call with services, 2/28/26: Staff report that on 2/27/26 patient used her lighter to try to burn something off in her room, resulting in some flames. No injuries occurred. Lighter was removed from patient. Patient was placed on 15-minute safety checks. This provider talked with patient on 2/28/26. Patient was calm discussing the incident. Patient reported I tried to burn a piece of string off my shoe with my lighter. Patient reported that she was sorry for doing this and that she did not realize the dangers involved with using her lighter inside the facility. She stated, I didn't realize the risks involved with this until someone told me and now I realize the danger of using a lighter with other residents on oxygen. Patient reported that my brain doesn't work right since it was cut into pieces, and I can't see things from other people's point of view. Discussed patient's mental health, and patient reported that she feels her mental health is about the same. She denied any increased mental health symptoms. She denied any suicidal or homicidal ideations. Discussed medication options, and patient did not feel that she needed to adjust her mental health medications today. Staff updated on my visit with patient.On 3/5/26 at 3:00 PM, CRN C (Corporate Registered Nurse) indicated the facility did not view the incident as unsafe smoking. CRN C indicated R1 was playing with her lighter and it was not an act of unsafe smoking. The facility was concerned for her mental health and that is why the facility acted immediately and started the 15-minute checks and reached out to psych. CRN C indicated the Smoking and Safety Assessment was completed in real time which means when they completed the assessment R1 was not demonstrating any unsafe actions and did not start a fire when they were observing her.The facility failed to reassess R1 for safety related to safe handling of smoking materials after R1 started a fire in her bedroom using her lighter that she was originally deemed safe to possess. The facility failed to identify the risk and continued to care plan and allow R1 to have smoking materials on hand even after starting a fire in her bedroom. These failures created a reasonable likelihood for serious harm to occur, thus leading to the finding of immediate jeopardy. The facility removed the jeopardy on 3/6/26. The deficient practice continues at a severity/scope level of E (potential for more than minimal harm/pattern) as the facility continues to implement the following action plan:Starting on 3/6/26 All staff re-educated on the facility's non-smoking policy prior to their next shift, including that smoking is not permitted inside the building and that smoking materials such as lighters, matches, and cigarettes must be stored at the nurse station or in an approved resident lockbox per facility policy.Starting on 3/6/26 a facility wide audit was conducted to ensure residents do not possess ignition sources or weapons. Any items identified were immediately secured according to facility policy.Starting on 3/6/26 all residents who smoke or possess smoking materials are being provided with a new smoking safety assessment. Staff were also educated that any resident demonstrating unsafe behavior with smoking materials will have materials secured and will receive an immediate reassessment, with care plan interventions implemented as appropriate such as starting fires and making threatening comments regarding weapons.On 3/6/26 residents who smoke were educated regarding not using smoking materials in the facility and safety of not starting a fire in the facility.The resident involved in the incident had smoking materials immediately secured by staff, was reassessed for safety, and care plan interventions were updated.On 3/6/26 the facility completed the following generated comprehensive list of all residents who expressed desire to smoke completed a smoking evaluation for each identified resident along with care plan revisions.The facility reviewed the smoking policy and expectations of possessions of weapons.Administrator or designee will conduct random audits 4 times weekly for 8 weeks on residents who smoke to ensure smoking is done safely, lighters/ignition materials are being kept appropriately or not in possession of those who are unsafe to have them, policy is followed, assessments are completed and care plans in place. Administrator or designee will conduct random audits 4 times weekly for 8 weeks of staff to ensure they know the proper procedures on what to do if a resident has a weapon. Administrator or designee will conduct random audits 4 times weekly for 8 weeks to ensure residents are free of weapons. Results of audits will be reviewed at QAPI for further recommendations.

Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 resident (R1) reviewed for self-administration of medications.Nursing staff reported to Surveyor that R1 has a backpack full of medications. R1 does not have a completed self-administration of medication assessment.Evidenced by:The facility policy, Self-Administration of Medications, dated 10/24, states, in part;.In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer.If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process.R1 was admitted to the facility on [DATE] with a diagnoses including alcohol use, chronic pain, generalized anxiety disorder, insomnia, cerebral aneurysm, non-ruptured (a brain aneurysm, is a bulge or ballooning in a blood vessel in the brain), cocaine abuse, homelessness, major depressive disorder, persistent mood disorder, post-traumatic stress disorder, and restlessness and agitation.R1's most recent Minimum Data Set (MDS) dated [DATE], indicates R1 has a Brief Interview for Mental Status (BIMS) of 15 indicating R1 is cognitively intact. R1 is own person.On 3/4/26 at 9:00 AM, LPN E (Licensed Practical Nurse) indicated R1 has medications in her bedroom.On 3/4/26 at 9:20 AM, LPN D and LPN H indicated that R1 has a backpack with medications in it. Both LPNs indicated that R1 does not allow anyone to go through her backpack, so they do not know what medications are in there.Surveyor reviewed R1's care plan and orders. R1 has not been assessed and care planned to safely self-administer medications at this time.On 3/5/26 at 11:45 AM, DON B (Director of Nursing) indicated he is currently working on the self-administration for medications assessment for R1. DON B indicated there is currently not one. DON B indicated he first learned about R1 having medications in her room on 3/2/26.R1's progress notes states, in part;.3/5/26 10:49.DON B, Writer at bedside with resident who is willing to go through her medications that she has in her bag. Resident medications that she has include: Topiramate 100mg (milligrams), Tylenol 500mg, Ibuprofen 200mg, Vitamin C 500mg, Jet Alert, Vitamin D3 2000iu (international units), iron supplement 28mg, Docusate Sodium 100mg, Ashwaganda pills, and Fluoxetine 20mg.NP notified of resident medications. New orders to discontinue Topiramate, Tylenol, ibuprofen, and fluoxetine. Resident was made aware of potential interaction with Ashwaganda pills and fluoxetine as well as risks. Resident stated she understands and will not take the Ashwaganda pills anymore however still kept them on her person. NP (Nurse practitioner) notified. Writer discussed self-administration with resident who agrees with plan. NP notified of resident wanting to self-administrate and agrees with plan.On 3/5/26 at 4:50 PM, DON B, NHA A (Nursing Home Administrator), and CRN C (Corporate Registered Nurse) indicated understanding of the above concern.The facility did not ensure R1 was clinically appropriate to self-administer medications.

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents/hazards with smoking material. Staff observed R3 to be smoking while using oxygen in his room this had the potential to affect R3 and 12 of 12 residents (R12, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24) who reside on the 100 hall. R4 was observed not to have smoking material secured, R4 handed a cigarette lighter to R5 in the hallway. R3, R12, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24 are cited at a severity level 4 (immediate jeopardy/pattern); R4 and R5 are being cited at a severity level 2 (potential for more than minimal harm).The facility's failure to ensure all staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on 1/6/26. Surveyor notified the NHA A (Nursing Home Administrator) of the Immediate Jeopardy on 2/4/26 at 12:22 PM. The Immediate Jeopardy was removed on 2/5/26, however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan.Evidenced by:The facility policy titled Resident Smoking includes: It is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protection applies to smoking and non-smoking residents. Smoking is prohibited in all areas except the designated smoking area. Safety measures. will include, but not limited to: prohibition of oxygen use in smoking area. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. Smoking materials of all residents will be maintained by nursing staff. 1.R3 admitted to the facility on [DATE] with diagnoses including Bipolar, COPD (Chronic Obstructive Pulmonary Disease), Anxiety, Post Traumatic Stress Disorder, Insomnia, and Agitation.R3's Medical Record contained the following:Physician Note dated 12/6/25 at 10:44 AM includes: Reason for visit - self care deficits. more than 35 minute visit spent with R3's record and staff. Assessment and plan - . 3/20/25 chronic hypoxic respiratory failure (condition where the lungs cannot effectively exchange oxygen and carbon dioxide, leading to chronically low oxygen levels or high carbon dioxide levels in the blood. ) in a patient with COPD, oxygen needed for survival benefit long term. Patient advised that we will be looking for oxygen lower than 88% in order to continue supplementing to saturation goal above 90%. Patient examined. Chart reviewed, patient compliant . R3 requires oxygen equipment related to the following physical exam findings: breathlessness, confusion, cough, disorientation, fatigue, headaches, tachycardia, and shortness of breath. 8/19/25 chronic hypoxic respiratory failure in a patient with COPD, oxygen needed for survival benefit long term. Patient advised that we will be looking for oxygen lower than 88% in order to continue supplementing to saturation goal above 90%. Patient examined. Chart reviewed, patient compliant. R3 requires oxygen equipment related to the following physical exam findings: breathlessness, confusion, cough, disorientation, fatigue, headaches, tachycardia, and shortness of breath.(It is important to note R3's MAR/TAR (Medication Administration Record/Treatment Administration Record) does not contain the above Physician orders related to R3's need for oxygen therapy.)Nurse Note dated 12/25/25 at 12:30 PM, includes: .Resident up before 6:30 AM this morning per his request. Resident has been noted to be smoking outside. Resident outside with another resident during lunch which is out of character for resident to miss a meal.SBAR (Situation, Background, Assessment, Recommendation) Change In Condition form, dated 12/25/25 at 12:52 PM, includes: .Resident wanted to get out of bed at 6:30 AM which is out of resident's normal time. Recently started to smoke.Nurse Note dated 12/25/25 at 9:29 PM, includes: .He has smoked 2 full packs of cigarettes in the last two days. In the previous 3 years he has never smoked cigarettes.(of note: R3 does not have a smoking assessment or Care plan even though staff are aware R3 is currently smoking.)Physician Note dated 12/26/25 at 11:17 AM, includes Reason for visit - Patient request and tobacco use disorder. Social history - tobacco use/smoking status-every day. type-cigarettes. Years since quitting-7.8. 12/26/25 Cigarettes, still craving. Assessment and plan . 3/20/25 chronic hypoxic respiratory failure in a patient with COPD, oxygen needed for survival benefit long term. Patient advised that we will be looking for oxygen lower than 88% in order to continue supplementing to saturation goal above 90%. Patient examined. Chart reviewed, patient compliant . R3 requires oxygen equipment related to the following physical exam findings: breathlessness, confusion, cough, disorientation, fatigue, headaches, tachycardia, and shortness of breath. 8/19/25 chronic hypoxic respiratory failure in a patient with COPD, oxygen needed for survival benefit long term. Patient advised that we will be looking for oxygen lower than 88% in order to continue supplementing to saturation goal above 90%. Patient examined. Chart reviewed, patient compliant. R3 requires oxygen equipment related to the following physical exam findings: breathlessness, confusion, cough, disorientation, fatigue, headaches, tachycardia, and shortness of breath.(It is important to note the above Physician order is not on R3's MAR/TAR. R3's MAR/TAR does not contain orders for oxygen use.)Nurse Note dated 12/29/25 at 10:30 PM, includes: .Resident was transferred into his chair and he immediately went outside to have a cigarette.Nurse Note dated 12/30/25 at 5:53 AM, includes: Resident has not slept at all tonight. All he did was smoke several cigarettes each time he went out. Resident was caught smoking inside the two doors and there were also two cigarette butts on the floor below him. When he was asked to not go out any longer because he was smoking in the building, he stated that he was not and continued to go outside. He would also not go to the sidewalk because he could not get himself up and down the ramp.(It is important to note R3 is found smoking inside of the doors.)Nurse Note dated 12/30/25 at 9:18 PM, includes: .Resident outside smoking frequently on this shift.Nurse Note dated 12/31/25 at 7:19 AM, includes: .Resident was placed in bed around 3:00 AM and then at 3:35 AM he put half his body off the bed making sure that we had to help get him up, so he could get a cigarette.Nurse Note dated 12/31/25 at 1:52 PM, includes: Resident outside smoking cigarettes blocking the main entrance. Writer informed R3 that this is a non-smoking facility and he would need to go to the sidewalk to smoke if he chooses to smoke. Resident stated he will smoke his cigarette right here. Writer discussed that R3 and visitors need to come through this door and some of them have oxygen, however resident disregarded. Police Department was called and informed. Officer (named) spoke with resident and resident stated he will go to the sidewalk to smoke.(It is important to note R3 is found smoking outside the main entrance and not 20 feet from the entrance in the designated smoking area. It is also important to note staff identified a risk with having oxygen equipment near smoking materials. R3 does not have a smoking assessment or smoking care plan in his medical record even after numerous observations of R3 smoking unsafely.)Facility Self Report, dated 1/7/26, includes: On January 6th at approximately 3:00 AM R3 was observed in his room smoking while oxygen was in use. Staff identified the situation as an immediate safety concern. In accordance with the resident's care plan, two staff members responded. A licensed nurse asked the resident to relinquish the smoking materials due to safety concerns. The resident refused. During the interaction, the resident became physically aggressive toward the nurse. Classification of injury mechanism: During the interaction, while the nurse was attempting to remove smoking materials due to immediate safety concerns and protect herself, the resident moved forward and bit the nurse's hand. The bite occurred during close proximity while staff were attempting to disengage and ensure safety. No chokehold or restrictive hold was used. Immediate Action Taken: Staff intervened to ensure safety. Emergency services were contacted. Law enforcement responded. The nurse elected to press charges. The resident was transferred to the hospital for psychiatric evaluation. At the time of the incident, the resident was unable to be safely redirected within the facility setting. Post-Incident Assessment: Following the incident, the resident received a skin integrity assessment, and no injuries or concerns were identified. Post-Incident Allegation: Following return from the hospital, the resident reported to the Nursing Home Administrator that during the prior incident the nurse jumped on him, placed him in a chokehold, and punched him. Facility Review and Findings: The allegation was reviewed immediately. Staff members present during the incident stated the alleged actions did not occur. No injuries consistent with the allegation were observed or documented. The report was made following recent psychiatric hospitalization. The resident's report was reviewed in the context of the resident's psychiatric condition and mental status at the time of the incident. Care Plan Review and Preventive Interventions: The resident has an active behavioral care plan addressing periods of behavioral dysregulation, including agitation, verbal escalation, and refusal of care. Following this incident, the resident's care plan was reviewed and reinforced to emphasize resident and staff safety and reduce hands-on interaction during periods of escalation. Interventions include a two staff approach, maintaining appropriate staff positioning (including doorway support), minimizing close physical contact when possible, and providing redirection in a calm environment. As part of the resident's behavioral interventions, 1:1 supervision from a distance is utilized as clinically indicated. Staff are directed to maintain appropriate distance, move other residents away for safety, and avoid close physical contact when the resident is exhibiting aggressive behaviors. Additional structure and monitoring were implemented, and the resident was subsequently transferred for psychiatric evaluation and stabilization. Outcome and follow up: The resident remained under the hospital care for psychiatric stabilization following the incident. Required notifications, documentation, and reporting were completed in accordance with facility policy and regulatory requirements.CNA P's (Certified Nursing Assistant) Statement: I was CNA working during the shift and was positioned outside of the resident's room per the resident's current care plan. At approximately 3:00 AM. I smelled cigarette smoke and observed that the resident was smoking in his room while oxygen was in use. I immediately notified RN CC (Registered Nurse), and we responded to the room together. RN CC entered the room, and I remained positioned nearby for observation and support. The nurse asked the resident to relinquish the smoking materials due to safety concerns. The resident refused. During the interaction, the resident became physically aggressive toward RN CC, striking her and subsequently biting her hand. I contacted emergency services. The nurse was able to remove the lighter, and the situation was stabilized until EMS (Emergency Services) and law enforcement arrived. At no time did the nurse or I strike the resident. After emergency responders departed, the nurse and I did not re-enter the room, and another staff member was assigned to meet the resident's care needs. RN CC's statement: At approximately 3:00 AM, I was at the nurse station when CNA P reported that R3 was smoking in his room. I responded to the room and observed the resident smoking while oxygen was in use. In accordance with safety procedures, I asked R3 to relinquish the smoking materials due to the immediate risk. R3 refused and became increasingly agitated. During the interaction, R3 became physically aggressive, striking me and subsequently biting my left hand. I attempted to protect myself and disengage while removing the lighter. Emergency Services were contacted. CNA P was present during the interaction and assisted with contacting 911. I exited the room once it was safe to do so. EMS and law enforcement responded. I later received medical attention for a human bite. NHA A (Nursing Home Administrator) was notified of the incident. ADON Q's (Assistant Director of Nursing) statement: I cared for R3 during the night shift following the incident involving staff. During routine care and interactions, R3 did not express any concerns regarding the care provided by staff the prior shift. R3 was assisted with repositioning and routine care as needed. No new concerns were identified during my shift.Nurse Note dated 1/9/26 at 4:38 PM, includes: Resident smoking cigarettes in room. Resident was asked to put the cigarette out which he refused initially. Oxygen was taken out of his room for safety. Police Department was called as resident was not putting cigarette out. Resident eventually started putting the cigarette out on the window drapes. Writer expressed to resident that this was unsafe and could cause a fire. Resident continued to put out cigarette on drapes. Writer pulled drapes back so they were out of reach. Police Department arrived and resident started being uncooperative and verbally aggressive toward Police Department. Police Department contacted crisis who came to building to speak with resident.During interview on 2/3/26 at 2:11 PM, CNA O indicated R3 used to be the Resident Council President and she did not know him to smoke until recently.During an interview on 2/3/26 at 2:24 PM, LPN N indicated R3 started smoking recently and he was observed smoking in his room while oxygen was in use. LPN N indicated if she observed a resident smoking while using oxygen, she would let them know they can't smoke inside. LPN N indicated if a CNA observes a resident to be smoking while using oxygen they are to make sure the cigarette is put out and report it to the nurse. LPN N stated, When a resident admits who is a smoker, we have to do an assessment for safety - where to light, where to extinguish.During an interview on 2/3/26 at 2:28 PM, CNA P indicated she was sitting outside of R3's room providing supervision when she smelled smoke. She looked in the room and saw R3 had a lit cigarette in his mouth while wearing oxygen. While standing outside of door, CNA P called to nurse station, RN CC, he has a lit cigarette in his mouth. CNA P stated, She came and we went in together. She asked him 2-3 times to put his cigarette out or give to her so she could put it out. That is when she reached out for cigarette to break it in half. He bit the outside of her hand and he was punching the upper half of her body. We got the cigarette out of his mouth after he bit her. She got it and we left the room. EMS and police arrived. Staff from other side came to assist EMS and police so we were not in there after altercation. He wasn't being very cooperative. Surveyor asked if CNA P received any education after the incident. CNA P indicated she received education related to how to handle residents with aggressive behaviors. CNA P indicated management told her next time to just unplug the oxygen source, call the cops, make sure everyone around is safe, and do not put herself in danger. Surveyor asked if CNA P received any further education related to the smoking policy. CNA P indicated she had not.On 2/4/26 at 8:21 AM, Surveyor observed R5 smoking outside in the designated smoking area. R5 indicated to Surveyor staff are to lock up smoking materials and give residents who wish to smoke one cigarette and their lighter to them on the way outside. R5 indicated residents are to turn their lighter in when they come inside after smoking, but the facility does not always enforce this.R3's Medical Record, reviewed 2/4/26, does not contain a Resident Safe Smoking Assessment.R3's Comprehensive Care Plan, reviewed 2/4/26, does not contain any goals or interventions related to safe smoking.On 2/4/26 at 9:25 AM, DON B (Director of Nursing) indicated staff should have completed a Resident Safe Smoking Assessment for R3, but he is not sure that was done.On 2/4/26 at 9:42 AM, Surveyors observed R3's room and 12 other resident rooms to be on a unit with 1 fire safe door upon entrance.On 2/4/26 at 9:50 AM, Corporate RN C indicated a Resident Safe Smoking Assessment was not completed for R3. Corporate RN C and Surveyor reviewed R3's comprehensive care plan. Corporate RN C indicated staff should have care planned goals and interventions related to safe smoking for R3 but did not. Corporate RN C indicated the facility did not do house wide education related to the facility smoking policy, including the storing of smoking materials, assessing safety of residents who choose to smoke, or care planning goals and interventions for residents with a desire to smoke.In interview on 2/4/26 at 10:15 AM, NHA A indicated a safe smoking assessment was not completed for R3, R3's care plan was not updated to include interventions or goals related to safe smoking, and R3's medical record did not have oxygen orders in his MAR/TAR and staff continued using it. NHA A indicated staff did not collect smoking materials to be stored per facility policy, staff did not document that R3 had smoking materials on him/had already been observed smoking in the building/and also uses oxygen, did not educate staff on what to do if a resident who uses oxygen refuses to turn over smoking materials, and did not educate all staff on what to do if a resident is observed smoking while oxygen is in use. NHA A indicated he did educate staff on how to care for a resident with aggressive behaviors and what it means to be 1:1. NHA A indicated if R3's oxygen tank blew up due to activated smoking materials or started a fire, there is potential for serious harm or death to all residents on that side of the fire doors, including R3, R12, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24. On 2/4/26 at 12:22 PM, Surveyor notified NHA A, DON B, and Corporate RN C of the finding of immediate jeopardy at F689.The facility failed to assess R3 for safety related to smoking. The facility failed to create a care plan with goals and interventions related to R3's smoking. The facility failed to secure residents' smoking materials per facility policy. The facility failed to document R3 was in possession of his smoking materials when they identified a risk having oxygen equipment near activated smoking materials. The facility failed to reeducate staff on the smoking policy and procedure after R3 was found to be smoking unsafely. These failures created a reasonable likelihood for serious harm to occur, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 2/5/26, however, the deficient practice continues at a scope/severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement the following action plan:The facility educated all staff on the following. Education began 2/4/26 on pm shift and All staff educated prior to working their shift moving forward:Facility smoking policy that includes Staff received immediate education on the facility smoking policy, including resident eligibility, and safe smoking practices. The spoken policy was revised to include provisions for residents who elect to self-store smoking materials. These residents must demonstrate safe management and utilize and proof locked storage box in accordance with the plan of care.Facility storage of smoking materials for residents Education included proper storage of smoking materials at the nurses station or in approved locked boxes per the resident's plan of care.Steps to take when residents display unsafe smoking staff were also trained on immediate actions for unsafe smoking, including redirection to securing materials, addressing oxygen risks, and notifying leadershipAll residents who smoke were reeducated on the smoking policy and the requirements of keeping materials on 2/4/26.On 1/26/26 the facility completed the followingGenerated a comprehensive list off all residents who expressed a desire to smokeCompleted a smoking evaluation for each identified resident along with care plan revisions and offering of smoking cessationOn 2/4/26 the facility reviewed and updated the smoking policyAdministrator or designee will conduct random audits 4 times weekly for 8 weeks of residents who smoke to ensure smoking is done safely and policy is followed, assessments are completed, and care plans in place along with updates as appropriate along with correct storage of smoking materials. Results of the audits will be reviewed at QAPI for further recommendations. 2. (the following example is at the severity/scope level of isolated no actual harm, potential for minimal harm/isolated).R4 admitted to the facility on [DATE] with the following diagnoses: anxiety, bipolar disorder, major depressive disorder, and type 2 diabetes mellitus.R5 admitted to the facility on [DATE] with the following diagnoses: acquired absence of left leg below the knee, anxiety, major depressive disorder, post traumatic stress disorder, alcohol abuse, and tobacco use.On 2/4/26 at 3:24 PM, Surveyors observed R4 hand R5 a lighter in the facility's hallway. Surveyor immediately reported this observation to LPN N. LPN N indicated that residents had the right to keep their own smoking materials and she stayed seated in the nurse station.On 2/4/26 at 3:26 PM, Surveyor reported to DON B (Director or Nursing) the observation of R4 handing R5 a lighter in the hallway. DON B indicated residents are to return their smoking materials to staff when they are done smoking and should not be handing them off to other residents. DON B indicated LPN N should follow facility policy and procedures related to safe smoking. DON B indicated he would take care of this right away.

Based on interview and record review, the facility did not ensure that each resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 resident (R1) reviewed for hydration.R1 did not consistently meet his required fluid intake goals and was sent to the hospital, where he received IV (intravenous) fluids, on 3 occasions between 12/12/25 and 1/17/26. The facility failed to complete hydration assessments, monitor R1's fluid intake, failed to update the Dietitian and R1's provider when indicated and failed to implement additional interventions to prevent dehydration.Evidenced by:Surveyor requested the facility's hydration policy. No policy was provided.R1 admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (a loss of muscle tissue and mass leading to weakness); morbid obesity; polyneuropathy (a condition characterized by damage to multiple peripheral nerves causing numbness, tingling, pain, and weakness); and chronic pain syndrome (chronic pain lasting for months or years, leading to emotional and physical symptoms, such as depression, anxiety, fatigue, and sleep disturbances, interfering with daily life.)R1's H&P (History and Physical), dated 11/24/25 and completed by NP H (Nurse Practitioner,) states in part: .Given the recent weight gain and mild bilateral lower extremity edema (swelling caused by excess fluid trapped in body tissues), fluid status should be closely monitored.On 2/4/26 at 10:49 AM, Surveyor interviewed ADON Q (Assistant Director of Nursing) who stated that 'fluid status should be closely monitored' referenced in the H&P would need to be clarified; do weights need to be monitored, are we just watching fluid intake. Surveyor asked if there had been clarification. ADON Q indicated she was unsure.On 2/4/26 at 1:32 PM, Surveyor interviewed DON B (Director of Nursing) who stated that 'fluid status should be closely monitored' means that staff should visualize how much the resident is drinking and put the information into the electronic health record. If there is a decline, notify the nurse to review. The nurse should update the provider if there are concerns. Surveyor asked if R1 was at risk for dehydration. DON B stated yes, due to his wounds. DON B stated the dietician was monitoring; saw R1 in November and was due to see R1 again in January, but R1 passed away.On 2/4/26 at 3:06 PM, Surveyor interviewed NP H and asked what is expected of the facility when H&P states to closely monitor fluid intake. NP H stated, make sure the resident is drinking the water provided and document how much fluid is going in each day. Surveyor asked if staff reported on R1's fluid intake. NP H stated, not that I recall.R1's Fluid Intake records indicate the following milliliter intakes:11/25/25 75011/26/25 185011/27/25 227511/28/25 2050R1's Dietary Note dated 11/28/25 at 5:43 PM, states in part: .Estimated needs.Fluids: 1ml (milliliter)/1 kcal (kilocalorie; a unit of energy representing 1,000 calories)=2376-2640 mls/day (milliliters per day). Resident is at risk for malnutrition related to multiple medical diagnoses including obesity, atrial fibrillation, HTN (hypertension; high blood pressure), seizures, chronic pain syndrome; CKD (Chronic Kidney Disease)-stage 3, mood disorder, and need for therapeutic diet and skilled nursing care. Goals: .Resident will consume and tolerate > (greater than) 50% of meals consistency to help maintain good skin integrity with no signs of dehydration or malnutrition.Appetite and meal/fluid intake appear adequate at this time.RD (Registered Dietician) to continue to monitor and f/u (follow up) prn (as needed).R1's Fluid Intake records indicate the following milliliter intakes:11/29/25 2400 (R1 met his estimated fluid needs (EFN))11/30/25 120012/1/25 195012/2/25 3100 (R1 met his EFN)12/3/25 195012/4/25 100012/5/25 168012/6/25 195012/7/25 192012/8/25 97012/9/25 145012/10/25 217412/11/25 195012/12/25 600Is it important to note that from 11/29/25 to 12/12/25, R1 did not meet the recommended fluid goal on 12 out of 14 days.R1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 12/12/25, states in part: Summarize your observations and evaluation: Resident notified nurse that he was having pain and burning in his kidneys. Resident rated pain as 8/10. Resident seemed more out of it than usual.R1 was sent to the ED/UC (Emergency Department/Urgent Care) on 12/12/25. R1's ED/UC Note-Provider, service date 12/12/25, states in part: .History of Present Illness.On arrival patient is awake and alert but has very dry mucous membranes and it is difficult for him to talk. Medical Decision Making .Patient's acuity is acute with moderate symptoms. Multiple diagnoses have been considered for this patient that include but are not limited to, UTI (urinary tract infection), dehydration, pneumonia, .I made a plan with the patient to place an IV (intravenous-a medical process for delivering fluids into a person's vein for rapid distribution throughout the body) . Patient received 1 L (liter) of normal saline to help with rehydration as patient's tongue is dry and shriveled.Patient will have a second liter of normal saline to help with continued rehydration as his mouth is beginning to have saliva and tongue not be so dry. Patient looks improved and is able to speak and respond much more easily.Patient Instructions . Please continue to orally rehydrate patient with plenty of water and electrolyte (electrically charged minerals including sodium, potassium, calcium, magnesium, chloride, phosphate) drinks.(of note: R1 had a dry and shriveled tongue and lack of saliva prior to receiving 2 L of fluid. R1's Medical Record has no evidence that he was provided with electrolyte drinks, hydration assessment was completed, continued monitoring or new interventions were implemented to prevent further dehydration.)On 2/5/26 at 7:44 AM, Surveyor interviewed RD I (Registered Dietician) and asked if R1 was meeting the recommended fluid goals. RD I reviewed the intake records and stated no, not every day. Surveyor asked what is recommended when a resident is not meeting goals for fluids. RD I stated, usually we have a weekly resident at risk meeting and the facility asks me to take a peek. I was not notified of him, to the best of my knowledge. Sometimes we would recommend additional fluids at meals or to be given with medication administration. Some of these (fluid levels) should have been notified. 12/3/25 through 12/7/25, I should've been notified. I would've ordered additional fluids and maybe asked for labs to be sure of kidney function. After 3 days, we would have intervened so that intake could come up and we'd continue to review. Surveyor asked about recommendation of electrolyte drinks following ED/UC visit on 12/13/25. RD I stated that RD I was not aware of the ED/UC visit or the recommendations and RD I indicated that Gatorade would have been provided had RD I known.On 2/5/26 at 10:05 AM, Surveyor interviewed DON B and asked about adequate fluid intake for residents. DON B stated would need to refer to dietician. Surveyor asked if the RD fluid recommendations for R1 were being met. DON B stated, not every day. Surveyor asked what is to occur if a resident is not meeting their goal. DON B stated if the goal is not met, maybe it wasn't charted completely, but if the resident is not taking in water, the nurse is to be updated, the resident is to be assessed and the provider and dietician are to be updated. Surveyor asked what is included in the assessment. DON B stated skin, mucous membranes, vital signs. Surveyor asked if the dietician or provider was updated regarding R1 not meeting goals. DON B stated there was no documentation of notification. Surveyor asked if the dietician was updated about the hospital recommendation of electrolyte drinks. DON B stated I don't recall that recommendation in the discharge paperwork.R1's Fluid Intake records indicate the following milliliter intakes:12/14/25 11512/15/25 220012/16/25 180012/17/25 205012/18/25 95012/19/25 185012/20/25 235012/21/25 120012/22/25 120012/23/25 80012/24/25 25012/25/25 4600 (R1 met his EFN)12/26/25 80012/27/25 4400 (R1 met his EFN)12/28/25 4400 (R1 met his EFN)12/29/25 3600 (R1 met his EFN)12/30/25 108012/31/25 600It is important to note that from 12/14/25 to 12/31/25, R1 did not meet the recommended fluid goal on 14 out of 18 days.On 2/5/26 at 7:44 AM, Surveyor interviewed RD I (Registered Dietician) who reviewed fluid intakes and stated there were consecutive days of poor intake from 12/21/25 through 12/24/25. RD I indicated expectation of being notified, but was not notified.R1's SBAR Communication Form, dated 12/31/25, states in part: The change in condition, symptoms, or signs observed and evaluated is/are: Altered Mental Status.Summarize your observations and evaluation: Resident is very difficult to arouse, not alert per his usual. His words/sentences aren't making sense.R1 was sent out to the hospital on [DATE] and remained hospitalized until 1/2/26. R1's Hospital Discharge summary, dated [DATE], states in part: .Hospital Course / Treatment Rendered .was diagnosed with dehydration.was given IV hydration.(Of note: this is the 2nd hospital visit for R1 that required fluids to be given for rehydration. There is no evidence in R1's chart to indicate a hydration assessment , increased monitoring or new interventions were implemented to prevent further dehydration.)R1's Fluid Intake records indicate the following milliliter intakes:1/2/26 12001/3/26 14001/4/26 11231/5/26 250It is important to note that from 1/2/26 to 1/5/26, R1 did not meet the recommended fluid goal on 4 out of 4 days.R1's Nutrition-Fluids records indicate the following for task record question: how much did the resident drink (in ml)?1/6/261:45 AM not applicable1:59 PM not applicable7:47 PM 20001/7/261:18 AM 10001:44 PM not applicable9:59 PM 2501/8/263:45 AM not applicable8:06 AM 7509:59 PM 25011:58 PM not applicable1/9/269:37 AM 7509:59 PM 6001/10/261:42 AM not applicable1:59 PM 2509:48 PM not applicable1/11/261:56 AM 30009:58 PM 2501/12/261:12 AM 200010:21 AM 7504:01 PM 20001/13/261:01 AM not applicable1:17 PM 8505:24 PM 2501/14/264:03 AM 2409:51 AM 7509:16 PM 25010:59 PM 2401/15/269:30 AM 5007:48 PM 10001/16/268:08 PM resident refusedIt is important to note that from 1/6/26 to 1/16/26, R1 did not meet the recommended fluid goal for 9 out of 11 days.On 2/4/26 at 1:49 PM, Surveyor interviewed CNA E (Certified Nursing Assistant) and asked about R1's fluid intake. CNA E stated it was hit or miss; if R1 was awake and with it, R1 would do really good, but other days R1 might refuse or need extra cueing and sometimes assistance. Surveyor asked about intake listings of Not Applicable. CNA E stated there was nothing gone, it would mean zero.R1's SBAR Communication Form, dated 1/16/26, states in part: The change in condition, symptoms, or signs observed and evaluated is/are: Altered mental status, seems different than usual .Summarize your observations and evaluation: Resident is not alert per usual, difficult to arouse, having trouble staying awake enough to swallow food/medications, respirations are low at 12 and labored. DON and MD aware.called for transport to ER for eval.R1's ED/UC discharge instructions, dated [DATE], state in part: Patient Instructions: Please make sure R1 is getting enough fluids. Diagnoses from Today's Visit Dehydration .(of note: this is R1's third ED visit related to dehydration, there is no evidence in R1' chart that a hydration assessment or continued monitoring were put in place despite being dehydrated)R1's Progress Note, dated 1/17/26 at 4:49 AM, states in part: Resident returned back from ED. Report given from ED nurse: resident dehydrated. Given 3L of IV fluids.On 2/5/26 at 7:44 AM, Surveyor interviewed RD I and asked about resident being sent out to the ED and receiving IV fluids. RD I stated that RD I was not aware of the ED trips and added, Ideally, they should tell me about the trip out and fluids given; there would be additional orders.On 2/5/26 at 7:58 AM, Surveyor interviewed NP H and asked about expectations when a resident is not meeting recommended fluid goals. NP H stated that an update would be expected if the intake is significantly less; less than half. Surveyor reviewed R1's intakes with NP H. NP H stated that NP H did not recall being updated by the facility about fluid intakes for R1.On 2/5/26 at 10:05 AM, Surveyor interviewed DON B who stated that nursing should be completing full assessments after R1's return from the hospital, and the resident should continue to be assessed for 72 hours. Nursing would look to see if there were any concerns/indications to need a full assessment and make sure that the resident is receiving adequate fluid. DON B stated that vital signs should be checked daily. Surveyor asked if assessments had been completed for 72 hours following R1's ED and hospital visits. DON B stated no, I am not seeing the assessments in the chart.R1 did not meet his estimated fluid needs daily. The facility failed to monitor and assess R1's hydration status, failed to implement interventions to prevent further dehydration from occurring and failed to update the RD and Physician when indicated. This resulted in R1 being sent out to the hospital three times for dehydration and receiving IV fluids.

Based on interview and record review, the facility did not ensure CNAs (Certified Nursing Assistants) received the required 12 hours of annual in-service training for 5 of 5 CNAs reviewed for in-service training.This had the potential to affect all residents who reside in the facility.CNA P, CNA/MA DD (Certified Nursing Assistant / Medication Assistant), CNA EE, CNA FF, and CNA GG did not have documentation of 12 hours of annual in-service training.Findings include:The facilty's Required Training, Certification and Continuing Education of Nurse Aides policy, dated 10/1/22, states, in part: . 5. The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. a. Documentation of in-services will be forwarded to the HR (Human Resources) Director and maintained in the employee's personnel file.Surveyors randomly selected 5 CNAs to review their 12 hours of in-service training and requested the documentation from the facility CNA P has a hire date of 2/8/2023. CNA P's education record, dated Year 2025, indicates 10 hours of completed in-service. A Nurse Aide Competency Form, dated 3/15/25, signed by CNA P does not indicate the number of credited in-service hours.CNA/MA DD has a hire date of 3/20/06. CNA DD's education record dated Year 2025 indicates 1 hour of completed inservice. A Nurse Aide Competency Form, dated 3/9/25, signed by CNA/MA DD, does not indicate the number of credited in-service hours.CNA EE has a hire date of 5/12/13. CNA EE's education record dated Year 2025 indicates 1 hour of completed in-service.CNA FF has a hire date of 4/24/24. CNA FF's education record dated Year 2025 indicates 1 hour of completed in-service.CNA GG has a hire date of 5/23/18. CNA GG's education record dated Year 2025 indicates 1 hour of completed in-service. A Nurse Aide Competency Form dated 4/22/25, signed by CNA GG, does not indicate the number of credited in-service hours.On 2/18/26 at 2:32 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about CNA in-service training. NHA A stated that the facility no longer has access to their computerized education system, as of about 3 months ago, and the facility has moved to in person in-services. NHA A stated that CNAs should receive at least 12 hours of continuing education. NHA A stated there is not documentation of 12 hours of in-service for these CNAs.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests, such as bed bugs for 4 of 4 residents reviewed (R14, R6, R15, R25). R6 indicated she has observed bed bugs in her room this week. Staff indicated they have seen bed bugs in R14's and R25's rooms within the last two weeks and captured one in a closed container to show NHA A (Nursing Home Administrator). Staff indicated they saw a bed bug in R15's room last night/this morning. Director of Maintenance K indicated he was not following manufacturer's guidelines for use of the facility's chemical treatment and does not know when the product was purchased or when it expires. NHA A indicated he was unaware the products were donated to the facility and not purchased. NHA A indicated he is unsure when the product expires or when it was opened. Evidenced by: Pest Control Invoice, dated 11/10/25, includes: Bed bug K9 inspection . Pest Control Invoice, dated 11/11/25, includes: Bed bug conventional treatment. Example 1 R6 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/15/26, indicates R3's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 2/5/26 at 8:21 AM R6 indicated she has bed bugs in her room and the facility does not do anything about it. R6 indicated she told NHA A (Nursing Home Administrator) and he replied, Are you sure, because we have to take everything out of your room. R6 indicated NHA A is trying to get her to say she did not see them. R6 indicated she has seen them in the last week. Example 2 R14 was admitted to the facility on [DATE]. Her most recent MDS with ARD of 1/5/26, indicates R14's cognition is moderately impaired with a BIMS score of 12 out of 15. R25 was admitted to the facility on [DATE]. Her most recent MDS with ARD of 1/23/26, indicates R25's cognition is intact with a BIMS of 15 out of 15. On 2/5/26 at 9:50 AM CNA/MT L (Certified Nursing Assistant/Medication Technician) indicated staff have seen bed bugs in R14's and R25's room within the last week. On 2/5/26 at 10:28 AM CNA M indicated last week, she was in R14's and R25's room when she caught a bed bug in a sealed container and confirmed it was a bed bug using the internet. She then stripped the beds and bagged up all of the clothes. Then she assisted R14 and R25 in the shower and gave them clean clothes while the housekeeping did a deep clean of the room. Example 3 R15 was admitted to the facility on [DATE]. Her most recent MDS with ARD of 1/1/26, indicated R15's cognition is severely impaired with a BIMS score of 3 out of 15. R15's Medical Record contained the following: 1/18/26: Resident has red, itchy bumps on right and left arms, middle of back, and back of neck under her hairline. 1/20/26: Numerous bug bite like bumps scabbed over, no issues. On 2/5/26 at 9:54 AM Housekeeper J indicated staff saw bed bugs in R15's room last night or this morning and sent photos to Director of Maintenance K. On 2/5/26 at 10:03 AM Director of Maintenance K indicated he has never found an infestation of bed bugs in the facility, but one or two pop up here and there every so often. Director of Maintenance K indicated a staff member sent him a photo on the social media outlet, Snapchat, last night, of a bug they thought was a bed bug in R15's room. Director of Maintenance K indicated he unzipped the mattress, looked around, but did not find anything. He also stated he planned to treat the room. On 2/5/26 at 12:51 PM Director of Maintenance K stated staff sporadically catch a bed bug here or there, but I was not aware of any bites. On 2/5/26 at 12:51 PM NHA A (Nursing Home Administrator) indicated he was made aware this morning about a bed bug issue. NHA A indicated he had staff bag up all of R15's clothing and linen to have it washed in high heat. He had staff assist R15 in the shower and gave her a gown to wear. Then NHA A indicated Director of Maintenance K chemically treated the room. NHA A indicated it is expensive to keep treating rooms when only one bug is observed every so often. NHA A indicated he had an exterminator come in, in November, and treated some of the building. NHA A indicated the exterminator brought a dog in to identify if there were any remaining bed bugs but the dog did not alert to any. NHA A indicated he instructed Director of Maintenance K to use facility owned chemicals to treat rather than calling an exterminator. On 2/5/26 at 3:40 PM, Surveyor interviewed DM K (Director of Maintenance) and asked about treatment for bed bugs. DM K stated that one container of Gentrol (one ounce vial of insect growth regulator designed to break the life cycle of pests including bed bugs) was mixed with one gallon of water in a pressure sprayer. The mix was then sprayed around the affected room. DM K stated that treatment has been performed three times with that one vial of Gentrol and there is still enough mixture left for an additional treatment. Surveyor asked when the treatments were done. DM K stated did not recall the date of first treatment, but second treatment was two weeks ago, and third treatment was today. DM K stated this was all done with the same mix. Surveyor observed the instructions on the box of Gentrol which state, in part; Dilution preparation:.use 1 fluid ounce of Gentrol to 1 gallon of diluent. Partially fill the mixing container with diluent, add the Gentrol, shake or stir, and fill to final volume. Use diluted solution within 48 hours of mixing. Surveyor asked if the solution was used within 48 hours, per manufacturer instruction. DM K stated no. Surveyor asked if it was possible that the second and third treatments were not effective. DM K stated, it is possible. On 2/5/26 at 5:19 PM NHA A and Corporate RN C indicated Director of Maintenance K should be following manufacturer's recommendations when mixing and storing the chemical treatment. NHA A indicated he was unaware Director of Maintenance K received these chemicals from a job he worked at over 5 years ago. NHA A and Corporate Consultant C indicated chemicals should have an expiration date and an open date to determine shelf life, and staff should use and store chemicals according to manufacturer's recommendations.

Based on interview and record review the facility failed to have evidence that all alleged violations are thoroughly investigated for 2 of 6 resident-to-resident altercations involving 4 Residents (R9, R10, R2, and R8). Resident to Resident altercation between R9 and R10 was not thoroughly investigated. Resident to resident altercation between R2 and R8 was not thoroughly investigated. Findings include: Review of the undated policy titled, Abuse/Neglect/Exploitation, specified it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Review of the facility's undated policy titled, Abuse/Neglect/Exploitation, revealed, The Administrator should will [sic] follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; . Investigating and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; . Providing complete and thorough documentation of the investigation. Review of the facility's undated investigation policy titled, Procedure, revealed it did not contain information on how to conduct and document a thorough investigation. Example 1 Review of the admission Record, located under the Profile tab in the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] with diagnosis including unspecified dementia with agitation. Review of a 10/04/25 Incident Report, for R9, provided by the facility and documented by Licensed Practical Nurse (LPN) N, revealed that, Resident was leaving dining room in w/c [wheelchair] after breakfast. Resident rolled up to another resident [R10] who was sitting at a table close to the door and without saying anything started to open hand slap [R10] in [sic] head/face 3 times. Medication Technician (MT) U heard the commotion and removed resident from dining room and redirected resident. Both residents were separated and assessed for injury. The report indicated R9 was unable to give a description. The Incident Report included two typed statements, one by MT U, and one by Certified Nursing Assistant (CNA) M, who witnessed the incident. Review of the quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 10/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. R9 had physical behavioral symptoms directed towards others. Review of a Trauma Informed Care Assessment, dated 10/10/25 and located in the Assessments tab of the EMR, revealed R9 denied experiencing any unusual or especially frightening, horrible, or traumatic events. Review of the admission Record, located under the Profile tab in the EMR revealed R10 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, moderate, with agitation and cognitive communication deficit. R10 died at the facility on 01/03/26. Review of R10's quarterly MDS, located under the MDS tab in the EMR with an ARD of 08/14/25 revealed R10 had a BIMS score of three out of 15, indicating severe cognitive impairment. R10 had physical behavioral symptoms directed towards others. Review of a 10/04/25 Incident Report, provided by the facility and documented by LPN N, revealed that MT U went into the dining room after hearing a commotion and saw resident being open handed slapped in [sic] head/face by [R9]. R10 was assessed for injury with no injuries noted. R10 was unable to give a description. Review of a Trauma Informed Care Assessment, dated 10/10/25 and located in the Assessments tab of the EMR, revealed R9 denied experiencing any unusual or especially frightening, horrible, or traumatic events. Review of the facility's investigation file, provided on 02/05/26, revealed it contained only the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, form used by the facility to initially report R9 hitting R10 to the SA on 10/04/25, the Misconduct Incident Report, and the two page Investigation Report. Review of the Misconduct Incident Report, indicated, Upon the completion of the entity's internal investigation of the incident, submit the completed form, any available documentation, and the results of your investigation within 5 WORKING days [Monday – Friday, excluding legal holidays] of the date the entity knew or should have known of the incident. The Report Submitted Date was 10/17/25, nine working days following the initial report on 10/04/25. Review of the Investigation Report, provided by the facility and dated 10/04/25, revealed that staff completed skin and pain assessments on the two residents, which were unremarkable. One-on-one supervision was maintained for both residents until they were calm. The facility completed a thorough investigation into the incident that occurred on 10/4/2025 between [R9] and [R10]. All staff working during the time of the incident were interviewed . All skin checks – including those for both involved residents and all other residents on the unit- were completed and revealed no injuries or additional concerns. During an interview on 02/05/26 at 4:30 PM, R9 was unable to recall hitting another resident. During an interview on 02/05/26 at 4:35 PM, Nursing Home Administrator (NHA) A and Corporate Nurse (CN) C confirmed that the resident-to-resident altercation was submitted to the SA on 10/04/25 and that the five-day investigation was submitted late on 10/17/25. CN C had submitted the initial report, and NHA A was locked out and unable to submit it timely. When asked if there was any documented communication with the SA regarding the inability to submit the report timely, they stated they would check. When asked for documentation of staff interviews and resident skin checks, documented as completed in the facility's Investigation Report, NHA A stated the skin checks for the two involved residents and others on the unit would be in the EMR and that he would have to check on the staff statements. During an interview on 02/06/25 at 9:20 AM, Social Services Director (SSD) R reported she was on vacation when R9 hit R10. Upon her return, she completed a BIMS on the two residents as well as a Trauma Informed Care Assessment. SSD R confirmed that the Trauma Informed Care Assessments were completed on 10/10/25, six days after the incident, since no one else was doing them at the time. NHA A instructed SSD R on her part in any abuse investigation. During an interview on 02/06/26 at 11:14 AM, LPN N was asked if she interviewed any staff or residents following R9 hitting R10. LPN N reported the risk management/ incident reporting form had an area for staff statements, and she recorded on it. LPN N reported she generally wrote a statement, or the facility asked her about incidents, but she could not recall either occurring for this incident. LPN N stated she had never been asked to do skin checks on additional residents on a unit following a resident-to-resident altercation. She had only done that with an injury of unknown origin. During an interview on 02/06/26 at 10:50 AM, MT U reported she witnessed R9 hit R10 on 10/04/25. She reported what occurred to the nurse but did not recall anyone following up with her to obtain additional information or write a witness statement. During a follow-up interview on 02/06/26 at 11:45 AM, NHA A and CN C were asked if there was any documentation with the SA about their difficulty submitting the five-day investigation timely. NHA A stated he had not communicated with the SA. CN C pulled up an email on her phone from the SA, saying she received it because she submitted the report. The email was dated 10/16/25, six days after the five-day investigation was due, and stated the SA was waiting for the report. CN C responded to the email saying that was what she had texted them about on Monday. During the interview, it was verified that the Monday in the text was 10/13/25, three days after the due date. NHA A stated he was responsible for ensuring investigations were reported timely. During an interview on 02/06/25 at 12:08 PM, Director of Nursing (DON) B stated that for resident-to-resident altercations, the facility interviewed all residents involved and all staff working that day. The interdisciplinary team determined who was responsible for each area of the investigation. All resident and staff interviews should be documented; they may be typed or handwritten. Skin assessments should have been completed on other residents on R9's and R10's hall. The nurses did them, and he assisted if needed. DON B reported he had not done any skin assessments following the incident between R9 and R10. The skin assessments were on paper and should be in the investigative file. During an interview on 02/06/26 at 1:17 PM, NHA A stated that R9's and R10's skin checks were documented in the Progress Notes area of the EMR. When asked about interviewing or completing skin checks on the other residents on the unit, NHA A stated the residents were not interview able because it was the dementia unit but provided the Angel Rounds documentation completed by Activity Director S who was the Manager on Duty on 10/04/25. NHA A provided handwritten statements by two staff members, Physical Therapy Assistant (PTA) BB and MT U. No documentation was provided for skin checks for other residents on the unit. Review of the Angel Rounds, provided by NHA A on 02/06/26 at 1:17 PM and completed by Activity Director S on 10/04/25, revealed four columns for documentation on each resident: Appearance Clothes Changes, Concerns Voiced, and Room Clean along with Comments. There was no documentation of whether residents felt safe, had witnessed any abuse, or had concerns about abuse. During an interview on 02/06/26 at 1:44 PM, CNA M reported observing R9 hit R10 on 10/04/25. CNA M thought she had written a statement but was unsure. During an interview on 02/06/26 at 2:00 PM, NHA A stated the facility only interviewed staff who witnessed R9 hit R10. They had not interviewed other staff who worked the hall that day or previous shifts to see if there were any behaviors leading up to or following the incident or if anyone had additional information. NHA A verified he had not provided any skin assessments that his investigation summary stated were done on other residents. NHA A verified that the Trauma Informed Care assessments were completed six days after the incident and said the facility had a plan in place now for when SSD R was not in the facility. During an interview on 02/06/26 at 2:33 PM, Activity Director S reported DON B notified her there had been an incident with R9 and R10 when she was Manager on Duty on 10/04/25 and asked her to get statements from staff who had witnessed R9 hit R10 and to check on the residents and ask if they felt safe or had witnessed altercations. Activity Director S reported she asked staff on that side of the building (the dementia unit) for statements and received two. She believed that one other staff member had witnessed the incident. DON B stated she filled out the Angel Rounds documentation and acknowledged it did not refer to residents feeling safe but said she would have written in the comments section if they did not feel safe. She could not recall being asked to notify staff to do skin assessments. Example 2 Review of R 2's Record of admission located under the Profile tab of the EMR revealed an admission date of 06/25/25 with diagnoses including personal history of traumatic brain injury, vascular dementia, and depression Review of R2's Care Plan, dated 06/26/25 located under the Care Plan tab in the EMR revealed that R2 had impaired neurological status related to cerebrovascular accident (stroke), seizure disorder, and traumatic brain injury. Interventions or tasks for employees instructed staff to have pleasant interactions with the resident when he is confused to give reassurance. A care plan, dated 09/26/25, revealed R2 sometimes had behaviors which include yelling and cursing. He would also shout and throw snacks at other residents. R2 was a bouncer at a bar; his job was to intervene when customers were belligerent. R2 thinks it is his responsibility to intervene. R2 is sometimes triggered when someone is rude to the staff. R2 sometimes had behaviors which included calling other residents' names when R2 sees other residents being rude to staff, when other residents are telling R2 what to do, or when other residents called female staff names. Interventions or tasks for this care plan, dated 09/26/26, instructed staff to attempt interventions before R2's behavior begins. Attempt to separate R2 if they get into an altercation with another resident and have staff help R2 avoid situations or people that were upsetting him. If R2 is the aggressor, place him on a one to one until he is calm. Make sure R2 is not in pain or uncomfortable. Additional interventions or tasks, dated 12/11/25, instructed staff to encourage R2 to move away from the person if he is feeling provoked to avoid a confrontation. Interventions or tasks, dated 01/01/26, instructed staff to call law enforcement if R2 is unable to be redirected when being aggressive and staff is to also move other residents away from the area. R2 is to have one on one supervision on AM and PM shifts. Interventions or tasks, dated 01/19/26, also notified staff that if R2 is in their private room, one on one supervision can be removed unless needed. A care plan, dated 01/21/26, revealed R2 sometimes had behaviors which included verbal aggression towards other residents including using racial slurs, sexual preference, and body shaming others. Interventions and tasks instructed staff to assess and address the situation for contributing sensory deficits. Staff were to discuss the resident's behavior, explain, reinforce, and/or educate why the behavior is not appropriate or acceptable. Staff were instructed to give R2 his personal space but also to intervene before escalation when R2 becomes agitated and engage calmly in conversation. Reapproach the resident later if the resident gets aggressive. Review of R2's significant change MDS with an ARD of 01/01/26 and located under the MDS tab of the EMR, revealed a BIMS score of four out of 15, which indicated the resident had severe cognitive impairment. The MDS also indicated R2 had physical behavioral symptoms directed towards others one to three days in the seven day look back period. Review of R8's admission Record, located in the Profile tab of the EMR revealed an admission date of 08/15/25 with diagnoses including major depressive disorder, anxiety disorder, and severe obesity. Review of R8's Care Plan, dated 09/15/25 located under the Care Plan tab in the EMR revealed R8 sometimes had behaviors which included cursing, yelling during cares, throwing urine at staff, and throwing food in dining room when extra items were not available. R8 would also sit in the hallway in his wheelchair and not allow others to pass and he would follow staff and not allow them to complete their duties. R8 would also tell staff that Director of Nursing (DON) B had approved of something that was not approved; intentionally being untruthful to get what he wants. Interventions or tasks, dated 09/15/25, instruct staff to attempt to intervene before behaviors begin such as offering a tabletop activity like a magazine about dogs or football or offering to turn on a television show of their choice. Staff were instructed to notify R8's physician and psychiatric physician of behaviors. A care plan, dated 09/26/25, revealed R8 sometimes had behaviors which included yelling, cursing, and shouting at other residents. Interventions or tasks instructed staff to attempt to separate the residents that are having altercations. Staff were instructed to encourage R8 to leave the area and notify the nurse if another resident is starting an altercation. If R8 is the aggressor, place R8 on one-to-one supervision until he calms down. Staff was to offer a diversion. Interventions or tasks, dated 10/20/25, instructed staff to encourage positive communication and encourage R8 to express his feelings every Friday during his sessions with his therapist. Staff were to validate R8's emotions, not his accusations, and attempt to intervene before behaviors begin. Staff were to help R8 avoid situations or people that are upsetting him. Review of R8's quarterly MDS with an ARD of 11/14/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated the resident had intact cognition. The MDS also indicated R8 had no behavioral symptoms directed towards others in the seven-day look back period. A review of Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, submitted on 10/04/25, revealed on 10/03/25 R8 reported R2 walked up to him and said, I'll slap you in your face right now, then walked away. The incident was not witnessed. It also revealed, explain what steps the entity took upon learning of the incident to protect the affected person(s) and other from further potential misconduct.Staff statements, staff interviews and resident interviews. A review of Misconduct Incident Report, submitted on 10/17/25, revealed on 10/03/25 R8 reported R2 walked up to him and said, I'll slap you in your face right now, then walked away. The final submission date was 10/17/25. A review of the Investigation Report, dated 10/10/25, provided by the facility, revealed R8 reported R2 walked up to him and said, I'll slap you in your face right now, then walked away. The incident was not witnessed by staff and was reported by R8 on 10/04/25 at 11:31 AM. The facility conducted a comprehensive investigation regarding this allegation. All staff working during the time of the incident were interviewed. Any available residents were interviewed as well. The investigation did not reveal any witnesses or evidence substantiating the allegation. A subsequent review of the facilities investigation revealed no staff interviews and additional resident interviews were obtained. A review of an untitled and undated document, provided by the facility, revealed on 12/11/25 at approximately 7:40 AM while in the dining room R2 approached R8 and struck him. Staff were present; however, they did not directly witness the incident. Additionally, it revealed a comprehensive investigation was conducted including interviews with available staff and residents. A subsequent review of the facility investigation revealed one staff member interview. During an interview on 02/05/26 at 1:36 PM, NHA A stated he did not have any documentation for the investigation regarding the incident that occurred on 10/03/25. During an interview on 02/06/26 at 11:45 AM, NHA A and Corporate Nurse C stated they verified the resident-to-resident allegations with reports submitted to the state agency on 10/04/25 had a submission deadline on 10/10/25 for the follow-up five-day report. They confirmed the two submissions were submitted on 10/17/25. NHA A stated he was responsible for submitting the reports to the state. During a telephone interview on 02/06/26 at 12:07 PM, DON B stated investigations need to include interviews with all staff that were involved and the ones that were working on the day of the incident. Residents should also be interviewed. DON B added they may not recall anything, but the facility staff need to ask. DON B stated the interviews should be a statement or a questionnaire of some kind. He then added he does not know if the facility staff was getting any written statements during investigations. DON B also confirmed that NHA A sent all reports to the SA. During an interview on 02/06/26 at 2:00 PM, NHA A stated he did interview staff but did not have any documentation for the interviews with staff and residents. He confirmed he did not, however, interview all staff and all residents, only the ones he knew were involved. He then added he understood the importance of the additional interviews. NHA A stated the administration does Angel Rounds with residents every day. He added that the residents would have been asked if they felt safe but acknowledged there is no documentation of this. During an interview on 02/06/26 at 2:48 PM, CN C stated she understood the need for documentation of the interviews done with staff when doing investigations. She confirmed they did not have any of the interviews. She also confirmed there were no additional resident interviews done when the incidents were investigated. CN C stated the five-day report for the incident on 10/03/25 was submitted late to the SA, confirming it was submitted on 10/17/25 and not 10/10/25, when it was due.

Based on interview and record review, the facility failed to protect 2 of 6 sampled residents (R3 and R6's) right to be free from abuse, neglect, or exploitation by a CNA I (Certified Nursing Assistant). R3 stated CNA I was rude to her, yelled at her, and refused to help her put her compression stockings on during morning cares (AM), resulting in a fall, and that she is terrified of CNA I. R6 stated CNA I mocks and belittles her, and often leaves her in a wet incontinence brief for over an hour. Evidenced by: Facility policy entitled Abuse/Neglect/Exploitation, undated, states, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or thing their hearing distance regardless of their age, ability to comprehend, or disability . Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Neglect meals [sic] failure of the facility, its employees, or service providers to provide good [sic] and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents . 3. The facility will provide ongoing oversight and supervision of staff in order to assure its policies are implemented as written . III. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation . and exploitation that achieves: H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . IV. Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse . 5. Verbal abuse of a resident overheard . 7. Psychological abuse of a resident observed. 8. Failure to provide care needs such as feeding, bathing, dressing . 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person . VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm . Examples include but are not limited to: C. Increased supervision of the alleged victims and residents; D. Room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation . Per the State operations Manual: Sections SS1819(c)(1)(A)(ii) and 1919(c)(1)(A)(ii) of the Social Security Act provide that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility must provide a safe resident environment and protect residents from abuse. Abuse may result in psychological, behavioral, or psychosocial outcomes including, but not limited to, the following: Fear of a person or place, of being left alone, of being in the dark, and/or disturbed sleep and nightmares; Example 1 R3 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 4, Hemiplegia and Hemiparesis following Cerebral Infarction (weakness and paralysis on one side of the body). R3's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/18/25, indicates R3 has a Brief Interview of Mental Status (BIMS) of 10 out of 15, indicating R3 has moderate cognitive impairment. R3's Care Plan includes, in part: Focus: I have a physical functioning deficit related to Mobility impairment, self-care impairment due to weakness, cancer, physical limitations, and need for staff assistance. Date initiated: 2/11/25 . Interventions: Dressing assistance of 1. Date initiated: 2/11/25 Personal hygiene assistance of 1. Date initiated: 2/11/25 . Toileting assistance of 1. Date initiated: 2/11/25. Transfer assistance of 1 with gait belt and walker. Date initiated: 2/11/25 . Alteration in elimination of bowel and bladder r/t (related to) functional incontinence due to weakness, physical limitations, and need for staff assistance. Date initiated: 2/11/25 . Interventions: Provide 1 assistance to toilet. Date initiated: 2/11/25 . On 3/20/25 at 11:06 AM, Surveyor interviewed CNA F. CNA F stated that when she came in that morning, she found CNA I and R3 in the lounge. R3 was in her wheelchair in the lounge wearing an incontinence brief and t-shirt but no pants. CNA I was telling R3 that she was disrespectful, that she was on her call light all the time, and that she was going to file a grievance against R3 with the facility. CNA I told R3 that if she would have stayed in bed she wouldn't have fallen, and told R3 she should not have come out to the lounge. R3 was crying and stated she would just go hide in my room. At this point CNA F intervened, telling CNA I she could go home, and she would help R3. R3 stated she was trying to put on her compression stockings and fell out of her wheelchair because no one would help her. CNA F said that R3 was terrified of CNA I. Surveyor asked CNA F if she would consider what happened this morning as abuse. CNA F stated yes, it was an allegation of abuse and that she followed the facility abuse policy by calling NHA A (Nursing Home Administrator) at home right away. Please note: CNA F indicated throughout this exchange, CNA I was loudly berating R3, who was crying and visibly upset. On 3/20/25 at 12:47 PM, Surveyor interviewed CNA E, who said she saw the incident that happened that morning between CNA F, CNA I and R3. CNA E stated that she observed CNA I say something to R3 and then CNA F told CNA I not to talk to R3 that way and that she should just go home since her shift was over. CNA E stated she did not hear what exactly CNA I said to R3, only CNA F intervening and telling CNA I not to talk to R3 that way. CNA E indicated that she would consider the way CNA I treated R3 as abuse. CNA E stated that R3 was afraid of CNA I and says that CNA I refuses to take her to the bathroom at night. Of note: CNA E was aware of R3 being afraid of CNA I and that R3 indicated CNA I refused to take her to the bathroom at night, yet CNA E did not report this to the facility. On 3/20/25 at 1:18 PM, Surveyor interviewed NHA A, who stated that he had received no reportable incident from today. On 3/20/25 at 1:24 PM, Surveyor called and left a message with CNA I regarding the incident that happened that morning. Surveyor did not receive a call back from CNA I. On 3/20/25 at 1:40 PM, Surveyor interviewed R3 who stated that she fell out of her wheelchair this morning while trying to put on her own compression stockings. Surveyor asked R3 if the staff normally help her in applying her compression stockings. R3 stated that normally they do, but that today they didn't. R3 indicated it was CNA I who was supposed to help her, but that she was afraid to say anything for fear of retaliation from CNA I and other staff members. Surveyor asked R3 if any staff had ever been rough with her. R3 replied, No comment, but stated, It will go right back to her and I'm afraid to say anything, but no one should be yelled at, and nobody should be treated that way. On 3/20/25 at 4:30 PM, Surveyor interviewed R3 who stated that she was concerned that CNA I would be working again tonight. R3 stated that when she even hears CNA I's voice in the hall, she becomes anxious and is so afraid that she can't sleep all night. R3 stated that she is afraid to put her call light on to go to the bathroom, for fear that CNA I will come in and yell at her. R3 stated that she has developed a UTI (urinary tract infection) due to being afraid of CNA I taking her to the bathroom. R3 said she is afraid that CNA I is going to come in her room at night and do something to her. R3 stated, I don't want to be here tonight. Every night I get anxious. I just want to run away and die. It's terrible, I shouldn't feel that way. (Of note: R3 is indicating that CNA I's presence is affecting her routine, such as becoming anxious and not being able to sleep. A reasonable person would not want to feel afraid of someone within their own home.) On 3/20/25 at 6:44 PM, Surveyor interviewed R3 who stated that everyone tells her not to be afraid of CNA I, but that they are afraid of her too. R3 stated that CNA I is mean to her, and that she starts shaking as soon as CNA I talks to her. Surveyor observed R3 was visibly trembling while discussing CNA I. R3 again stated that if CNA I is in the building that she is so anxious that she lays awake all night, unable to sleep from fear. (Of note: per R3's interview staff were aware R3 was afraid of CNA I, and telling R3 not to be afraid.) On 3/20/25 at 7:09 PM, Surveyor interviewed RN J (Registered Nurse) who stated that she saw the entire incident between CNA I and CNA F. RN J stated that CNA F and CNA I were raising their voices and getting R3 all worked up. RN J stated she would consider what happened to R3 as psychological abuse. Surveyor asked RN J if she had told anyone about the psychological abuse she had witnessed. RN J stated no, she hadn't because everyone saw what happened. (Of note: nurses are mandatory abuse reporters, and RN J did not report abuse to the facility or intervene even though she witnessed psychological abuse.) Example 2 R6 was admitted to the facility on ,d+[DATE] with diagnoses that include Morbid Obesity, Type 2 Diabetes Mellitus, Insomnia, and Major Depressive Disorder. R6's most recent MDS, with an ARD of 1/30/25, indicates R6 has a BIMS of 15 out of 15, indicating R6 is cognitively intact. R6's Care Plan includes, in part: Focus: I have a physical functioning deficit related to Mobility impairment, self-care impairment due to morbid obesity, weakness, physical limitations. Date initiated: 1/20/25 . Interventions: Dressing assistance of 1. Date initiated: 1/20/25 Personal hygiene assistance of 1. Date initiated: 1/20/25 . Transfer assistance of 1 with gait belt and walker. Date initiated: 1/20/25 . Alteration in elimination of bowel and bladder r/t (related to) functional incontinence due to morbid obesity physical limitations and need for staff assistance. Date initiated: 1/20/25 . Interventions: Provide 1 assistance to toilet. Date initiated: 1/20/25 . On 3/20/25 at 10:19 AM, Surveyor spoke with R6 who stated that CNA I makes fun of her accent and the way she talks. R6 said she feels belittled by CNA I, and there are many nights she can't sleep and just lies awake in bed and cries because of her pain, immobility, and having CNA I make fun of her on top of everything else that she is experiencing. R6 stated that many nights she will put on her call light, and CNA I will turn off her call light and tell her she will come right back, but that she doesn't come back for over an hour, resulting in her being soaked and getting a rash. R6 stated that she had talked to NHA A on more than one occasion about CNA I, her lack of care, and how she made fun of her accent, but that nothing was ever done about it. On 3/20/25 at 1:18 PM, Surveyor interviewed NHA A, who stated that he had received no reportable incident from today. On 3/20/25 at 6:12 PM, Surveyor interviewed NHA A, who stated that CNA F told him that her and CNA I had an argument over cares for a resident. NHA A stated he did not know which resident it was. NHA A said that CNA F told him that she was going to call the state, that she didn't give a reason, but it was based on how CNA I treated the residents. Surveyor asked NHA A if a staff member saw another staff being disrespectful and rude to a resident, would he expect that to be reported to him right away. NHA A replied yes. NHA A stated that both CNA I and CNA F would be educated on not arguing in the building. NHA A stated it could have been an abuse situation if a resident was around. Surveyor pointed out that R3 was around and witnessed the incident between CNA I and CNA F. Surveyor asked NHA A if he would expect staff to report allegations of abuse. NHA A replied yes, if it truly was abuse. Surveyor asked if a staff member raising their voice and refusing to help them would be considered abuse. NHA A replied yes absolutely. Surveyor asked NHA A when should staff report allegations of abuse. NHA A replied staff should report allegations of abuse to him immediately. On 3/20/25 at 7:17 PM, Surveyor interviewed NHA A who stated that no one had ever reported concerns about CNA I. Surveyor asked NHA A if R6 had ever brought concerns to him about lack of care with CNA I and that CNA I makes fun of her accent. NHA A stated that he had talked to R6's sister, and that her memory has been going a little and she will say things happened that really didn't happen. Surveyor pointed out that R6 has a BIMS of 15 and no dementia diagnosis. Surveyor asked NHA A if he should take all allegations of abuse seriously. NHA A replied yes absolutely. Surveyor pointed out that R3 and R6 do not feel safe in their own home. NHA A agreed that R3, R6, and all the residents should feel safe in their home. (Of note: NHA A was aware that R6 had concerns.) The facility failed to protect two residents from verbal abuse, including belittling, mocking, yelling and withholding of cares, resulting in ongoing fear and anxiety. R3 was afraid to speak up for fear of retaliation, and R6's concerns of humiliation were not addressed. These residents, who trust and rely on facility staff to meet their needs, have the reasonable expectation to be safe in their home and to be treated with respect and dignity. Cross Reference F609.

Based on observation, interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 3 of 3 sampled residents (R49, R29, R63) and 1 supplemental resident (R5). (R29 is being cited at actual harm) R29 was identified to be at risk for PI development. R29 developed two stage 3 PI's and a stage 2 PI. The facility down staged R29's Pressure injury to a stage 2 when the PI contained slough. Facility staff reported they were not able to turn/reposition R29 every 2 to 3 hours as care planned. The facility failed to update R29's Care Plan with Physician recommendations for turning and repositioning every one to two hours. The facility utilized a bariatric air mattress and when the power source was partially interrupted staff noted R29 to be on a deflating air mattress for 30 to 60 minutes. Staff did not transfer R29 onto an offloading surface that was functioning. R49, R63, and R5 were identified to be at risk for PI development or have a current PI. R49, R63, and R5 were noted to be on deflating air mattresses for 30 minutes to an hour when the facility's power source was partially interrupted. Evidenced by: Facility policy, entitled Wound Management, undated, includes: it is the policy of the facility to provide evidence based treatments in accordance with current standards of practice and physician orders . treatment decisions will be based on a) etiology of the wound- pressure injuries will be differentiated from non pressure ulcers . b) characteristics of the wound- pressure injury stage or level of tissue destruction if not a pressure injury . size-including shape, depth, and presence of tunneling or undermining . volume and characteristics of exudate . presence of pain . presence of infection . condition of tissue in the wound bed . condition of peri wound skin . the effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: lack of progression towards healing, changes in characteristics of the wound, changes in the residence goals . National Pressure Injury Advisory Panel current standards of practice, titled Staging, dated 2016, includes: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Example 1 R29 admitted to the facility on [DATE] with the following diagnoses: schizotypal disorder (mental health condition characterized by a pervasive pattern of intense discomfort with and reduced capacity for close relationships, by distorted cognition and perceptions, and by eccentric behavior), altered mental status, contracture of muscle, and abscess of bursa left hip. R29's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/12/25, indicates R29 is dependent on staff assistance to meet his needs in toileting hygiene, dressing, bed mobility, and transfer. R29's MDS also indicates R29's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. R29's Comprehensive Care Plan, initiated 1/22/21, includes: 1/22/21 Focus: I am at risk for skin breakdown related to limited mobility, history of pressure ulcers, and my need for extensive assistance with repositioning and mobility. I am also at risk due to bowel and bladder incontinence. Goal: I will have no signs and symptoms of skin breakdown through the review date of 5/13/25 . Interventions: 6/15/21 air mattress setting at 150 to 180 per patient weight and comfort. Settings to be checked every shift. 1/22/21 Complete Braden scale per living center policy. 10/13/22 I am incontinent of bladder and bowel. Please help me maintain good hygiene and skin integrity by providing me with incontinence care after each episode. 10/13/22 please report any new and abnormal skin concerns to licensed staff such as bruises, reddened areas, tender areas, cuts or abrasions so that they can update my physician. 12/9/21 I know that licensed staff will conduct a full body inspection per policy. 2/5/25 Wedge in bed for repositioning every two to three hours staff to reposition wedge as needed. 2/1/21 Focus: I have a physical functioning deficit related to mobility impairment, self-care impairment. Goal: I will improve my current level of functioning with target date of 5/13/25 . Interventions: 12/9/21 Bed mobility assistance: extensive 2 assist . 2/15/24 Transfer assistance- 2 assist with hoyer. Towel to be placed between right side strap and right leg to prevent rubbing skin injury . (It is important to note the facility had no evidence of R29's mattress settings being checked every shift.) (It is important to note R29 has an infection that set in around the hardware in his left hip. R29 had the hardware removed and his legs now lay in a frog leg position. The facility has accommodated this deformity by keeping R29 on a bariatric bed and mattress.) R29's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 11/13/24, indicates R29 is at high risk for PI development. R29's Body Check Form, dated 11/13/24, indicates R29 has a new skin disruption/open spot wound on his coccyx area. What kind of skin disruption was found? Open spot on bottom . open area on butt . R29's Physician Summary, dated 11/13/24, includes: Chief complaint: Patient has wound on his sacrum and a rash . Review of Systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Non-pressure Wound Sacrum Partial Thickness: etiology- moisture associated skin damage . Objective: healing . Wound size: 6.0cm x 0.5cm x 0.1cm . Exudate: light serosanguinous . Dermis: open areas exposed dermis . Dressing Treatment Plan: Primary- Zinc ointment apply every shift (3 times a day) for 30 days . Recommendations: Off-load wound, reposition per facility protocol . R29's Physician Summary, dated 11/20/24, includes: Chief complaint: Patient has wound on his sacrum . Review of Systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Non-pressure wound sacrum partial thickness: etiology- moisture Associated Skin Damage, objective- healing, wound size: 5.0cm x 0.5cm x 0.1cm . Exudate: light serosanguinous . Dermis: open area with exposed dermis . Dressing Treatment Plan: Primary: Zinc ointment apply every shift (3 times a day) for 23 days . Recommendations: Off-load wound; Reposition per facility protocol . R29's Physician Summary, dated 11/27/24, includes: Chief complaint: Patient has wound on his sacrum . Review of Systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm x 0.7cm x 0.1cm . Additional Wound Details: Adjusting etiology given appearance of wound bed . Dressing Treatment Plan: Primary: Zinc ointment apply every shift (3 times a day) for 16 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . (Of note: R29's sacrum wound is now being identified as a pressure injury. Even though the physician ordered repositioning to offload the wound, there is no evidence R29's care plan was updated to include this intervention. R29's Physician Summary, dated 12/4/24, includes: Chief complaint: Patient has wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm (centimeter) x (by) 1.0cm x 0.2cm . Exudate: moderate serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply three times per week for 30 days . Secondary: Dry dressing apply three times per week for 30 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . (It is important to note in this assessment there is no description of the wound characteristics, including color, tissue type or tissue percentage. Wound MD note indicates unstageable DTI within and around wound.) R29's Physician Summary, dated 12/11/24, includes: Chief complaint: Patient has a wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm x 0.7cm x 0.2cm . Exudate: moderate serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply three times per week for 23 days . Secondary: Dry dressing apply three times per week for 23 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . R29's Body Check Form, dated 12/11/24, indicates R29 has a new skin disruption/old wound on his coccyx area. What kind of skin disruption was found? Open area on bottom . R29's Physician Summary, dated 12/18/24, includes: Chief complaint: patient has wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 2.5cm x 0.7cm x 0.2cm . Exudate: moderate serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply three times per week for 16 days . Secondary: Dry dressing apply three times per week for 16 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . R29's In House Assessment, dated 12/24/24, includes: Type of wound: non-pressure . Location of wound: coccyx . admitted or Acquired: in house acquired . Date identified: 11/13/24 . Measurements: 2.5cm x 1.5cm x 0.2cm . Treatment: Clean. Pat dry. Calcium alginate dry dressing . Frequency: 3 times per week and as needed . Care planned: yes . Orders up to date in (electronic health record): yes . (It is important to note in this assessment the PI is larger in width, there is no description of the wound including color, drainage description, drainage amount, drainage color, if there was an odor, description of wound edges, description of wound bed, or description of the surrounding area. It is important to note even though the physician is now identifying the area as an unstageable deep tissue injury, which is a pressure injury, the facility continues to identify it as non-pressure wound.) On 3/11/25 at 12:15 PM, Surveyor spoke with DON B, who indicated R29's coccyx/sacrum PI and non-pressure wound are the same wounds. DON B indicated R29 did not have two different wounds to the sacrum/coccyx area. R29's Physician Summary, dated 12/31/24, includes: Chief complaint: patient has wound on his sacrum. Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Unstageable Deep Tissue Injury Sacrum: etiology- pressure, objective- healing, wound size: 3.0cm x 1.0cm x 0.2cm, exudate- light serosanguinous . Dressing Treatment Plan: Primary: Alginate calcium apply once daily for 30 days; Leptospermum honey apply once daily for 30 days . Secondary: Dry dressing apply once daily for 30 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . The physician continued to order repositioning and offloading. There is no evidence this intervention was added to the care plan to promote healing. R29's Physician Summary, dated 1/8/25, includes: Chief complaint: patient has wounds on his sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, wound size: 4cm x 4cm x 0.2cm, Exudate- moderate serosanguinous, Granulation tissue- 70%, Skin- intact normal color 30% . Dressing Treatment Plan: primary- Alginate calcium apply once daily for 22 days, Secondary- dry dressing apply once daily for 22 days, Recommendations- reposition per facility protocol; offload wound; group 2 mattress . Stage 2 Pressure Wound of the Right Buttock Partial Thickness: Etiology- pressure, objective- healing, wound size- 4.0cm x 5.0cm x 0.1cm, Exudate- light serosanguinous, dermis- open areas with exposed dermis . Stage 2 Pressure Wound of the Left Buttock Partial Thickness: Etiology- pressure, objective-healing, wound size- 4.0cm x 5.0cm x 0.1cm . Additional wound details- multifactorial, reviewed need for dressings and for continued offloading of wounds . Dressing Treatment Plan: primary dressing- alginate calcium apply once daily for 22 days. Leptospermum honey apply once daily for 22 days, secondary- dry dressing apply once daily for 22 days . Recommendations: Reposition per facility protocol; offload wound; group 2 mattress . (It is important to note R29 now has three in house acquired PI, one stage 3 on the sacrum, a stage 2 on the right buttock, and a stage 2 on the left buttock. R29's Stage 3 pressure injury has increased in size. ) On 1/8/25, R29's Nursing advance skin check indicates additional skin issue education documentation: Staff for am also updated and will updated [sic] pm staff cop (change of position) q 2 hours, check for incont, only 1 sheet under him, check hob (head of bed) position. R29's Body Check Form, dated 1/12/25, staff circled coccyx area indicating R29 has a skin disruption on his coccyx area and handwritten note indicating wounds. R29's Physician Summary, dated 1/15/25, includes: Chief complaint: patient has wounds on his sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, wound size: 3.0cm x 1.0cm x 0.2cm . Exudate- Moderate Serosanguinous, granulation tissue-100% . Stage 2 Pressure Wound of Right Buttock Partial Thickness: etiology- pressure, objective- healing, wound size- 3.0cm x 3.0 x 0.1cm . Exudate- moderate serosanguinous, dermis- open area with exposed dermis . Dressing Treatment Plan: primary dressing- collagen sheet apply once daily for 30 days, secondary- dry dressing apply once daily for 30 days, Recommendations- reposition per facility protocol; offload wound; group 2 mattress . Stage 2 Pressure Wound of Left Buttock Partial Thickness: etiology- pressure, objective-healing; wound size 2.0cm x 2.0cm x 0.1cm .; exudate- moderate sersanguinous[sic]; dermis- open areas with exposed dermis . Dressing Treatment Plan: primary- collagen sheet apply once daily for 30 days, secondary- dry dressing apply once daily for 30 days . Recommendations- reposition per facility protocol, offload wound, group 2 mattress . R29's Body Check Form, dated 1/19/25, indicates R29 has a new skin disruption on his coccyx area. What kind of skin disruption was found? (blank) . (It is important to note staff circled the coccyx area on the image indicating a new skin disruption noted, but then handwrote No when asked if new skin disruption found.) R29's Physician Summary, dated 1/23/25, includes: Chief complaint: patient has wounds on his sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, wound size: 3.0cm x 0.8cm x 0.2cm . exudate- light serosanguinous, Thick adherent devitalized necrotic tissue- 80%, slough- 10%, granulation tissue- 10% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 30 days . secondary- gauze island with border apply once daily for 30 days . Peri wound treatment- Skin prep apply once daily for 30 days . Recommendations: cleanse with soap and water, turn side to side in bed every one to two hours if able, offload wound, group 2 mattress already on . surgical excisional debridement was performed today on this wound . surgical excisional debridement procedure: indication for procedure- remove necrotic tissue and establish the margins of viable tissue . procedure note: the wound was cleansed with normal saline and anesthesia was achieved by using topical benzocaine . then with clean surgical technique, 15 blade was used to surgically excise 2.16cm ^2 of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.3 centimeters and healthy bleeding tissue was observed. As a result of this procedure, the non viable tissue in the wound bed decreased from 90% to 0%. Hemostasis was achieved and a clean dressing was applied (Of note: R29's Sacrum/coccyx wound deteriorated from 100% granulation tissue to 80% necrotic tissue requiring debridement (removal of necrotic and devitalized tissue).) . Stage 3 Pressure Wound of the Right Buttock Full Thickness: etiology- pressure, objective- healing, wound size- 2.0cm x 2.0cm x 0.1cm, exudate- light serosanguinous, slough- 80%, granulation tissue- 20% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 30 days . secondary- gauze island with border apply once daily for 30 days . Peri wound treatment- skin prep apply once daily for 30 days, zinc ointment apply once daily for 30 days . Recommendations: offload wound, reposition per facility protocol, group 2 mattress, cleanse with soap and water, turn side to side in bed every one to two hours if able, changing schedule every two hours . Sharp Selective Debridement Procedure: indication for procedure-remove biofilm. Remove devitalized tissue at margins of a wound . procedure note: the wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to selectively remove biofilm, remove devitalized tissue at margins of a wound over the wound surface area of 4cm ^2. The wound was cleansed again and clean dressing was applied . Employing selective debridement of slough only. (Of note: R29's Right buttock PI deteriorated to a stage 3 pressure injury and required debridement.) . Stage 2 Pressure Wound of Left Buttock Partial Thickness: etiology-pressure, objective-healing, wound size- 2.0cm x 0.7cm x 0.1cm, exudate light serosanguinous, dermis- open areas with exposed dermis . Dressing Treatment Plan- Primary- zinc ointment apply once daily for 30 days, Iodosorb gel apply once daily for 30 days, Secondary- Gauze island with border apply once daily for 30 days, peri wound treatment- Skin prep apply once daily for 30 days . Recommendations: group 2 mattress, offload wound, repositioned per facility protocol, cleanse with soap and water, turn side to side in bed every one to two hours if able, changing schedule every two hours . (It is important to note R29 now has two in house acquired stage 3 pressure injuries and one stage 2 PI. The facility did not update R29's care plan to reflect the recommendations of turn side to side every one to two hours.) R29's Body Check Form, dated 1/26/25, indicates R29 has skin disruption on his coccyx area circled by staff. Are there any new skin disruptions found? No. What kind of skin disruption was found? (blank) . R29's Physician Visit Summary, dated 1/30/25, includes: Chief complaint: wound on sacrum, right buttock, left buttock . Review of systems: urinary incontinence, fecal incontinence, deconditioning, contractures . Support surfaces: bed- group 2, chair- pressure reduction cushion, feet- pillow . Stage 3 Pressure Wound Sacrum Full Thickness: etiology- pressure, objective- healing, Wound size (length x width x depth) - 2.5cm x 0.5cm x 0.2cm . periwound radius- macerated, exudate- light serosanguinous, Thick adherent devitalized necrotic tissue- 80%, slough- 10%, granulation tissue- 10% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 23 days . secondary- gauze island with border apply once daily for 23 days . Peri wound treatment- Skin prep apply once daily for 23 days . Recommendations- cleanse with soap and water; turn side to side in bed every one to two hours if able; offload wound; group 2 mattress already on . Stage 3 Pressure Wound of Right Buttock Full Thickness: etiology-pressure, Wound size- 1.0cm x 2.0cm x o.1cm, exudate- light serosanguinous, Slough- 80%, Granulation tissue- 20% . Dressing Treatment Plan- primary- Iodosorb gel, apply once daily for 23 days . secondary- gauze island with border apply once daily for 23 days . Peri wound treatment- Skin prep apply once daily for 23 days . Recommendations- offload wound, reposition per facility protocol, group 2 mattress, cleanse with soap and water, turn side to side in bed every one to two hours if able, changing schedule every two hours .Sharp Selective Debridement Procedure: indications for procedure- remove biofilm, remove dried exudates or debris . procedure note: the wound was cleansed with normal saline and anesthesia was achieved by using topical benzocaine . then with clean surgical technique, 15 blade was used to selectively remove biofilm, remove dried exudates or debris over the wound surface area of 2.0cm ^2. The wound was cleansed again and a clean dressing was applied . Stage 2 pressure wound of the left buttock: resolved . Of note: due to deterioration of the right buttock PI, the physician debrided the PI to remove debris and biofilm.) R29's Body Check Form, dated 2/2/25, includes: no new skin disruptions noted .In House Weekly Wound Roster, dated 2/5/25, includes: R29- Coccyx, non pressure, in house acquired, date identified 11/13/24, stage-3, measurement- 3.0cm x 1.0cm x 0.2cm . Treatment- Clean, pat dry, medi-honey, calcium alginate, dry dressing . frequency- daily and as needed . Care planned- yes . Orders up to date in electronic health record- yes .Right buttock, pressure, in house acquired, date identified 1/8/25, stage- 2, measurement- 3.0cm x 3.0cm x 0.1cm . Treatment- collagen sheet, dry dressing . frequency- daily and as needed . Care planned- yes . Orders up to date in electronic health record- yes .Left buttock, pressure, in house acquired, date identified 1/8/25, stage- 2, measurement- 2.0cm x 2.0cm x 0.1cm . Treatment- collagen sheet, dry dressing . frequency- daily and as needed . Care planned- yes . Orders up to date in electronic health record- yes . (It is important to note the facility continues to measure R29's left buttock wound after it was noted to be resolved on 1/30/25. There is no indication the facility notified R29's Medical Doctor when this area reopened. It is important to note the Facility down staged R29's wound to the sacral region from a stage 3 to a stage 2. The facility documents it as being non-pressure even though the physician indicates it's a stage 3 pressure injury.) On 2/5/25, R29's care plan was updated to include Wedge in bed for repositioning every two to three hours staff to reposition wedge as needed. This is the first time the care plan had been updated to include repositioning; however, the facility documented that repositioning should be done every 2-3 hours, when the physician actually ordered every 2 hour side to side repositioning. R29's Physician Note, dated 2/11/25, include: pressure ulcer sacral region, measurements: 5.2cm x2.0cm x0.2cm . Stage 2, moderate exudate, serosanguineous, no odor, necrotic- (blank), granulation tissue: 0% .Tissue exposed- subcutaneous, periwound- non-blanchable, erythematous, macerated . Treatment Recommendations: the plan for the pressure ulcer is to cleanse the area with wound cleanser and the periwound area with vashe wound solution. Wound filler- Iodosorb Gel . Primary dressing- mepilex . This treatment will be done daily for 1 month. Today's treatment will be performed by the wound care team and other care performed by the staff of the facility . The pressure ulcer is to be offloaded using low air loss mattress . will be able to heal if offloading is able to continue in the setting of this acute illness. (It is important to note there are no weekly measurements or description for R29's left buttock PI or right buttock PI in this note or indication that the areas resolved. R29's sacrum (coccyx) PI has increased in length and is documented as a stage 2. Per standards of practice, a pressure injury should not be down staged.) R29's Braden Scale for Predicting Pressure Ulcer Risk, dated 2/12/25, indicates R29 is at high risk for developing pressure ulcers. On 2/15/25 the facility updated R29's care plan to include transfer assistance - 2 assist with Hoyer (full body lift) towel to be placed between right side strap and right leg to prevent rubbing skin injury. Physician Note, dated 2/18/25, includes: sacral region, wound type-pressure ulcer, measurements: 5.2cm x 2.0cm x 0.2cm . Tunnels- none, Stage 2, moderate exudate, serosanguineous, no odor, wound margins- well defined, necrotic material- over 50% .25% granulation tissue, scattered beefy red, pale . Tissue exposed- subcutaneous . Treatment Plan: The plan for the pressure ulcer-sacral region is to cleanse the area with wound cleanser and the periwound area with vashe wound solution . Wound filler- santyl . Primary dressing- mepilex . This treatment will be done twice a day for 1 month. The pressure ulcer was debrided using sharp debridement. The pressure ulcer is to be offloaded using a low air loss mattress . Left gluteal, wound type- abrasion, measurements- 1.5cm x 1.5cm x 0.1cm . Exudate amount- low, Exudate type- sanguinous, Odor-none, Wound Margins- poorly defined, periwound-denuded . Tissue exposed- partial thickness . Treatment Plan: The plan for the abrasion is to cleanse the area with vashe wound solution and the periwound area with vashe wound solution . Periwound Skin Treatment- SurePrep rapid dry, no sting barrier film . Primary dressing: Hydrocolloid dressing. This treatment will be done 3 times per week for 1 month. (Of note the Physician staged R29's sacral wound at a stage 2 but described the wound bed as having more than 50% necrotic tissue) On 2/23/25 at 2:40 PM LPN U (Licensed Practical Nurse) indicated the facility lost some power and then lost total power. LPN U indicated R29's air mattress was deflated for 30 minutes to an hour. LPN U indicated staff did not attempt to transfer R29 to a different surface or plug his bed into an emergency outlet. On 2/25/25 at 10:33 AM Surveyor observed R29's wound care with ADON C (Assistant Director of Nursing). ADON C indicated the sacral wound measures at 3.1cm x 0.6cm with 0.2cm. ADON C stated, There is some slough, 25 % granulation. Surveyor asked ADON C if there is slough in the wound how can it be a stage 2. ADON C stated, The slough is going away. Physician Note, dated 2/25/25, includes: wound- sacral region, wound type- pressure ulcer, measurements- 3.1cm x 0.6cm x 0.2cm . Stage- 2, Exudate amount- moderate, exudate type- serosanguinous, Odor- none, wound margins- well defined, peri wound- erythematous, necrotic material- 50%, granulation between 25% and 50% scattered, beefy red, pale, tissue exposes-subcutaneous . Treatment Plan: the plan for the pressure ulcer is to cleanse the area with wound cleanser in the peri wound area with Vashe wound cleanser . Wound filler- santyl . Primary dressing- mepilex . this treatment will be done twice a day for one month. The pressure ulcer was debrided using sharp debridement. The pressure ulcer is to be offloaded using low air loss mattress. Dressings can be changed as needed for soiling or if they are dislodged between scheduled dressing changes . wound- Left gluteal- healed Wound Type- abrasion . exudate amount- low, exudate type- sanguinous, wound margins- poorly defined, peri wound- denuded, tissue exposed- partial thickness . (Of note: During the dressing change on 2/25/25 ADON C and Surveyor both observed and noted slough in the wound bed while the physician does not mention slough. The left gluteal area is indicated as resolved.) On 2/25/25 at 2:38 PM, DON B (Director of Nursing) indicated the facility needed to provide education on emergency preparedness. DON B indicated staff should have transferred residents with pressure injuries whose bed was deflating/deflated to a support surface that was functioning appropriately. On 2/26/25 at 11:25 AM, CNA L (Certified Nursing Assistant) indicated they try to turn and reposition R29 every 2 to 3 hours, but there are times they are late doing this because they are busy with other residents. On 2/26/25 at 11:46 AM, RN G (Registered Nurse) stated, Staffing is a concern on this unit and to be honest, there have been times the staff was late to reposition and turn R29. It is very difficult for aides to get to him every 2 to 3 hours. On 2/26/25 at 4:36 PM, CNA S indicated staff turn and reposition R29 every 3 hours most days but they cannot get to him every 1 to 2 hours. CNA S indicated because of the acuity on the unit, they could use some more help especially [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure that a resident with a pressure injury received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new injuries from developing for 6 of 6 residents (R3, R2, R5, R8, R9, and R10) with pressure injuries or at risk for developing pressure injuries. R3 admitted to the facility with a stage IV pressure injury to her sacrum that worsened. R3 developed six other pressure injuries while in the facility, all identified as a stage III or unstageable. R3 did not have treatments done for her wounds on all dates and times as ordered. R3 had two wound care orders that were not completed. R3 did not have treatment orders transcribed for four wounds that were discovered at the facility 4/30/24 (three wounds) and 5/7/24 (one wound). The facility's failure to ensure residents with pressure injuries receive the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing, created a finding of immediate jeopardy that began on 4/30/24 when three new wounds developed. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 6/13/24 at 3:29 PM. The immediate jeopardy was removed on 6/15/24; however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as evidenced by the following examples: R5, R8, R9, and R10 were observed for multiple hours not being assisted with repositioning or using the restroom. R2 did not receive treatment to his pressure ulcers 12 times between 5/1/24 and 6/10/24. This is evidenced by: The facility's Policy and Procedure entitled Wound Management dated 10/28/21, documents in part: .To promote wound healing of various types of wounds it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of treatment nurse .7. Treatments will be documented on the Treatment Administration Record . R3 was admitted to the facility for short term rehab and wound care. R3 had the following diagnoses: malignant neoplasm of bone and articular cartilage (cancer), acute respiratory failure with hypoxia (condition where the body's tissues don't have enough oxygen), paraplegia (chronic condition that causes the loss of muscle function and voluntary movement in the lower half of the body), pressure injury sacral (bottom of the spine that lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone) stage 4, combined systolic (heart at work) and diastolic (heart at rest) heart failure (condition that occurs when the heart's left ventricle can't contract normally so the heart can't pump enough blood into circulation with enough force), Peripheral Vascular Disease (PVD; circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anxiety disorder, and Urinary Tract Infection (UTI) diagnosed on [DATE]. R3's most recent Minimum Data Set (MDS) dated [DATE] documents, a score of 15 on her Brief Interview of Mental Status (BIMS), which indicates R3 was cognitively intact. R3's Care Plan included the following: 2/23/24 Pressure ulcer at risk due to weakness, paraplegia, and need for staff assistance for positioning. Interventions documented in part: . Float heels when in bed and as resident will allow, Nutritional and Hydration support, Provide pressure reducing wheelchair cushion, Provide pressure reduction/relieving mattress, Provide thorough skin care after incontinent episodes and apply barrier cream, Turning and repositioning about every 2 hours while awake and as resident will allow .; Intervention added 3/8/24, Resident does not want the head of the bed lowered during cares as it causes pain to her back and the wound on her coccyx. 3/7/24 Pressure ulcer actual due to admitted with stage 4 pressure injury to coccyx area. Interventions documented in part: .Provide pressure reducing wheelchair cushion, Provide pressure reduction/relieving mattress . 3/13/24 Physical functioning. Interventions documented in part: .R3 can sit up in the broda chair for half hour to 1 hour either at breakfast or for lunch. Place pillow behind legs when sitting, Floating boots on while up in broda chair . R3's Braden Scales (tool to identify residents' risks for forming pressure injuries) document the following: R3's admission Braden Scale dated 3/7/24 score was 16 which indicates she is at risk. R3's Braden Scale dated 3/14/24 score was 13 which indicates she is at moderate risk. R3's Braden Scale dated 3/26/24 score was 12 which indicates she is at high risk. R3's Braden Scale dated 4/3/24 score was 12 which indicates she is at high risk. R3's Braden Scale dated 4/17/24 score was 12 which indicates she is at high risk. It is important to note that as these Braden Scale scores worsened and R3's risk increased, the facility did not implement any further or more aggressive actions. R3's MDS dated [DATE] section M. Skin documents the following in part: R3 has two unstageable wounds present on admission. R3 should have a bed device for pressure relief, chair device for pressure relief, nutrition plan, and pressure injury care. Turning and repositioning for R3 was marked No. It is important to note that there are only measurements for one unstageable wound. R3's medical record does not contain any documentation that R3 was being turned and repositioned until 4/26/24. R3's Physician Orders document, in part: The following two orders do not include the location of the wound: 3/8/24 Wash wound with wound cleanser or NS (normal saline), dry with gauze and then pack wound with gauze moistened with Dakin's (dilute solution of sodium hypochlorite and other stabilizing ingredients) 25% and cover with dry dressing or border gauze every day shift for wound dressing through 3/12/24. 3/12/24 Wash wound with wound cleanser or NS, dry with gauze and then pack wound with gauze moistened with Dakin's 25% and cover with dry dressing or border gauze every day and evening shift for wound dressing 3/19/24. R3's Physician Orders do not include wound care orders for R3's wounds to her center midline spine (discovered 4/30/24) or additional center midline spine wounds or left inferior ischium (discovered 5/7/24) wound. It is important to note that wound care orders for center midline spine and left inferior ischium were never transcribed by the facility as a result there were no treatments done for this area. R3's Treatment Administration Record (TAR) documents, in part: R3's wound care orders for her coccyx/sacrum wound have blanks on the following dates - 3/15/24 AM, 3/19/24 AM, 3/20/24 AM, 3/22/24 AM and PM, 4/1/24 PM, 4/11/24 AM, and 4/25/24. R3's Wound Documentation documents in part: Coccyx/Sacrum wound (present on admission) - ~ Admission skin assessment dated [DATE], coccyx and buttocks stage 4 wounds with slough. ~ assessment dated [DATE] - coccyx, stage 4, 30% granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), 50% necrotic (dead or dying tissue), 5.42 cm (centimeters) x 3.52 cm x not measurable (measurements are length x (by) width x depth; depth can't be measured when there is necrotic tissue present as you don't know what is underneath that tissue). This assessment documents the following .Reviewed off-loading surfaces and discussed surfaces care plan. Recommend upgrading off-loading devices in bed and/or chair . It is important to note that R3's admission assessment of stage IV pressure injury to coccyx has no measurements until 3/12/24. Of note, R3's wound assessment dated [DATE] documents that R3's bed and chair devices should be upgraded, the facility was not able to speak to if that occurred or produce any documentation indicating an upgrade took place. ~assessment dated [DATE] - coccyx, stage 4, 40% granulation, 40% necrotic, 20% muscle, bone, 7.37 cm x 5.21 cm x 3 cm. ~ assessment dated [DATE] - coccyx, stage 4, 70% granulation, 10% necrotic, 20% muscle, 6.2 cm x 4 cm x 3 cm. ~ assessment dated [DATE] - center posterior sacrum, stage 4, 80% granulation, 20% necrotic, 6.8 cm x 5.81 cm x 2 cm, undermining (edges of a wound separate from the surrounding healthy tissue, creating a pocket under the wound's surface, undermining is caused by erosion, pressure, shear, moisture, or infection and can significantly impact wound healing and closure. ) 2.2 cm from 12 o'clock to 3 o'clock and 1 cm from 8 o'clock to 11 o'clock. ~ assessment dated [DATE] - center posterior sacrum, stage 4, 85% granulation, 15% necrotic, 7.09 cm x 6.37 cm x 2 cm, undermining 2.2 cm from 12 o'clock to 3 o'clock and 1 cm from 8 o'clock to 11 o'clock. ~ assessment dated [DATE] - center posterior sacrum, stage 4, malodorous (bad smell), 22.59% granulation, 77.41% necrotic, 14.93 cm x 11.35 cm x 2.5 cm, undermining 2.2 cm from 12 o'clock to 3 o'clock and 1 cm from 8 o'clock to 11 o'clock. ~ assessment dated [DATE] - center posterior sacrum stage 4, 85% granulation, 15% necrotic, 14.5 cm x 11.25 cm x 2.5 cm, undermining 2.2 cm from 12 o'clock to 3 o'clock and 1 cm from 8 o'clock to 11 o'clock. ~ assessment dated [DATE] - center posterior sacrum, stage 4, 60% granulation, 40% necrotic, 13.4 cm x 8.05 cm x 2.5 cm, undermining 2.2 cm from 12 o'clock to 3 o'clock and 1 cm from 8 o'clock to 11 o'clock. ~ assessment dated [DATE] - center posterior sacrum, stage 4, 95.08% granulation, 2.49% necrotic, 2.43% fibrous (tissue made up of tough protein fibers called collagen and cells called fibroblasts), 14.82 cm x 14.39 cm x 2.4 cm, undermining 2.4 cm from 12 o'clock to 3 o'clock and 1.7 cm from 8 o'clock to 11 o'clock. Right Posterior Ischium Wound - ~ assessment dated [DATE] - right posterior ischium, stage 3, 62.61% granulation, 37.39% necrotic, 2.07 cm x 3.54 cm x 0.1 cm. ~ assessment dated [DATE] - right posterior ischium, stage 3, 20% granulation, 80% necrotic, 2.36 cm x 2.47 cm x 0.1 cm. Center Midline Back - ~ assessment dated [DATE] - center midline back, stage 3, 80% granulation, 20% necrotic, 1.5 cm x 0.4 cm x 0.1 cm. ~ assessment dated [DATE] - center midline back, stage 3, 15% granulation, 85% fibrous, 4.8 cm x 1.8 cm x 0.2 cm. It is important to note that the picture of this wound dated 5/7/24 has three separate wounds that have intact skin islands between them, however there is only one set of measurements indicating two of the wounds were not assessed or received treatment. Right Lateral Leg - ~ assessment dated [DATE] - right lateral leg, unstageable, 100% necrotic, 16.17 cm x 3.67 cm x 0.1 cm. ~ assessment dated [DATE] - right lateral leg, unstageable, 100% necrotic, 16.4 cm x 4.89 cm x 0.1 cm. Left Inferior Ischium - ~ assessment dated [DATE] - left inferior ischium, stage 3, 80% granulation, 20% fibrous, 2.11 cm x 1.85 cm x 0.1 cm. R3's Progress Notes include the following: 4/30/24, there is a note by the ADON (Assistant Director of Nursing) identifying new wounds to R3's right posterior ischium and center midline spine. There is no documentation of the wound to R3's right lateral leg. There is no documentation regarding identification of the wound to R3's left inferior ischium that was discovered on 5/7/24. It is important to note that the facility has no investigation into the root cause analysis of how these wounds developed. It is important to note that on 4/30/24 three additional wounds were discovered, two at a stage III and one unstageable (full thickness pressure injury where the base of the wound is covered by dead tissue or eschar.) Of note, on 5/7/24 one more additional wound was discovered at a stage III. R3's hospitalization admit documentation of wounds, dated 5/10/24: Center Posterior Sacrum - stage IV pressure injury, 8.2 cm, x 8.6 cm x 2.9 cm, undermining from 7 o'clock to 5 o'clock with the deepest depth at 1 o'clock of 3.4 cm and 1 cm from 8 o'clock to 11 o'clock, 40% slough present. Right Posterior Ischium - stage III pressure injury, 2.3 cm x 3.5 cm 0.2 cm, 40% slough present. Center Midline Back - stage III pressure injury, three ulcerations with small skin island separating them located along the spinal process, 11.2 cm x 4.5 cm x 0.2 cm, 40% slough present. Right Lateral/Posterior Calf - unstageable pressure injury, 14.6 cm x 2.9 cm x > (greater than) 0.1 cm (unknown depth), 100% eschar (dead tissue that forms over healthy skin). Left Posterior Ischium - stage III pressure injury, 3 cm x 1.9 cm x 0.1 cm, 40% slough present. On 6/11/24 at 12:06 PM, Surveyor interviewed FM T (Family Member). Surveyor asked FM T what concerns she had with R3's care. FM T explained that R3 was admitted for wound care so that was the primary focus for her stay at this facility. Surveyor asked FM T what concerns she had regarding R3's wounds., FM T stated R3 is supposed to be on a special mattress; her sacral wound worsened, and she developed 6 other wounds. Neither the condition of her wounds nor the development of 6 other wounds were communicated to FM T. FM T stated the facility was giving her ProStat (high protein supplement) not Ensure, she wasn't being repositioned timely or with the correct amount of assistance, and she had boots on in the hospital but not here in the facility. Surveyor asked FM T what type of mattress R3 was on at the facility, FM T said she had a pump that hung on the footboard, but it wasn't like the mattress she was on at either hospital she was at prior to coming to this facility. Surveyor asked FM T if she had called the facility or asked the staff to give her an update on R3's wounds, FM T stated yes, and no one seemed to know, or they directed me to talk with the wound nurse who was not in the facility in evening when we typically visited. Surveyor asked FM T what her concern was with the ProStat versus Ensure. FM T explained that R3 didn't always drink the ProStat but was accepting of the Ensure Max which has more protein, FM T stated that the facility said they couldn't provide her the Ensure Max. Surveyor asked FM T if R3 was being turned and repositioned, FM T stated no, R3 would call me if they hadn't been in to turn and reposition her and then I'd have to call the nursing home. R3 didn't like to turn side to side as it caused her pain in her wound on her bottom and in her ribs but she would reposition. FM T went on to explain that when R3's family visited, no staff would come in to reposition her and on the rare occasion someone did, it would only be one staff member and R3 required two assist for repositioning. FM T stated that R3 told her that often there was only one staff so they would go behind her bed and pull her up with the sheet under her. Surveyor asked FM T if there was anything else surrounding R3's wounds that she had concerns with, FM T stated that R3 had boots on her feet in the hospital but that the facility didn't continue to use them, and she didn't understand why. On 6/13/24 at 9:12 AM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J if R3 admitted to the facility with wounds, CNA J stated yes, to her bottom. Surveyor asked CNA J if she recalled what interventions R3 had in place, CNA J said R3 had an air mattress, Broda chair, blanket between knees, and a cushion. Surveyor asked CNA J if she knew what kind of cushion it was, CNA J said no, she was unable to recall the type of cushion. Surveyor asked CNA J if R3 had boots or if her heels were floated, CNA J stated R3 didn't have any boots to start with but did end up getting boots, blue fluffy ones. Surveyor asked CNA J if R3 developed other wounds while she was here, CNA J said yes. Surveyor asked CNA J what was used to move R3 while in bed, CNA J said the draw sheet. Surveyor asked CNA J what areas of R3's body would the draw sheet cover, CNA J stated buttocks, thighs, and lower back. Surveyor asked CNA J how many staff did it take to assist R3 for turning and repositioning, CNA J replied two assist. Surveyor asked CNA J if R3 was ever turned and repositioned with one assist, CNA J stated, I always got another person. On 6/13/24 at 9:13 AM, Surveyor interviewed LPN S (Licensed Practical Nurse). Surveyor asked LPN S if all wounds should have treatment orders, LPN S stated yes. Surveyor asked LPN S should wound orders include the location of wound, LPN S said yes. Surveyor asked LPN S if she recalled what interventions R3 had in place, LPN S said air mattress, pillows/wedges, and a cushion. Surveyor asked LPN S how many assist it took to reposition R3, LPN S stated normally two and if R3 wasn't repositioned when she was supposed to be, R3 would call her daughter and then her daughter would call the facility. Surveyor asked LPN S what was used to boost R3, LPN S said the draw sheet. Surveyor asked LPN S if R3 was ever turned and repositioned with one assist, LPN S replied, I don't think back then because we had more help. On 6/13/24 at 10:41 AM, Surveyor interviewed DOM Y (Director of Maintenance). Surveyor asked DOM Y if R3 had an air mattress. DOM Y stated it is our standard of practice if R3 had wounds to have an air mattress, I think when she came in she had one or if we had to order it, it would've come the next day. On 6/13/24 at 11:20 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B would you expect all wounds to have treatment orders, DON B stated yes. Surveyor asked DON B would you expect wound orders to include the location of wound, DON B replied yes. Surveyor asked DON B if R3 had wounds when she admitted , DON B said I believe she did. Surveyor asked DON B if R3 developed more wounds while here, DON B replied I believe she did develop one. Surveyor asked DON B if there was an investigation into the root cause of R3 developing other wounds, DON B explained yes there should be, R3 had a lot of stuff going on - she had cancer; Surveyor asked DON B where the investigation would be documented, DON B said it would be in the wound nurse's notes. Surveyor asked DON B what interventions were in place for R3, DON B said an air mattress, R3 spent most of the time in bed and turning and repositioning. Surveyor asked DON B if R3 had boots or heels floated, and any type of cushion, DON B stated don't recall boots, and there was a discussion about a Roho cushion. Surveyor asked DON B when the air mattress was placed on R3's bed. DON B stated it is our standard of practice that if a resident has wounds, they should have an air mattress. It is important to note that the facility was not able to confirm what date R3 had the air mattress placed on her bed. On 6/13/24 at 2:10 PM, Surveyor interviewed DON B again. Surveyor asked DON B if R3 had her offloading surfaces updated after recommendation from wound team on 3/12/24, DON B said an air mattress would've been in place that's what they write for everyone. Surveyor showed DON B a picture of R3's wound assessment documentation in R3's record dated 5/7/24 (picture clearly shows three wounds present with intact skin in-between); Surveyor then asked DON B if he would expect there to be three sets of measurements, DON B said yes. On 6/13/24 at 4:50 PM, Surveyor interviewed CNA U. Surveyor asked CNA U if she recalled what interventions R3 had in place, CNA U stated an air mattress and we were to float bottom with pillows. Surveyor asked CNA U if R3 developed more wounds here, CNA U said I'm not sure about more, but they weren't changing the bandages every day and you could notice the smell. Surveyor asked CNA U what was used to move R3 in bed. CNA U said either a draw sheet or a bath blanket. Surveyor asked CNA U how many staff did it take to assist R3 with turning and repositioning, CNA U replied two assist. Surveyor asked CNA U if R3 was ever turned and repositioned with one assist, CNA U stated they don't have enough staff, so could have. On 6/13/24 at 5:08 PM, Surveyor interviewed RN Q (Registered Nurse.) Surveyor asked RN Q if all wounds should have treatment orders, RN Q stated they should. Surveyor asked RN Q should wound orders include the location of the wound, RN Q stated yes. Surveyor asked RN Q if R3 admitted with any wounds, RN Q said yes, stage 4 to her coccyx. Surveyor asked RN Q if R3 developed any wounds while she was here, RN Q stated she developed multiple wounds here. Surveyor asked RN Q if she recalled what interventions R3 had in place, RN Q replied, an air mattress, every 2 hours turning and repositioning, followed by the wound care team, and wound care orders. Surveyor asked RN Q if staff were able to turn/reposition R3 every two hours, RN Q explained that R3 had the head of her bed elevated for comfort and often she wasn't repositioned a lot (as in small movements) and that's how the shearing wounds to her spine happened. Surveyor asked RN Q how many staff it took to assist R3 with repositioning, RN Q said two assist for wound care, there's no way I could complete it alone. Surveyor asked RN Q what was used to reposition R3 in bed, RN Q said the draw sheet. Surveyor asked RN Q if R3 was ever turned and repositioned with one assist, RN Q stated, I don't think they could do independently without shearing her skin. On 6/13/24 at 4:48 PM, Surveyor interviewed CNA V. Surveyor asked CNA V if R3 admitted with wounds, CNA V stated yes a big wound on her lower back. CNA V shared the facility uses wound doctor's and she did notice the wound developed a really bad smell. Surveyor asked CNA V if she recalled what interventions R3 had in place, CNA V said an air mattress, pillows, floated heels used pillows, can't remember if she had boots, and Broda chair but I never used that because she never got out of bed on PM shift. Surveyor asked CNA V if R3 developed any wounds here, CNA V couldn't recall. Surveyor asked CNA V what was used to boost R3 in bed, CNA V replied draw sheet and chux pad. Surveyor asked CNA V how many staff were required to turn and reposition R3. CNA V stated turning side to side, R3 could help. On 6/13/24 at 5:55 PM, Surveyor interviewed RN X. Surveyor asked RN X if all wounds should have treatment orders, RN X stated yes. Surveyor asked RN X should wound orders include the location of the wound, RN X said yes. Surveyor asked RN X if R3 admitted with wounds, RN X replied yes on her coccyx/sacrum area. Surveyor asked RN X if R3 developed any wounds here, RN X said she did not recall. Surveyor asked RN X if she recalled what interventions R3 had in place, RN X said an air mattress, boots, turning and repositioning, and pillows. Surveyor asked RN X how many staff it took to reposition R3. RN X stated two assist. Surveyor asked RN X what was used to reposition R3 in bed. RN X said draw sheet or incontinence chux pad that was under her. Surveyor asked RN X if R3 was ever turned and repositioned with one assist, RN X stated it's possible but on NOC shift we work as a team. On 6/14/24 at 12:19 PM, Surveyor interviewed RN W. Surveyor asked RN W if R3 admitted with any wounds, RN W said yes to her buttocks. Surveyor asked RN W if R3 developed any wounds here, RN W replied not sure, but her wound didn't improve. Surveyor asked RN W if she recalled what interventions R3 had in place, RN W said an air mattress. Surveyor asked RN W how many assist did R3 require for repositioning, RN W stated to be done properly it would require two assist, however, cutting staff to one CNA to each hall makes everything that requires two assist a lot harder. Surveyor asked RN W what was used to reposition R3 in bed, RN W said draw sheet or chux. Surveyor asked RN W if R3 was ever turned and repositioned with one assist, RN W stated yes it happened often with one CNA. RN W went on to state not having enough staff is the basis for most of our problems, including not getting dressing changes completed and turning or repositioning. R3 admitted to the facility with a stage IV sacrum pressure injury that deteriorated. R3 developed six other pressure injuries while in the facility, all identified as stage III or unstageable. The facility failed to complete all wound treatments and failed to have wound care orders for four wounds discovered at the facility transcribed. These failures created a reasonable likelihood for serious harm, which led to a finding of immediate jeopardy beginning on 4/30/24. The facility removed the immediacy on 6/15/24 when they completed the following: Skin sweep will be completed. Audit will be completed of all residents to ensure their risk for developing pressure injuries have been identified with robust care plan interventions in place to reduce risk of developing pressure injuries or worsening of current pressure injuries. All current wounds will be reviewed to ensure treatment orders are in place. Education will be provided to all nursing leadership on next working shift regarding monitoring of the wound management program. Education will be provided to all licensed staff and CNAs on next working shift regarding turning and repositioning. Education will be provided to licensed staff on next working shift regarding completing weekly skin assessments, documentation in the TAR when completing treatments, and ensuring treatment orders are in place for all wounds. Additionally, education will be provided on reviewing risk for pressure injuries on admission to ensure robust interventions are in place to reduce risk of developing pressure injuries or worsening of current pressure injuries. Pressure injury and prevention as well as wound management policy were reviewed with no policy changes at this time. All new admissions will be reviewed for pressure injury risk to ensure robust interventions are in place to reduce risk for developing pressure injuries or worsening of current pressure injuries. Audits to be completed x4 weeks. Results to be reviewed at the QAPI meeting for further recommendations. Audits will be completed weekly with wound rounds to ensure treatment orders are in place for all wounds. Audits to be completed x4 weeks. Results to be reviewed at the QAPI meeting for further recommendations. Treatment administration record will be audited 5x (five times)/week to ensure treatments are completed as ordered and documentation is present in the medical record. Audits to be completed x4 weeks. Results to be reviewed at the QAPI meeting for further direction. 5 audits will be completed weekly to ensure residents are provided turning and repositioning as per their plan of care. Audits will be completed x4 weeks. Results to be reviewed at the QAPI meeting for further direction. 44552 Example 2: R5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes, dementia, heart disease, age related macular degeneration, hallucinations, insomnia, and kidney disease. R5's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/24/24, indicates R5 has a Brief Interview Mental Status (BIMS) score of 03, indicating R5 is severely cognitively impaired. R5 has an activated Power of Attorney. R5's Comprehensive Care Plan, states, in part; .Focus Pressure ulcer risk due to: diagnosis of diabetes, functional incontinence, weakness, physical limitations and need for staff assistance 5/7/21 .air mattress, complete Braden scare per living center policy, conduct weekly skin inspections, diabetic foot monitoring, heel boots on when in bed, provide pressure reducing wheelchair cushion, provide thorough skin care after incontinent episodes and apply barrier cream .Focus Pressure ulcer actual due to stage 3 on sacrum area 5/13/24 .conduct weekly skin inspection, monitor vital signs as needed, provide pressure reducing wheelchair cushion, provide pressure reduction/relieving mattress, .resident to lay down in bed following meals to off load her back side for a while as a prepositioning intervention, treatments as ordered, weekly wound assessment. Focus Impaired physical mobility 5/7/21 .1A with ADLs (Activities of Daily Living) 2A Sara lift with transfers to WC (Wheel Chair), after the noon meal resident to be placed in bed/recliner for a nap r/t (related to) falling asleep in wc, assist resident in performing movements .utilize pressure relieving devices on appropriate surfaces. Focus alteration in elimination of bowel and bladder functional incontinence .encourage exercise, encourage fluids, .evaluate frequency/timing of incontinence episodes, .use of briefs/pads for incontinence protection . R5's Kardex, states, in part: .Safety .Resident to be checked and changed during all night rounds to prevent resident restlessness .Skin Integrity .Air mattress, heel boots on when in bed .Skin integrity Provide pressure reducing wheelchair cushion, .repositioning PRN (as needed) as resident allows, resident to lay down in bed following meals to off load her back side for a while as a repositioning intervention .Resident care after the noon meal resident to be placed in bed/recliner for a nap r/t falling asleep in w/c .ADLs 1A with ADLs, 2A Sara lift with transfers to WC .Toileting use of briefs/pads for incontinence protection . On 6/12/24 at 7:30 AM, Surveyor observed R5 sitting in living room area. Surveyor observed multiple residents sitting in front of a TV with no sound on. At 7:53 AM, Surveyor observed staff assist R5 to the dining room for breakfast. Surveyor observed R5 being brought from dining room to living room area around 8:55 AM. R5 was brought back to dining room area around 9:23 AM-10:40 AM to observe activities making cookies. Surveyor observed R5 from 7:30 AM-11:20 AM; at 11:15 AM, R5 was brought back down to dining room for lunch, during this time frame R5 was not assisted with repositioning, not encouraged to exercise/movement, and not assisted to use the bathroom. On 6/12/24 at 12:36 PM, Surveyor interviewed CNA H (Certified Nursing Assistant). Surveyor asked CNA H when R5 was last toileted or repositioned, CNA H replied, I don't know I was called in at 11 AM to help feed residents. On 6/12/24 at 12:38 PM, Surveyor interviewed CNA O. Surveyor asked CNA O if R5 was toileted or checked and changed before lunch, CNA O said, No. Surveyor asked CNA O when R5 was last repositioned, CNA O said she got here at 10 AM today and is unable to say. CNA O indicated that her and her partner were going to be changing folks soon. On 6/12/24 at 1:00 PM, Surveyor interviewed CNA E. CNA E indicated she has not gotten to R5 since getting her up this morning due to not enough help. CNA E indicated she worked alone this morning until Scheduler F came over to assist with getting residents up who require two staff assist. On 6/12/24 at 1:10 PM, Surveyor observed R5 sitting in her wheelchair in the lounge on the unit. Example 3: R8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, hypertension, abnormalities of gait and mobility, and muscle weakness. R8's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/19/24, indicates R8 has a Brief Interview for Mental Status (BIMS) score of 00 indicating R8 is significantly cognitively impaired. R8 has an activated Power of Attorney. R8's Comprehensive Care Plan, states, in part; .Focus: Pressure ulcer risk due to: incontinence, weakness, physical limitations, and need for staff assistance 7/19/21 .Goal: Skin will remain intact 7/19/21 .Interventions .Provide pressure reducing wheelchair cush

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 4 sampled residents (R3 and R12). R3 had a change in condition on 5/8/24. R3's respiratory status was not fully assessed, there is no evidence of continuous monitoring of R3's condition or respiratory status, and R3's provider was not updated timely resulting in R3 being sent to the hospital on 5/10/24 for sepsis due to pneumonia. R12 had a change of condition following a fall including increased complaints of leg pain. The facility did complete a comprehensive assessment of R12 resulting in delay of treatment. Evidenced by: The facility's 'Notification of Changes Policy,' implemented 3/1/19, states in part: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate .all pertinent information will be made available to the provider by the facility staff.Overview of Components of the Policy. 1. Requirements for notification of resident, which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significantly. (i) a significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments . Procedure. 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list is not all inclusive) .c. a need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment . 2. the nurse will notify the resident, resident's physician, and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. 3. document the notification and record any new orders in the resident's medical record.6. Update the resident's care plan, transcribe, and implement the provider's orders. 7. communicate the changes to the rest of the care team and inform the supervisor. 8. communicate the changes to the staff on the oncoming shift . R3 was admitted to the facility for short term rehab and wound care. R3 had the following diagnoses: malignant neoplasm of bone and articular cartilage (cancer), acute respiratory failure with hypoxia (condition where the body's tissues don't have enough oxygen), paraplegia (chronic condition that causes the loss of muscle function and voluntary movement in the lower have of the body), pressure injury sacral (bottom of the spine that lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone) stage 4, combined systolic (congestive) and diastolic (congestive) heart failure (condition that occurs when the heart's left ventricle can't contract normally so the heart can't pump enough blood into circulation with enough force), Peripheral Vascular Disease (PVD; circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anxiety disorder, and Urinary Tract Infection (UTI) diagnosed on [DATE]. R3's most recent Minimum Data Set (MDS) dated [DATE] documents a score of 15 on her Brief Interview of Mental Status (BIMS), which indicates R3 was cognitively intact. R3's Care Plan indicates the following: Impaired cardiovascular status related to congestive heart failure (CHF); peripheral vascular disease (PVD) date initiated 2/23/24 . interventions: Monitor intake and output (2/23/24), observe and report headaches, flushing, nosebleeds, nausea, shortness of breath (2/23/24), observe and report signs of chest pain, edema, shortness of breath (SOB) . (2/23/24). R3's Physician Orders indicates O2 (Oxygen) per NC (Nasal Cannula) PRN (as needed) to keep O2 Stats >92% (greater than 92%) one time a day for Hypoxia, start date 4/24/24, discontinued on 5/24/24. (This order was not on any of the Medication Administration Record/Treatment Administration Records (MAR/TARs) provided to Surveyor for April or May, therefore Surveyor is unable to see documentation of how often R3 was using the PRN oxygen order.) R3's MAR for March 2024 indicated R3 used her PRN (as needed) albuterol sulfate inhaler once on 3/12, twice on 3/13, and once on 3/15. R3's MAR for April 2024 indicated R3 did not use her PRN albuterol sulfate inhaler all month. R3's TAR for March, April, and May 2024, does not indicate any oxygen orders for R3. On 5/6/24 at 1:49 PM, R3's Nurses Note states in part: Advanced Skilled evaluation . Respiratory: no signs of difficulty breathing. No shortness of breath noted. Right lung clear. Left lung clear. Humidification: No. No oxygen. HOB (head of bed) is not elevated. No cough . On 5/7/24 at 9:41 AM, R3's Nurses Note with effective date of 5/7/24 indicates: Advanced Skilled evaluation: Vitals T (temperature) 97.1 5/8/2024 10:22 .BP (blood pressure) 107/62 - 5/8/2024 10:22 . P (pulse) 88 - 5/8/2024 10:22 type regular R (respirations) 20 - 5/8/2024 10:22. O2 (oxygen) 98% - 5/8/2024 10:22 Method: oxygen via Nasal cannula Mental status: Resident is alert & oriented x3, oriented to place. Oriented to time. Oriented to person. level of cognitive impairment: Alert. Resident is coherent. Speech is clear. Language barrier: No, Resident makes self-understood. Resident understands others .Respiratory: No signs of difficulty breathing. No shortness of breath noted. Humidification: Yes: oxygen via nasal cannula. HOB (head of bed) elevated. Head elevated at 30 degrees. No cough . On 5/8/24 at 8:37 AM, R3's eMAR - Medication Administration Note, indicates: Note text: Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 2 puff inhale orally every 4 hours as needed for wheezing, SOB (shortness of breath) Client complaints of SOB, O2 is 97% on 2 lts (liters). RR (respiratory rate) 22, HR (heart rate) 88 Author: RN Q (Registered Nurse) On 5/8/24 at 9:20 AM, R3's eMAR - Medication Administration Note, indicates: Note text: Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 2 puff inhale orally every 4 hours as needed for wheezing, SOB (shortness of breath). PRN Administration was: Effective Author: (RN Q) On 5/8/24 at 12:40 PM, R3's Nurses note states in part: Client (R3) was having episodes of SOB (Shortness of Breath) throughout the shift while writer was in room. Client (R3) sats were holding 98-97% on 2lt (liters) no s/x (signs or symptoms) or respiratory distress, RR (respiratory rate) 18 - 20. No barrel chested or nasal flares. During these episodes (sic), writer would stay in room and do breathing exercises and do education of anxiety and ways to control. (sic) Writer visually observed client several times during shift when walking by clients (R3) room and seen client resting comfortable with no s/sx of SOB. Client (R3) took noon medication with 240ml (milliliters) of water through a straw with no difficulty or SOB. Client refused all cares due to her SOB and refused therapy. Author (RN Q) . (No lung assessment is documented for R3 or any further documentation of monitoring R3's respiratory status on 5/8/24 or 5/9/24 is noted in R3's record. No documentation indicating R3's provider was updated regarding her shortness of breath on 5/8/24, when on 5/7 and 5/6, R3 was not experiencing SOB per nurses' notes and R3 was not using oxygen on 5/6 but is using it on 5/7 and 5/8. R3 does not have an order for oxygen on her MAR or TAR.) On 5/10/24 at 11:06 AM, R3's Nurses Note indicates: Resident called c/o (complaint of) SOB this morning. Pain med given, antianxiety med given, and albuterol given thru out am. NP R (Nurse Practitioner) contacted and stated to send resident to ED (emergency department) if SOB does not resolve. At this time resident and family are deciding on the options. Will monitor. On 5/10/24 at 11:15 AM, R3's Nurses Note indicates: Advanced Skilled evaluation: Lookback: Vitals temperature 97.1, blood pressure 107/62, pulse 88, respirations 20 and oxygen 96% on room air. Pain: indicators of pain: none. Neurologic (blank) EENT (eyes, ears, nose, throat): (blank) Mental status: Resident is alert & oriented x3, oriented to time, oriented to place, oriented to person. Mood and behavior: (blank) Cardiovascular: (blank) Respiratory: (blank) (of note, no indication if R3's lungs were assessed for abnormal lung sounds) Gastrointestinal: (blank) Nutrition: (blank) Genitourinary: Urinary catheter intact. Skin: Skin issues . Special care: (blank) Safety: (blank) Functional: (blank) Education/notification: (blank) Completed clinical suggestions: (blank) On 5/10/24 at 11:18 AM, R3's Nurses Note indicates: Advanced Skilled evaluation: Vitals temperature 97.1, blood pressure 107/62, pulse 88, respirations 20 and oxygen 96% on room air. Pain: indicators of pain: none. Neurologic (blank) EENT: (eyes, ears, nose, throat) (blank) Mental status: (blank) Mood and behavior: (blank) Cardiovascular: (blank) Respiratory: (blank) (of note, no indication if R3's lungs were assessed for abnormal lung sounds) Gastrointestinal: (blank) Nutrition: (blank) Genitourinary: Urinary catheter intact. Skin: . Special care: (blank) Safety: (blank) Functional: (blank) Education/notification: (blank) Completed clinical suggestions: (blank) On 5/10/24 at 11:51 AM, R3's Nurses Note states in part: Resident called on light and requested to be sent to the ED (emergency department) for evaluation because SOB was getting worse. 911 called and report called to (Hospital staff name) in ED at (Hospital name). On 5/10/24 at 1:55 PM, R3's Nurses Note indicates in part: Situation: Change in condition shortness of breath (SOB), outcome of physical assessment, respiratory status evaluation shortness of breath. Nursing observations, evaluation, and recommendations are SOB and anxious, feeling like she can't catch her breath at this time. Primary care Provider feedback: send to ED (emergency department) if no relief after albuterol and medications. R3's MAR for May 2024 indicated R3 only used her PRN albuterol sulfate inhaler on 5/8/24, this medication is not signed out on 5/10/24 as being given. (There is no evidence that a nurse assessed R3's lung sounds and R3's PRN albuterol medication is not signed out on the MAR for 5/10/24.) On 5/10/24 R3's Hospital Paperwork indicates: Emergency documentation service date/time: 5/10/2024 at 2:19 PM . Time seen: 5/10/24 at 12:42 (PM). Chief complaint: SOB for the past couple days. Not eating or drinking. History of present illness: .complains of 3 days history of shortness of breath. She complains of a little wheezing but denies any fever, URI (upper respiratory infection) symptoms, cough, chest pain, abdominal pain, vomiting or diarrhea . (heart rate) 121. (Blood pressure) 93/50, (respiratory rate) 23 SPO2: 98% nasal cannula 3 L/min. constitutional: Alert, interactive, appears pale. Respiratory: bilaterally wheezing, tachypneic (breathing that is faster and shallower than normal), mild respiratory distress . Medication decision making: .patient presented to the ED with complaint of shortness of breath. Patient is always on 2l of nasal cannula. Her initial pulse ox was 90%. Her initial blood pressure was in the 70's over 40s. Her heart rate was in the 120s. patient was treated with 2 DuoNeb's (breathing treatment) and a liter of normal saline IV (intravenous). Afterwards, she appeared improved. She still has bilateral wheezing. Her heart rate is in the 1 teens. Her blood pressure is in the 90s over 50s. Chest x-ray revealed bibasilar pneumonia. Due to patient's tachycardia (rapid heart rate), hypotension (low blood pressure) and bilateral pneumonia. She will be admitted for IV antibiotics . On 5/10/24 R3's Hospital Paperwork indicates: History and Physical 5/10/2024 at 3:45 PM, Chief complaint SOB for the past couple days. Not eating or drinking. History of present illness: .presents to the ED today for new onset SOB. Pt is accompanied by son breathing difficulty began about 3 days prior and has been progressively worsening. She is fatigued from the breathing efforts. Has a nonproductive cough and feels like something is stuck in her chest. Notes she is nauseated. Not normally on oxygen is now requiring 5 L NC (Nasal cannula) . physical exam: .Resp (respiratory): diffuse rhonchi but L>R (left greater than right), fast shallow breathing, on nasal cannula, breath sounds bilaterally vitals & measurements .(heart rate) 119bpm (beats per minute) .(blood pressure) 94/55, SPO2% (oxygen) 85% O2 therapy: nasal cannula O2 flow rate: 5l/min .diagnostics: XR chest 1 view: XR chest 1 view (05/10/24 12:43) chest Xray portable . impression: bibasilar airspace opacities pneumonia versus atelectasis. Favor Pneumonia. Assessment/Plan: 1. Sepsis due to pneumonia continue on IV antibiotics: Cefepime. 2. Bilateral Pneumonia .admit to inpatient .bilateral pneumonia/sepsis. 3. COPD exacerbation, acute COPD exacerbation brought on by PNA (pneumonia) . On 5/15/24 at 11:22 AM, R3's Hospital Discharge/Transfer information, states in part: Discharge diagnoses: 1. Bacteremia. 2. Sepsis due to pneumonia. 3. COPD exacerbation. 4. Acute Respiratory failure with hypoxia. 4. Acute respiratory failure/hypoxia 5. Pulmonary hypertension .Hospital course/treatment rendered: presented to the ER (hospital name) with 3 days of SOB, CXR shows BL (bilateral) PNA and was septic with hypotension needing levophed after sepsis protocol fluid resuscitation. Pt was started on cefepime + vancomycin. (Sepsis is a life-threatening medical emergency that occurs when the body's immune system overreacts to an infection, which damages its own tissues and organs. Levophed is a medication used to treat low blood pressure and heart failure. Cefepime and vancomycin are antibiotics used to treat bacterial infections.) On 6/13/24 at 11:29 AM, Surveyor interviewed DON B (Director of Nursing) regarding R3. Surveyor asked DON B to read 5/8 and 5/10/24 documentation/notes. DON B indicated he would expect a lung assessment to be completed to see if there were any changes, update the provider with R3 having SOB. DON B indicated he is not able to tell how long RN Q was in R3's room with R3, and that he would expect that to be documented. DON B indicated he would expect follow up monitoring/assessments to be done on R3. DON B indicated R3 should have had monitoring on 5/8 and 5/9. DON B indicated he would expect a lung assessment to be completed on 5/10/24 as well. DON B indicated he would expect PRN breathing medications to be offered as ordered. On 6/13/24 at 1:40 PM, Surveyor interviewed NP R (Nurse Practitioner), regarding R3. Surveyor read R3's note from 5/8/24 to NP R. NP R indicated she would expect a call from the facility with any change and with a SBAR (Situation, Background, Assessment, and Recommendation). NP R indicated she would expect nursing staff to monitor R3 for a few days for further signs/symptoms. Surveyor asked NP R, if staff would have monitored R3's lung sounds and assessed her respiratory status on 5/8 and 5/9, if R3's pneumonia could have been treated sooner. NP R referred Surveyor to Medical Director and would not give an answer to the question. On 6/13/24 at 4:51 PM, Surveyor interviewed RN Q (Registered Nurse) regarding R3. RN Q indicated she recalled R3 having complaints of shortness of breath on a night shift and with her on another shift. (Unable to remember dates.) RN Q indicated if someone is saying they're SOB she would get vitals, check their oxygen, check for respiratory distress and if they are having respiratory distress you would need to call the provider and administer as needed medications. Surveyor asked RN Q if she would do a lung assessment. RN Q replied yes, you would do a full assessment like a head to toe. Surveyor asked RN Q if she did a full assessment on R3 on 5/8/24? RN Q indicated she is unable to say without reviewing documentation and indicated she no longer works at the facility. Surveyor read RN Q's note from 5/8/24 to her. RN Q indicated she should have done a lung assessment and charted it. RN Q indicated R3 should have been monitored for SOB if it was passed on in report. R3 experienced a change in condition on 5/8/24 per documentation and was put on 2 L of oxygen. R3's provider was not updated regarding the SOB or oxygen use. R3 was not monitored any further until 5/10/24 when R3 was sent out to the hospital and was admitted with sepsis due to pneumonia which required IV antibiotics to be provided. 30992 Example 2 R12 had a change in condition on 6/5/24 following a fall out of bed. R12 began complaining of pain and staff did not assess despite a known fall. There is no evidence of continuous monitoring of R12's condition despite obvious signs of increased pain. R12 was later found to have a hip fracture. The facility's 'Falls Management Process,' undated, states in part: In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident .Resident is NOT to be moved until assessed for injury by a nurse unless life-threatening situation exists. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating, and examining all areas for breaks in the skin and/or other abnormal findings. If no obvious injury or only minor injury move resident to a comfortable position. If significant injury, severe pain, or abnormal assessments observed, call 9-1-1. The facility's 'Notification of Changes Policy,' implemented 3/1/19, states in part: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate .all pertinent information will be made available to the provider by the facility staff.Overview of Components of the Policy. 1. Requirements for notification of resident, which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significantly. (i) a significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments . Procedure. 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list is not all inclusive) .c. a need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment . 2. the nurse will notify the resident, resident's physician, and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. 3. document the notification and record any new orders in the resident's medical record.6. Update the resident's care plan, transcribe, and implement the provider's orders. 7. communicate the changes to the rest of the care team and inform the supervisor. 8. communicate the changes to the staff on the oncoming shift . This is evidenced by: R12 was admitted to the facility on [DATE] with diagnoses including, but not limited to, the following: displaced spiral fracture of shaft of left femur, alcohol abuse, Wernicke's encephalopathy, urinary retention, metabolic encephalopathy, hyperosmolality, and hypernatremia. R12's Admission BIMS (Brief Interview of Mental Status) demonstrates that R12 is severely cognitively impaired. R12 has an APOAHC (Activated Power of Attorney for Healthcare). R12's comprehensive care plan documents the following: Focus: Needs pain management and monitoring related to surgically repaired hip fracture, and generalized pain. (Date Initiated: 4/22/24) Goal: Patient will achieve acceptable pain level goal 4. Interventions/Tasks: Administer Pain medication as ordered; Evaluate and establish level of pain on numeric scale/evaluation tool; Evaluate characteristics and frequency/pattern of pain; Evaluate need for bowel management regimen; Evaluate need for routinely scheduled medications rather than PRN (as needed) pain med administration; Evaluate need to provide medication prior to treatment or therapy; Evaluate what makes the patient's pain worse; Repositioning for comfort as needed (All interventions with Date Initiated: 4/22/24) R12's comprehensive care plan documents, in part, the following: I have a physical functioning deficit related to: Mobility impairment, self-care, impairment r/t (related to) weakness, physical limitations, need for staff assistance, hip fx (fracture) and cognitive deficits. Goal: R12 will improve my current level of physical functioning. Interventions/Tasks: Bed mobility assistance of 1, Dressing assistance of 1, Locomotion assistance of 1 in w/c (wheelchair), Monitor and report changes in physical functioning ability, Personal hygiene assist assistance of 1, Toileting assistance of 1, Transfer assistance of 2 with full body lift (Date Initiated 4/24/24) At risk for falls related to cognitive deficits, weakness, physical limitations, and need for staff assistance. Actual fall on 4/30/24, 5/16/24 Goal: No serious Fall related injuries Interventions: Bolster mattress placed on bed (Date Initiated: 4/24/24), Dysom (sic) on wheelchair seat (Date Initiated: 4/20/24), Encourage participation in activities to improve strength or balance (Date Initiated: 4/19/24, Revised 4/24/24), Encourage rest periods if feeling fatigued (Date Initiated: 4/19/24, Revised 4/24/24), Encourage use of a chair with arm rests (Date Initiated: 4/19/24, Revised 4/24/24), Footwear to prevent slipping (Date Initiated: 4/21/24, Revised 4/24/24), Keep bed locked (Date Initiated: 4/21/24, Revised 4/24/24), Keep environment well-lit and free of clutter (Date Initiated: 4/21/24, Revised 4/24/24), Keep personal items within reach (Date Initiated: 4/21/24, Revised 4/24/24), Nonskid socks/slippers (Date Initiated: 4/19/2 Revised 4/24/24), Resident is not to be left in the dining room alone (5/17/24), Staff to set up an activity table for resident if appearing restless (Date Initiated: 5/11/24, Revised 5/13/24), Therapy to work with DON on positioning calf pad on wc (wheelchair) between leg rests. (Date Initiated: 5/1/24), On 6/5/24 at 5:00 PM, R12 sustained an unwitnessed fall from bed. On 6/5/24 at 5:35 PM, LPN D (Licensed Practical Nurse) documented the following progress note: R12 found on floor, no injuries, Neuro checks started. BP (Blood Pressure) 124/88, resp (Respirations): 22, Temp (Temperature): 98.1, Pulse: 52 Spo2 (oxygen concentration) 98% room air. MD (Medical Doctor) notified, ADON (now Interim Director of Nursing), IDON CC notified. Significant other notified. On 6/5/24 at 5:45 PM, LPN D documented the following Fall Risk: History of falls (past 3 months): 3 or more falls in past 3 months. Level of consciousness/mental status: Intermittent confusion. Resident is chairbound/incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 3 or more present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait/balance: N/A (not applicable) - not able to perform function. medication: Takes 3-4 these medications (or medication classes) currently and/or within the last 7 days. Fall Risk Score: 19 (Note, R12 is at risk of falls as he was admitted to the facility with a fracture.) LPN D (Licensed Practical Nurse) documented the following Post Fall Evaluation: Fall Details Date/Time of Fall: 6/5/24 at 5:00 PM Fall was not witnessed. Fall occurred bedside. Activity at the time of fall: Attempting to self-transfer - The reason for the fall was not evident. Did an injury occur as a result of the fall: No Did fall result in ER visit/hospitalization : No Provider: Physician AA Time Notified: 6/5/24 Notified of fall with no injury. Contributing Factors: Resident change in environment: No Was fluid spilled on floor: No Clutter present on the floor: No Floor mat was on floor: No Poor lighting in the area: No Bed was at an improper height: No Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall. No Foot wear at the time of fall: Non-skid shoes/socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen at the time of fall. Resident was using incontinent supplies at the time of the fall. Incontinent at time of fall: No Bedside call light on when Resident was found: No Bathroom call light on when Resident was found: No Personal alarm sounding when Resident found: No Other Residents were not involved in fall. Medication Changes: No Vitals at 6:01 PM: T (Temperature): 98.2 BP (Blood Pressure): 128.86, P (Pulse: 56, R (Respirations) 20, Oxygen: 98% Method: Room Air Pain: Indicators of pain: None Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Physical Findings: Change in diagnosis status: No Recent diagnosis of stroke, TIA (Trans ischemic Accident/mini stroke) or arrhythmia: No Decrease in fluid intake: No Change in blood glucose levels: No Change in blood pressure: No Change in behaviors: No Change in mobility status: No Recent weight loss: No Sensory impairment: No Resident does not have orthostatic BP (blood pressure) changes. Actioned Clinical Suggestions: Blank On 6/5/24 at 5:45 PM, LPN D documented the following progress note: Type: Skin Only Evaluation - Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. On 6/5/24 at 8:09 PM, LPN D documented the following progress note: R12 c/o (complained of) pain right hip after fall, Physician AA ordered an x-ray, x-ray company called, and they are expected to come tomorrow morning. LPN D did not document R12's pain level, administer pain medication, complete range of motion, or do an assessment of R12's lower extremities. R12's MAR (Medication Administration Record) documents the following order: Tylenol Oral Tablet 325 mg (milligram) - Give 650 mg by mouth every 4 hours as needed for pain. Order Date: 6/5/24 11:12 PM The MAR indicates LPN BB (Licensed Practical Nurse) administered Tylenol to R12 at 3:05 AM with a documented pain rating of 5. LPN BB did not follow up with R12 to ensure the Tylenol was effective. The oncoming shift marked the medication with an I indicating ineffective on 6/6/24 at 8:45 AM with a pain rating of 6. On 6/6/24 at 3:05 AM, LPN BB (Licensed Practical Nurse) documented the following progress note: upon start of shift, R12 with visible pain and reporting butt and legs hurting, sitting in broda chair at time of arrival. Writer and CNA (Certified Nursing Assistant) transferred resident to bed via Hoyer. Resident yelling and hollering my leg. R12 with severe pain to right leg/hip with transferring/repositioning. Notified Physician AA of yelling and hollering, gave order for Tylenol 650 mg (milligram) Q4H (every 4 hours) PRN (as needed). It is important to note, LPN BB entered the order for Tylenol PRN in the MAR at 11:12 PM. It is important to note despite R12's known fall, yelling my leg, there was no assessment of R12's right leg or hip and no continuous monitoring of R12. On 6/6/24, there is no documentation from LPN BB or any staff after 3:05 AM until 8:41 AM to indicate if the Tylenol was effective or not. There is no follow up pain assessment or continued monitoring documented until 8:41 AM (over 5 1/2 hours). On 6/6/24 at 8:41 AM, staff document in the progress notes: Tylenol Oral Tablet 325mg - Give 650 mg by mouth every 4 hours as needed for pain. PRN (as needed) Administration was: Ineffective Follow up Pain Scale was: 6. On 6/6/24 at 10:41 AM, staff documented the following progress note: Xray of right hip post fall one time only for diagnostic for 30 days. Resident was sent to the hospital for X-ray of his right hip. Called x-ray company and talked to (name omitted) to cancel the X-ray. On 6/6/24 at 10:55 AM, IDON CC (Interim Director of Nursing) documented the following eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers. At the time of the evaluation resident/patient vital signs, weight and blood sugar were: Pulse P 56 6/5/24 6:01 PM RR R 20.0 6/5/24 at 6:01 PM Temp T 98.2 6/5/24 6:01 PM Weight 134.0 lb. (pounds) 6/2/24 Pulse Oximetry O2 98.0 6/5/24 at 6:01 PM Note, these vitals are not current. (The most recent vitals documented on the Neuro Checks indicates the last vitals were obtained on 6/6/24 at 7:00 AM. The vitals were as follows: Temperature: 90 (type-o), Pulse: 97, Respirations: 20, Blood Pressure: 106/64.) Outcomes of Physical Assessment: Positive findings reported on the resident/patient for evaluation for this change in condition were: Functional Status Evaluation: Fall Pain Status Evaluation: Does the resident/patient have pain: Yes. Nursing observations, evaluation, and recommendations are: R12 with unwitnessed fall out of bed last evening with no apparent injury noted. Resident developed pain overnight and increased swelling to R (right) hip joint. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: Send to ED (Emergency Department) for eval if the condition has worsened and pain has increased. On 6/6/24 at 4:17 PM, R12's hospital report documents, in part, as follows: Pt (patient) brought in by medic. Per report Pt fell yesterday afternoon and is c/o (complaining of) back pain and right hip pain. Pt hypotensive upon arrival to ER (emergency room ). Patient with longstanding history of alcohol abuse (now with Wernicke's encephalopathy/dementia), chronic urinary retention with indwelling Foley, and a history of a multitude of fractures from multiple falls . He reportedly fell out of bed yesterday (details not available since unwitnessed) and presented to the ER today due to pain Imaging confirms a right intertrochanteric hip fracture no other acute injuries (multiple old various healed fractures noted along with the recently healed distal L (left) spiral femur fx (fracture). R12's right hip x-ray documents the following findings: Bones: Comminuted, displaced, right proximal femoral intertrochanteric fracture. Left hip arthroplasty in position. Remote right pubic rami fractures. The facility has three (3) staff statements related to R12's fall on 6/5/24. On 6/6/24, CNA Z (Certified Nursing Assistant) documented the following statement: I was in the dining room feeding a resident when I heard R12 yelling I went to see what was wrong and he was on the floor in his room I asked hi [TRUNCATED]

Based on interview and record review, the facility failed to provide care consistent with professional standards of nurse practice (N6, Wisconsin Nurse Practice Act) by failing to monitor a resident while the resident was experiencing a change in condition despite an order from the primary physician to monitor for 1 (R2) of 3 residents reviewed for change in condition out of a total sample of 12 residents. R2 experienced a change in condition on [DATE]. The facility failed to complete ongoing assessments of the resident's condition. R2 continued to decline throughout the day; the facility did not update the physician or complete thorough assessments of resident's condition. Approximately eight hours later, the resident's condition deteriorated significantly, and the resident was sent to the emergency room (ER) and found to be in septic shock. The facility's failure to complete ongoing thorough assessments and notify the primary physician of continued deterioration created a delay in treatment. R2 returned to the facility on hospice services and expired on [DATE]. The facility's failure to complete thorough assessments and notify the primary physician of continued deterioration resulted in a delay in treatment, which created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 4:45 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility policy titled, Notification of Changes Policy, includes: .Procedure .1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list is not all inclusive): .b. A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication . The facility provided Surveyor a handout that the facility follows as a standard of practice titled, Change in Condition: When to report to the MD/NP/PA (medical doctor/nurse practitioner/physician assistant), .Immediate Notification .Any symptom, sign or apparent discomfort that is: Acute or sudden in onset, and: A marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed . According to N6.03(1), Wisconsin Nurse Practice Act, a registered nurse (RN) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R2 was admitted to the facility on [DATE] with diagnoses including: adjustment disorder with depressed mood, post traumatic seizures, chronic post traumatic headache, edema, reflux disease, insomnia, asthma, anxiety disorder, personal history of traumatic brain injury, hypertension, dementia, respiratory failure, pneumonia, and urinary tract infection. R2's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE], indicates R2 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R2 is cognitively intact. R2 has an activated Power of Attorney (POA). R2's Comprehensive Care Plan states, in part: .Focus: Diet alteration related to adjustment disorder with depressed mood, GERD, anxiety, and hypertension. Resident is at risk for malnutrition r/t (related to) recurrent hospitalization , edema, UTI, pneumonia, obesity, hypertension, and hx. (history) decreased PO (by mouth) intake. Date initiated: [DATE] .Encourage adequate fluid and meal intake .Monitor meal & fluid consumption daily .monitor/document/report to MD PRN (as needed) for s/sx. (signs/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals [DATE] .Focus: Alteration in elimination of bowel and incontinence r/t weakness physical limitations and need for staff assistance. Date initiated: [DATE] .Monitor and report s/s of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain . R2's daily documentation for amount eaten on [DATE] states, in part; blank documentation for PRN, 0900, 1300, and an X for 1800 . R2's documented vitals state, in part: .BP, last completed on [DATE] .O2 stats, last completed [DATE] 18:02 (6:02 PM) 96.94% (oxygen via nasal cannula) .Pulse Summary, last completed on [DATE] .Temperature, last completed [DATE] 18:02 98 F . On [DATE] at 11:00 AM, during interview with Surveyor, MT D (Medication Technician) indicated she works on R2's hallway. MT D indicated that R2 has challenging behaviors, but that it's all in the approach when working with R2. MT D indicated R2 and MT D have a good relationship and joke around. MT D indicated she worked on [DATE] and doesn't remember any significant changes with R2. MT D indicated it is not R2's baseline to be struggling to eat/drink and having food falling out of R2's mouth. On [DATE] at 11:10 AM, during interview with Surveyor, LPN J (Licensed Practical Nurse) indicated LPN J worked NOC (night) shift on [DATE] and does not recall any changes with R2 during her shift. LPN J indicated if a resident experiences a change in condition or is not at their baseline, a full set of vitals should be taken, and monitoring should be documented in the computer system under resident name. R2's Progress Notes state, in part: XXX[DATE] 9:56 Note Text: Resident laying upright in bed. Slow to arouse. Yells out at times and then falls asleep. Staff attempted to feed resident, but she is not drinking or eating well. Resident holds liquids and food in her mouth and is unable to completely swallow. Call out to guardian for update. (MD Name) updated and wants guardian to respond with plans for resident's care. Social Services is aware as well .11:04 eMAR (electronic medication administration record)-Medication Administration Note Ref. (refused) .13:05 (1:05 PM) eMar-Medication Administration Note .NA. (not applicable) .17:35 (5:35 PM) .resident pocketing food.18:01 (6:01 PM) .resident unable to sit up in wheelchair.19:24 (7:24 PM) Resident sleeping throughout shift and slow to arouse. Resident taking a few sips of fluids. HOB (head of bed) is elevated. Oxygen in continuous use. No c/o (complaints of) pain. Oral care provided 20:04 (8:04 PM) .Resident is lethargic and yells out at times. She is unable to swallow fluids and food. Resident has congestion. Has pain with or without movement. Writer called 911 for transfer to (hospital name) for an evaluation. (MD Name), DON (director of nursing), and guardian were notified . It is important to note there are no documented assessments or a full set of vitals on the day of [DATE]. It is also important to note the only documented notifications to primary physician and corporate guardian were at 9:58 AM and 8:00 PM when resident went out by ambulance. Surveyor reviewed R2's hospital discharge notes from [DATE] which state, in part: past medical history of asthma, hypertension, traumatic brain injury, with resulting cognitive impairment, post-traumatic headaches and seizures, post-traumatic hydrocephalus (fluid on brain) requiring VP (ventriculoperitoneal-tube inserted into brain ventricle) shunt, dementia, anxiety, insomnia, who presents in transfer from (nursing home name) for acute respiratory failure. Patient presented with septic shock secondary to urinary tract infection .She will require 14 days of treatment for complex UTI (urinary tract infection) in the setting of septic shock . It is important to note that despite R2's complex history and recent hospital visit from [DATE], the facility did not create detailed parameters for monitoring and reporting as outlined in R2's Comprehensive Care Plan. R2's EMS Prehospital Care Report states, in part: .unit notified [DATE] 19:46:15 .Primary Impression: Other general symptoms and signs. Secondary Infectious - Sepsis .Narrative .Dispatched to .health is declining, acting lethargic and not eating or drinking, requesting transport to the (hospital name) .Responded immediately without delay. Upon arrival, crew was met inside the building by staff and directed to Pt (patient). Pt's care person stated Pt has not been able to eat or drink in the last day and is concerned with her declining health. Pt's caregiver stated Pt has been making a gargling sound and is expressing a lot of pain. Caregiver stated her temperature has been normal .Pt's vitals were taken showing an elevated heart rate and temperature .Arrival 20:08:26 (8:08:26 PM) BP (blood pressure) ,d+[DATE] .Pulse 120 Resp (respirations) 16 labored .SpO2 (oxygen saturation) 94 . R2's Emergency Department (ED) Physician Note states, in part: .Admit: [DATE] Medical Decision Making .Patient arrived with triage vitals slip of fever [sic]. 38 degrees, tachycardic at 123, tachypneic (increase respirations) at 34, hypoxic (low oxygen levels) down to 86% on room air, borderline blood pressure with initial BP of ,d+[DATE] .labs show her to have a leukocytosis (indication of infection) of 12.2 with a left shift, normal lactic acid at 1.1, elevated procalcitonin at 2.4 (indicating severe sepsis), elevated CRP of 13 (inflammation in body). Elevated potassium of 5.5 (lack of kidney function seen in severe sepsis), normal viral swab with negative influenza, RSV (viral respiratory infection), COVID-19. Her vitals and labs would indicate that she has some degree of sepsis. She appears to be responding to the IV (intravenous) fluids as her blood pressure has improved. I also provided her with some IV Tylenol which has likely also improved her fever and initial vitals. I administered her on some broad-spectrum antibiotics to cover her for sepsis. Blood cultures have been obtained. We are currently waiting on a urinalysis and urine culture. I anticipate that she will need to be transferred to another facility so she can be admitted for continued treatment of her sepsis. Patient has allergies to cefepime and tetracycline. The patient previously had Zosyn and Levaquin in the past for pneumonia and cystitis. Consequently, I started her on both for sepsis coverage. I am still awaiting a urine sample and CT results (imaging), as of 10:04pm. A cathed (catheter-tube in bladder) UA (urinalysis) shows turbid urine. Awaiting UA results currently. Her UA returned with 3+ blood trace ketones 2+ leukocyte esterase, greater than 100 white blood cells, ,d+[DATE] red blood cells, yeast present, and white blood cell clumps present. It was a cath specimen and had ,d+[DATE] squamous epithelial cells. This appears consistent with a urinary tract infection, which is the likely source of her sepsis . R2's hospital discharge paperwork states, in part: .Assessment and Plan . in poor condition with sepsis ,d+[DATE] (secondary to) urologic source and approved for inpatient admission .1. Urinary tract infection without hematuria, site unspecified. 2. Sepsis - WBC's 12.2, (elevated white blood cell count indicating infection) tachycardic (elevated heart rate), RR (respiratory rate) elevated meeting criteria for sepsis. Normal lactic. UA c/w (consistent with) infection and has hx. (history) of frequent UTIs (urinary tract infections) with chronic indwelling foley catheter. Appearance was reported as brown pyuria (pus in urine) in catheter on presentation. Replaced in ER. There were concerns for possible pneumonia reported, but CXR (chest x-ray) without acute findings and elevation not c/w pna (pneumonia). Unclear if AMS (altered mental status), but since that was not the indication for staff to prompt EMS to ER, it seems less likely that she was altered from baseline. If so, could also consider seizure given hx. of, although with normal LA (lactic acid) that is unlikely. Hx. of VP shunt - given source of infection suspected urologic at this time and improvement on arrival to (hospital name) did not pursue lumbar puncture but could consider if worsening. CT head no acute findings in ER Zosyn and Levaquin dosed at outside facility in setting of multiple allergies including cefepime . On [DATE] at 6:30 PM, RN G (Registered Nurse) indicated to Surveyor RN G was the RN that worked with R2 on [DATE] and [DATE]. RN G indicated R2 was steadily declining on [DATE]. RN G indicated RN G worked with R2 on [DATE] and R2 appeared to be eating and acting more at baseline. On [DATE], R2 was lethargic, not eating/drinking, and unable to take medications. RN G indicated she contacted R2's corporate guardian and primary physician the morning of [DATE]. RN G indicated she talked to MD H and MD H instructed RN G to contact corporate guardian to determine next steps for R2's care. RN G indicated MD H instructed RN G to continue to monitor R2 as well. RN G indicated she thinks that she called MD H a few times on [DATE]. RN G indicated she thinks she tried calling the corporate guardian a few different times on [DATE] as well. (It is important to note the only documentation in R2's progress notes for notification/communication on [DATE] is at 9:56 AM and then at 8:00 PM when R2 was sent out by ambulance. There is no other documentation of notification to the MD or guardian.) RN G indicated the corporate guardian never returned calls throughout the weekend. RN G indicated there had been discussion of R2 going on palliative care or hospice, but that nothing had been set up. RN G indicated RN G continued to monitor R2 throughout the day on [DATE]. RN G indicated she would have completed vitals and believes she completed RN assessments. RN G indicated vitals and assessments would be documented in the computer under R2. (It is important to note there are no documented assessments or full set of vital signs for R2 on [DATE].) RN G indicated R2's care was getting more and more complex, and that RN G called 911 and sent R2 out at 8:00pm on [DATE]. RN G indicated at that time she notified DON (Director of Nursing), left a message for the corporate guardian, and MD that R2 was being sent out. On [DATE] at 9:16 AM, Surveyor spoke with MD H (Medical Doctor) who indicated he is R2's primary physician. MD H indicated that there was discussion on R2 going on palliative care or hospice, but that nothing had been set up. MD H indicated that the facility had been calling him often regarding R2 and R2's health concerns. MD H indicated R2 is very young with many medical concerns. Surveyor asked MD H what orders he gave RN and if he recalls any calls on [DATE]. MD H indicated on [DATE] he gave the orders to the RN G to contact corporate guardian and continue to monitor R2. MD H looked at R2's progress notes from [DATE] in PointClickCare and verified that he remembers the call at 9:58am on [DATE]. MD H indicated it was difficult to get in touch with the corporate guardian and that was making things complicated. MD H indicated he would expect that when monitoring a resident, it would consist of a full set of vitals and assessments. MD H indicated staff were usually good with contacting him with updates for R2. MD H indicated he was not sure of exact times that the facility contacted him on [DATE]. Surveyor asked MD H if MD H would expect to be notified if R2 had been declining throughout the day on [DATE]. MD H indicated he would expect to be notified. Surveyor asked MD H to call Surveyor back if MD H is able to recall and/or find notes regarding [DATE] for R2. MD H sent a message to Surveyor on [DATE] at 11:32 AM where he indicated there was no additional information from his notes regarding [DATE]. On [DATE] at 9:40 AM, during interview with Surveyor, Guardian I indicated she was R2's guardian. Guardian I indicated she is a corporate guardian and that there were some issues with the facility calling the correct on-call number. Guardian I indicated that there is a different phone number for after hours and weekends. Guardian I indicated the facility was calling her phone number, but that she was not on call the weekend of [DATE]. Guardian I indicated there were two messages from the facility on [DATE]. The first message was left at 10:00 AM and said that R2 was having difficulty swallowing. The second message that was left on [DATE] was at 8:05 PM and it stated that the facility was sending R2 out by ambulance. Guardian I verified no other messages were left throughout the weekend of [DATE]. Guardian I indicated R2 is ready for discharge and will be discharging back to facility today, [DATE] on hospice. Surveyor asked Guardian I what R2 was diagnosed with while at hospital. Guardian I indicated she was not sure, she knows that R2 has reoccurring UTIs. On [DATE] at 11:10 AM, during interview with Surveyor, CNA K (Certified Nursing Assistant) indicated she was the staff that worked with R2 the day of [DATE]. CNA K indicated she knows R2 well and worked with R2 often. CNA K indicated the last couple of days prior to R2 being admitted to the hospital were very difficult. CNA K indicated R2 had been declining and the last couple of days it was hard to keep her awake, she was very pale, and struggling with eating/drinking and taking medications. CNA K indicated R2 wasn't even eating fruit on [DATE] and that R2 usually loves fruit. CNA K indicated on [DATE], R2 couldn't eat or drink and that food was just falling out of R2's mouth. CNA K indicated this was not normal for R2, this was not R2's baseline. CNA K indicated that R2 had gone to the emergency room several times over the last few months, and that staff were telling DON R2 was not at baseline. CNA K indicated she heard it was very difficult to get ahold of the corporate guardian. On [DATE] at 5:15 PM, during interview with Surveyor, RDCO C (Regional Director of Clinical Operations) indicated she would expect a full set of vitals and assessments to be completed and documented if instructed to monitor from primary physician. RDCO C provided Surveyor R2's progress notes from [DATE] and the temperature and O2 saturations that Surveyor had already reviewed. Surveyor asked RDCO C to please provide any additional documentation for R2 regarding vitals and assessments from [DATE]. It is important to note no further documentation was provided. On [DATE] at 12:50 PM, during interview with Surveyor, RDCO C indicated R2 had been having health concerns for over a month and had been frequently going into the emergency room to be evaluated. RDCO C indicated the pattern had been R2 would come back on an antibiotic and be feeling better, and then when finished with antibiotic would tank and have to be sent back out. It is important to note, the facility recognized the on-going health concerns and despite having this knowledge, failed to monitor and seek outside treatment on [DATE]. On [DATE] at 3:05 PM, during interview with Surveyor, DON B (Director of Nursing) and RDCO C indicated there is no additional information for R2 from [DATE]. DON B indicated he would expect a full set of vitals and assessments to be completed for monitoring of a resident. DON B indicated if resident refused it should be documented in the resident progress notes. DON B indicated he would expect notification to physician if a resident continued to decline. DON B indicated he received a text message on [DATE] at 8:16 PM from RN indicating R2 was being sent out. DON B indicated he received no other notifications before 8:16 PM on [DATE]. R2 experienced a change in condition on [DATE]. The facility failed to complete on going assessments of the resident's condition. R2 continued to decline throughout the day, the facility did not update the physician or complete thorough assessments of resident's condition. Eight hours later R2's condition deteriorated significantly, and R2 was sent to the ER and found to be in septic shock. The facility's failure to complete ongoing thorough assessments and notify the primary physician of continued deterioration resulted in a delay of treatment and a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it completed the following: All below education will be conducted prior to the start of next scheduled shift. 1) Licensed nursing staff to be educated on ensuring all residents with a change of condition are thoroughly assessed to include at a minimum of blood pressure, temperature, oxygen saturation, and respirations. 2) Education to include communication with provider, guardian, responsible party through the change of condition. 3) All staff to be educated regarding recognizing and reporting a change of condition. 4) All licensed Nurses to be educated regarding how to complete a system focused assessment. 5) All nurses to be educated regarding documentation of assessments, notification, and changes in condition. 6) Staff responsible for notifications i.e.: IDT members, licensed nurses, Social Services, Registered Dietician, to be educated on process if unable to reach family/guardian/responsible party and updating the provider if unable to reach especially if deterioration in condition. On [DATE] facility reviewed policy and procedure regarding notification of changes with Medical Director, (Dr. Name). Policy updated to include notification to provider, guardian, responsible party until condition is resolved and/or resident transferred to a higher level of care with ongoing documentation. DON and/or designee will audit progress notes, 24-hour board and risk management to ensure any changes in condition were identified and assessments completed, provider and responsible party notified, documentation completed, care plans initiated or updated if needed. This will occur daily x3 weeks, 3x/week x3 weeks, then weekly x3 weeks. Results of audits will be reported and recorded to QAPI for further direction.

Based on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 3 residents (R4) reviewed for PIs out of a sample of 12 residents. R4 was admitted to the facility without a PI. R4 was at risk for PI development and had significant co-morbidities including diabetes and right ankle fracture requiring a sugar-tong splint (rigid device that fixes and maintains stability of the ankle). An external fixator was placed on 3/10/23 to the right lower extremity. The facility failed to clarify physician orders regarding removing the sugar tong splint daily to check the skin underneath or checking skin around the splint, failed to complete all weekly wound assessments, failed to complete all diabetic foot checks, failed to complete all weekly treatments, failed to remove and assess under R4's Kerlix wrap daily and monitoring CMS (circulation, movement, and sensation) checks to the right lower extremity (RLE). R4 developed multiple unstageable PIs which deteriorated, including a Stage IV (4) PI. This created a finding of immediate jeopardy that began on 3/8/23. NHA A (Nursing Home Administrator) was informed of the immediate jeopardy on 1/17/24 at 3:25 PM. The immediate jeopardy was removed on 1/17/24, however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. https://www.merckmanuals.com/how-to-apply-a-sugar-tong-ankle-splint states in part: Sugar-tong ankle splints are rigid devices that fix and maintain stability of the ankle joint. Sugar-tong ankle splints, also called U-shaped splints, are typically used for injuries that benefit from immobilization. Complications of a Sugar-Tong Ankle Splint: Excessive pressure causing skin sores and/or ischemic injury. According to https://www.skilledwoundcare.com/lower-extremity: Great care must be taken when applying wound dressings in the form of kerlix gauze wraps to wound dressings. If the wrapping is too tight it may cause further arterial occlusion and the formation of additional wounds. The facility's Pressure Injury Prevention Guidelines, undated, indicate in part, as follows: Preventative Skin Care: 1. Inspect skin while providing care, paying close attention to bony prominences; 2. Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust devices as needed for proper fit. According to AMDA (American Medical Doctors Association) - The Society for Post-Acute and Long-Term Care Medicine - Pressure Ulcers - Clinical Practice Guideline - http://www.amda.com/tools/guideline.cfm#pressureulcer .Treatment of foot problems in patients with diabetes is generally stratified into three broad risk categories: at-risk foot; current mild foot, ankle, or heel infection or ulcer; and limb-threatening foot, ankle, or heel infection or ulcer . Risk Category: At-risk foot (patients who smoke; have vascular insufficiency, neuropathy, retinopathy, nephropathy, history of ulcers or amputations, structural deformities, infections, skin/nail abnormality; are on anticoagulation therapy; cannot see, feel, or reach their feet.) Treatment Plan: Train caregivers to perform daily foot care and inspection The NPIAP (National Pressure Injury Advisory Panel) classifies a PI as follows: Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts may be associated with Stage 4 pressure ulcers. Unstageable: Obscured full-thickness skin and tissue loss full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Advancing Excellence notes that, Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: o Decrease in bowel and bladder function o More incontinence o Decrease in ability to move without help o Decrease in mental capacity o Increase in pain o Increased risk for infection o Less participation in activities http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Reducing%20Pressure%20Ulcers.pdf R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to: diabetes mellitus type 1, acute on chronic congestive heart failure (CHF), nephrotic syndrome, morbid obesity, major depressive disorder, muscle weakness, and difficulty walking. R4 is his own decision maker. R4's Admission Braden Assessments (a measure of pressure injury risk) indicate R4 is at risk for PI development. R4's Admission Minimum Data Set (MDS) dated [DATE] indicates R4 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and he requires extensive assistance of 2 for bed mobility, transfers, dressing, toileting, and hygiene. R4's MDS indicates he is at risk for PI development, and he was admitted with no PIs. R4's comprehensive care plan indicates the following (Date Initiated 2/10/23): Pressure ulcer at risk due to: Assistance required in bed mobility, Braden Score 18 or less, Obesity, Presence of edema - Goal: Will remain free from further breakdown. Conduct weekly skin inspection; Diabetic foot monitoring; Monitor vital signs as needed; Notify practitioner if symptoms worsen or do not resolve; Provide pressure reducing wheelchair cushion; Provide pressure reduction/relieving mattress; Referral to therapy; and Heel boots when lying down (Date Initiated: 3/14/23) R4's comprehensive care plan indicates the following (Date Initiated 2/10/23): Alteration in Blood Glucose due to: Insulin Dependent Diabetes Mellitus - Goal: Maintain health and promote quality of life through Disease Management. Assessment of skin and foot condition weekly by licensed nurse; Report to Nursing/Physician .poorly healing wounds . R4's comprehensive care plan indicates the following (Date Initiated 2/10/23): Bed mobility assistance of 1; Assistive devices 1; Encourage resident to call for assist when needing to get up (Date Initiated: 3/8/23); Toileting assistance of 1 (Date Initiated 2/10/23) R4's comprehensive care plan also indicates the following (Date Initiated 2/10/23): I have a physical functioning deficit related to: Mobility impairment, Self care impairment: Toileting assistance of 1, Transfer assistance of 1 with a Pivot transfer; Walking assistance of 1 R4's Treatment Administration Record (TAR), dated 2/9/23, documents, Heels/Feet check nightly (also known as daily diabetic foot checks) every evening shift per facility policy (Order Date: 2/9/23 D/C 4/6/23). The facility did not complete daily diabetic foot checks on 3/2/23, 3/11/23, 3/18/23, 3/19/23, 3/21/23, or 3/23/23 per standards of practice/TAR. R4's progress notes dated 3/7/23 at 10:25 PM document the following: Resident sent to ED (emergency department) after fall in the bathroom and c/o (complained of) pain to R (right) lower extremity with deformity. MD (Medical Doctor) on call contacted for R4 with update. R4's emergency room (ER) report dated 3/7/23 states, in part, as follows: .R4 presents from facility for a fall and right ankle injury. The injury occurred just prior to arrival. He has been at the nursing home for rehab for a CHF (Congestive Heart Failure). Medical History: Cardiovascular: congestive heart failure Respiratory: sleep apnea, Chronic respiratory failure on 2L (liters oxygen) NC (nasal cannula) Endocrine: diabetes type 1 Psychiatric: depression, alcohol abuse Respiratory: Lungs are clear to auscultation, respirations are non-labored. Musculoskeletal: Obvious right ankle deformity. The ankle is rotated approximately 40 degrees externally. Appears to be laterally dislocated .He will likely need reduction and possible surgery. R4's x-ray indicates: Ankle complete xr (xray) - Right 3 views, TIBIA-FIBULA- Right: Bones: Communicated, angulated, and displaced fracture distal fibular shaft. Comment communicated, displaced, and angulated fracture of the proximal fibular shaft (ankle fractures). Fracture Reduction Procedure Right Ankle - After adequate analgesia a closed fracture was reduced by myself with axial traction and manual manipulation of fracture fragments resulting in improved alignment. A sugar tong splint with a post mold was placed. Patient tolerated the procedure well.Post reduction radiograph shows improved alignment. On 3/8/23 at 12:12 AM, the ER Physician documents, in part, as follows: I spoke with orthopedist, and described the x-rays and injury. He advised that the patient keep the leg elevated. He should be toe touch weight bearing only, and can follow up in the office tomorrow to plan anticipated surgery. R4's Discharge Instructions, dated, 3/8/23, indicated in part, as follows: Check the skin under the splint every day. If you can't remove the splint, check the skin around the edges. Tell your doctor if you see redness or sores.Call your doctor now or seek immediate medical care if you have increased or severe pain. * R4's Discharge Documentation, dated 3/8/23, includes, in part, as follows: Most splints can be adjusted. Your doctor will show you how to do this and will tell you when you might need to adjust the splint. A splint is sometimes called a brace. You may also hear it called an immobilizer. An immobilizer, such as a splint or cast, keeps you from moving the injured area. Splint and skin care: Check the skin under the splint every day. If you can't remove the splint, check the skin around the edges. Tell your doctor if you see redness or sores. It is important to note, there is no evidence that the facility checked the skin under the splint every day or checked the skin around the edges every day. Note, it is of critical importance to identify, treat and monitor any PI caused by a medical device. On 3/9/23 R4 was transferred to a different hospital and kept under observation. On 3/10/23, R4 underwent application of external fixator to right ankle fracture. On 3/10/23, R4's Discharge Instructions include the following: Weight bearing status: non-weightbearing to right lower extremity Apply prevalon boots to bilateral LEs (lower extremities) to prevent heel sores Dressing changes: DAILY pin care cleaning Need to shower daily and get ex fix (external fixator) wet. Do not soak/submerge. Wash pin sites daily with 50/50 saline and hydrogen peroxide mix. Tightly rewrap base of pin site with Kerlix, as seen when returned from OR (Operating Room). Change dressings daily and when saturated. Reinforce dressings as needed. It is normal for pin sites to drain quite a bit. Change dressings as often as needed.Would recommend DAILY wound care from wound care nurse to continue to monitor for skin breakdown. Wound care nurse will need to send our office pictures of his RLE (right lower extremity) on 3/17/23 to assess soft tissues. (emphasis intended). **It should be noted the pictures of the soft tissue were not completed or sent to the provider as ordered on 3/17/23.** Complete antibiotics as directed. Take with food. Order Sulfamethoxazole-trimethorpim 800-160 mg tab take 1 tablet by mouth twice daily for 14 days. Indications: Infection of the Skin and/or soft tissue, ex fix (external fixation) RLE (right lower extremity,) DOS (date of service) 3/10/23. Advised to take multi-vitamin daily and Vitamin D (2000 units) daily until fracture is healed. Take with food. **Of note, R4 received 1,000 units of Vitamin D beginning 3/21/23 and was not provided with a multivitamin.** What's Next: Removal of external fixator with surgical fixation of right ankle fracture 3/21/23 Outpatient surgery. The facility did not complete the following orders: The facility did not follow order: Dressing changes: DAILY pin care cleaning R4's Treatment Administration Record (TAR) indicates: Dressing changes and daily pin care cleaning as following: 1. wash pin sites daily with 50/50 saline and hydrogen peroxide mix. 2. Tightly rewrap (emphasis intended) base of pin site with Kerlix every day shift for pin care. (Order Date: 3/13/23 D/C date: 4/6/23) The TAR documents the facility did not complete this treatment order on the following dates: 3/13/23, 3/14/23, 3/19/23, 3/24/23. It is also important to note, this order is dated 3/10/23 and the facility did not enter the order until 3/13/23 and did not complete a treatment until 3/15/23. The facility did not follow order: Need to shower daily and get ex fix wet. Do not soak/submerge. Surveyor requested shower/bath documentation/skin checks for R4. The facility did not provide the requested shower documentation or skin inspections. The facility should have removed R4's wrap and performed skin checks during these daily showers. There is no documentation to demonstrate that showers were completed, the wrap was removed, or the skin was inspected. The facility did not follow the recommendation: Would recommend DAILY (emphasis intended) wound care from wound care nurse to continue to monitor for skin breakdown. The facility did not follow order: multi-vitamin daily and Vitamin D (2000 units) daily until fracture is healed. Take with food. R4 received 1,000 units of Vitamin D beginning 3/21/23 (11 days later) and was not provided with a multivitamin. On 3/22/23, R4 was transferred to the hospital. R4's Summary of Hospital Course dated, 3/23/23, includes, in part: R4 had ex fix placement on 3/10/23 . The plan was to admit him the day prior for definitive ex fix removal and ORIF (Open Reduction and Internal Fixation) of the ankle on 3/23/23, however anesthesia required medical and cardiac optimization and cardiology clearance. He arrived on 3/22/23 for this.Cardiology was consulted and declined to see patient - advising he needs to get clearance from his own cardiologist. Without cardiology clearance, anesthesia unable to move forward with surgical intervention . Ok for as tolerated ROM (range of motion) of the knee, wiggle toes. The patient will be discharged back to the SNF (Skilled Nursing Facility) in stable condition. On 3/22/23 while at the hospital, PA L (Physician Assistant) indicated, in part, R4 has: Fracture blisters noted throughout right ankle and foot. PA L documented, R4 reports the SNF (Skilled Nursing Facility) only changed his dressings twice and he has not been showering daily as ordered/directed on DC (discharge) summary . Orthopedic Discharge Instructions External Fixator Pin site care: MUST BE PERFORMED DAILY TO PREVENT INFECTION!!! (emphasis intended) Wash pin sites with 50/50 saline and hydrogen peroxide mix using a Q-tip to clean away ALL drainage build up. Tightly rewrap (emphasis intended) base of pin site with Kerlix or gauze No antibiotic ointment around pin sites Ok to shower with the wounds exposed to water then proceed with the applying dressings to pin sites if there is still drainage RECOMMENDED to shower over the ex fix to help clean the skin and pin sites. RECOMMEND SHOWER AT A MINIMUM EVERY OTHER DAY. Ok to use a soapy wash cloth on the leg as well as to help clean skin. Added order for Vitamin D3 (1,000 units total by mouth once daily.) 3/27 Telephone Order: 2 large blisters R foot. Skin prep to anterior shin, Dorsal foot and lateral foot blisters, allow to dry daily. If ruptures, please notify provider ASAP (as soon as possible) for new order. Of note, PA L noted the blisters on 3/22/23 yet the facility did not implement orders for blister treatment until 3/27/23. R4's TAR documents the following: Skin prep to blisters right foot-anterior shin, dorsal foot and lateral foot. If ruptures, please notify providers ASAP (Order Date: 3/27/23 and D/C Date: 4/6/23). The TAR indicates no skin prep was applied until 3/28/23. On 3/29/23 at 10:25 AM, LPN M (Licensed Practical Nurse) documented the following progress note: Res (R4) right foot noted to have intact blisters appear to have intact blisters throughout right foot also, green drainage noted from surgical rod site on right lateral foot and top of foot by shin, no redness, no warmth denies pain, NP (Nurse Practitioner) updated, area cleaned kerlix applied waiting CB (call back) from NP. Note, LPN M is no longer employed at the facility and unavailable for interview. On 3/29/23 at 11:08 AM, R4's progress notes document the following: Writer received a call from NP N (Nurse Practitioner) regarding wound drainage. New order to send to hospital ER (emergency room ) for further evaluation and treat. NP N states that resident can go non-emergent. Writer updated resident and resident's family .Writer set up transport at 1:00 PM . On 3/29/23 the hospital report documents, in part, as follows: .He (R4) reports his dressings have been changed 3 times in the past 3 weeks . The hospital documents the following Active Wounds upon admission to the hospital: Pressure Injury Heel Right Pressure Injury Foot Right: Doral Pedis Pressure Injury Ankle Right: Anterior Pressure Injury Shin Distal: Right Pressure Injury Foot Right: Lateral Pressure Injury Ankle Right: Posterior Wound 4/4/23 Incision Ankle Lateral: Right surgical incision; Duration: 3 days The hospital has a photo of R4's right lower extremity and the visible PIs that present as SDTI (Suspected Deep Tissue Injuries). Suspected Deep Tissue Injuries are defined as purple or maroon localized areas of discolored intact skin or blood-filled blisters due to damage of underlying soft tissue from pressure and/or shear. R4's Hospital Course dated, 4/7/23, includes, in part, as follows: He (R4) was admitted to orthopedic service. Hospital medicine and Diabetes management were consulted for co-managements . On admission, the patient had numerous pressure injuries on his foot, heel, and ankle (please refer to wound and skin note from 3/31/23). These were splinted during ORIF R (right) ankle fx (fracture) and ex fix (external fixator) removal on 4/4/23. Current plan is to leave splint in place until he has a two week follow up appointment in clinic. He will be stand pivot to chair only with no gait training until his 2 week follow up. On 4/29/23 at 9:40 PM, LPN O (Licensed Practical Nurse) documented the following progress note: Sutures to right ankle removed this shift, resident tolerated procedure well, Eschar noticed to top right foot 6.5 x 4.5 x 0.0 with no drainage or order [sic] noticed to site. Resident denies pain to site. Eschar noticed to inner right ankle 5.0 x 0.1 x 0.0. Eschar noticed to outer right foot close to pinky toe 5.0 x 3.0 x 0.0 and eschar noticed to lower right foot under eschar close to pinky toe 3.0 x 4.0 x 0.0. Eschar noted to right heel 4.0 x 3.0 x 0.0 . Of note, the facility failed to assess and measure R4's PIs for two weeks. There is no PI assessment or measurements for 5/6/23 or 5/13/23. R4's PI documentation includes the following: Right heel: Stage 3 (wound doctor says present for more than 46 days,) measured as follows: Start Date 4/28/23 05/23 - 1.7 x 1.0 x 0.1, 100% granulation 05/30 - 2.0 x 1.7 x 0.1, 100% granulation (deteriorated) 06/06 - 1.3 x 1.1 x 0.1, 100% granulation (improved) 06/13 - 1.1 x 0.7 x 0.1, 100% granulation (improved) 06/20 - no documentation located Right foot dorsum: Start Date 4/28/23 05/23 - 6.5 x 3.6 x 0.1, 100% eschar/necrotic 05/30 - 7.3 x 4.4 x 0.1, 100% eschar/necrotic 06/06 - 7.1 x 3.8 x na (not applicable), 80% eschar, 20% granulation 06/13 - 5.6 x 3.7 x 0.1, 20% granulation, 80% eschar, debrided, called a Stage 4 Right middle dorsum: (facility calling new on 05/30 but states 04/28 origin) Start Date 4/28/23 05/30 - 5.7 x 2.1 x 0.1, 100% eschar 06/06 - 5.5 x 1.7 x 0.1, 50% epithelial, 50% granulation 06/13 - 1.2 x 1.6 x 0.1, 100% granulation, facility calls Unstageable On 5/23/23, the visiting wound physician started assessing and measuring R4's PIs. The wound physician's assessments indicate the following: Dorsal Foot - Unstageable (Due to Necrosis) of the Right, Dorsal Foot Full Thickness 5/23/23: Wound Size: 6.47 x 3.55 x 0.1 cm (centimeters) Etiology: Pressure *Stage: Unstageable Necrosis Duration: > (greater than) 20 days Objective: Healing Exudate: Moderate Sero-sanguinous Thick adherent devitalized necrotic tissue 100% Primary dressing: Leptospermum honey apply once daily for 30 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 30 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot *Surgical Excisional Debridement Procedure - Indication for Procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue Procedure Note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 6.42 cm (centimeters) squared of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 80 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. 5/30/23: Wound Size: 7.3 x 4.4 x not measurable cm (centimeters) Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 26 days Objective: Healing Exudate: None Thick adherent devitalized necrotic tissue 100% Wound progress: 100% Primary dressing: Leptospermum honey apply once daily for 23 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 23 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/6/23 Wound Size: 7.06 x 3.81 x not measurable cm (centimeters) Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 33 days Objective: Healing Exudate: Moderate Sero-sanguineous Thick adherent devitalized necrotic tissue 80% Granulation tissue: 20% Wound progress: Improved evidenced by decreased surface area, decreased necrotic tissue Primary dressing: Leptospermum honey apply once daily for 16 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 16 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/13/23 Wound Size: 5.57 x 3.7 x 0.1 cm (centimeters) Etiology: Pressure *Stage: 4 Duration: > (greater than) 40 days Objective: Healing Exudate: Moderate Sero-sanguineous Thick adherent devitalized necrotic tissue 80% Granulation tissue: 20% Wound progress: No change Primary dressing: Leptospermum honey apply once daily for 9 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 9 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/20/23 Wound Size: 5.5 x 3.2 x 0.2 cm (centimeters) Etiology: Pressure *Stage: 4 Duration: > (greater than) 46 days Objective: Healing Exudate: Moderate Sero-sanguineous Thick adherent devitalized necrotic tissue 60% Granulation tissue: 40% Wound progress: Improved evidenced by decreased surface area Primary dressing: Leptospermum honey apply once daily for 30 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 30 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot Right Heel Full Thickness - Stage 3 5/23/23 Wound Size: 1.69 x 1.02 x 0.1 cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 20 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 100% Primary dressing: Leptospermum honey apply once daily for 30 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 30 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 5/30/23 Wound Size: 1.97 x 1.73 x 0.1 cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 20 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 100% Wound Progress: Deteriorated due to multifactorial Expanded Evaluation: The progress of this wound and the context surrounding the progress were considered in greater depth today. Reviewed off-loading surfaces and discussed surfaces care plan. Primary dressing: Leptospermum honey apply once daily for 23 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 23 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/6/23 Wound Size: 1.32 x 1.11 x 0.1 cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 33 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 100% Wound Progress: Improved evidenced by decreased surface area Primary dressing: Leptospermum honey apply once daily for 16 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 16 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/13/23 Wound Size: 1.11 x 0.67 x 0.1 cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 40 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 100% Wound Progress: Improved evidenced by decreased surface area Primary dressing: Leptospermum honey apply once daily for 9 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 9 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/20/23 Wound Size: 0.6 x 0.8 x 0.1 cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 46 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 100% Wound Progress: Improved evidenced by decreased surface area Primary dressing: Leptospermum honey apply once daily for 30 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 30 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot Right Foot Full Thickness - Stage 3 6/6/23 Wound Size: 5.52 x 1.66 x 0.1 cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 33 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 50% Skin: 50% Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater depth today. Reviewed off-loading surfaces and discussed surfaces care plan. Primary dressing: Leptospermum honey apply once daily for 16 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 16 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/13/23 Wound Size: 1.19 x 1.57 x 0.1 cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 40 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 100% Primary dressing: Leptospermum honey apply once daily for 9 days Secondary Dressing(s): Gauze island with bdr (border) apply once daily for 9 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot 6/20/23 Wound Size: 1.5 x 6.0 x Not Measurable cm (centimeters) Etiology: Pressure Stage: 3 Duration: > (greater than) 46 days Objective: Healing Exudate: Moderate Sero-sanguineous Granulation tissue: 100% Primary dressing: Skin prep apply once daily for 30 days Recommendations: Off-load wound; Reposition per facility protocol; Float Heels in Bed; Pressure Off-Loading Boot On 6/23/23, R4 discharged home. On 1/16/24 at 8:50 AM, Surveyor spoke with R4. R4 stated he made the decision to ambulate independently to the bathroom. R4 added if he knew all of this was going to happen as a result of ambulating independently he would not have done it. R4 stated, I made the wrong decision. R4 stated he broke his ankle when he fell and required multiple surgeries. Surveyor asked R4, did facility staff complete daily diabetic foot checks. R4 stated, no. Surveyor asked R4, did the facility clean the pins daily per physician orders. R4 stated, Not daily, no. Surveyor asked R4, did the facility complete skin inspections during showers. R4 stated, Not that I know of. Surveyor asked R4 would facility staff elevate your feet while in bed. R4 stated, Sometimes. Surveyor asked R4 who discovered your PIs initially. R4 stated, I'm not sure who discovered the PIs first. Surveyor asked R4, were you able to turn and reposition in bed. R4 stated, Somewhat. Surveyor asked R4, did staff offer to reposition you. R4 stated, they would reposition me when I pushed the call light and requested it. R4 added, there were some staff that were very good and would come in to reposition me without having to ask. Surveyor asked R4, what type of mattress did you have at the facility. R4 stated, an air mattress. R4 stated he discharged home from the facility on 6/23/23. R4 shared in December 2023 he developed multiple PIs to his left foot (opposite foot) and his left foot/leg was amputated in January 2024. R4 stated the PIs on his right foot are almost healed. On 1/16/24 at 3:32 PM and 4:53 PM, Surveyor spoke with DON B (Director of Nursing) and RDCO C (Regional Director of Clinical Operations). Surveyor asked DON B and RDCO C, does the facility have a process for completing foot checks. RDCO C stated, she does not see that the facility has a policy regarding foot checks. RDCO C stated, for diabetic residents it's an expectation that daily diabetic foot checks are done. RDCO C added, daily diabetic foot checks are a standard of practice. Surveyor asked DON B and RDCO C, do you expect daily diabetic foot checks to be done for R4. RDCO stated, Yes. Surveyor reviewed R4's TAR (Treatment Administration Record) which documents daily diabetic foot checks were not completed on the following dates: 3/2/23, 3/11/23, 3/18/23, 3/19/23, 3/21/23, and 3/23/23. Surveyor asked DON B and RDCO C, should R4's diabetic foot checks have been completed daily. DON B and RDCO C stated, Yes. Surveyor asked DON B and RDCO C, do you expect staff to follow physician orders. RDCO stated, Yes. DON B stated, It's kind of the reason we have them. Surveyor stated R4 has an order for daily pin cleaning following sur

Based on staff interview and record review, the facility did not ensure quality end of life care was provided to 2 Residents (R) (R6 and R5) of 11 sampled residents. R6's hospice plan of care, related to pain management and comfort, was not consistently followed from the time R6 was admitted to hospice services on 4/14/23 until R6 passed away on 4/23/23. On 4/21/23, R6 was prescribed liquid morphine every 4 hours and liquid lorazepam every 6 hours. The orders were not transcribed in R6's medical record and the medications were not administered. In addition, R6's medical record did not contain hospice visit notes and the facility did not follow up on hospice staff concerns reported on 4/15/23. This example is being cited at a level G (Actual Harm/Isolated). R5 was diagnosed with edema and had physician orders to complete daily weights indefinitely and put compression stockings on in the AM and remove in the PM. R5 also had a physician order to place a wedge provided by the facility or R5 to elevate R5's legs while in bed. The orders were not consistently followed. Findings include: The facility's Hospice Services Facility Agreement, dated 3/1/19, contained the following information: It is the facility's responsibility to .meet the resident's personal care and nursing needs in coordination with the hospice representative . 1. R6 was admitted to the facility on [DATE] with diagnoses to include a stroke, hypertension, insomnia, bipolar disorder, anxiety disorder, major depressive disorder, and a chronic venous ulcer of the left foot. R6's most recent Minimum Data Set (MDS) assessment, dated 3/26/23, indicated R6's cognition was not assessed and R6 required the assistance of one to two staff for activities of daily living (ADLs), including bed mobility, toileting, bathing, transferring, and personal hygiene. R6's plan of care, revised 4/17/23, stated R6 would be comfortable and have needs met. Interventions included: coordinate care plan with hospice, evaluate effectiveness of medications/interventions to address comfort, and notify hospice of any change in condition or medication changes. R6's hospice plan of care (POC), dated 4/14/23, stated R6 was admitted to hospice services for terminal diagnoses of aspiration pneumonia, sepsis, metabolic encephalopathy, and acute respiratory failure with hypoxia. The POC listed the following goals and interventions: -The facility will support R6's needs along with hospice services' support for end of life care, including but not limited to, pressure rotation every 1-2 hours in bed, incontinence cares, oral cares, and symptom relief medication administration for pain/shortness of breath. -R6's pain will be 4 or less on a scale of 0-10 as evidenced by resting peacefully, not calling out, and not moaning when touched or turned. R6's medical record contained the following hospice orders, dated 4/14/23: - Atropine Opthalmic solution 1% - 4 drops by mouth every 15 minutes as needed for terminal congestion. - Morphine Sulfate Oral tab 15 mg (milligrams) - give 1/2 tablet by mouth every 30 minutes as needed for pain or dyspnea (difficulty breathing) by mouth/sublingual, may crush. Give for mild symptoms. - Morphine Sulfate Oral tab 15 mg - give 1 tablet by mouth every 30 minutes as needed for pain or dyspnea by mouth/sublingual, may crush. Give for moderate to severe symptoms. - Lorazepam 1 mg by mouth at bedtime for agitation/anxiety. - May crush oral medications with instruction from hospice nurse or pharmacist. - Small sips/bites as tolerated and for pleasure. R6's medical record contained the following hospice order, dated 4/19/23: - Scopolamine Transdermal Patch 72 hour - apply 1 patch every 72 hours as needed for mild/moderate airway secretions. On 6/14/23, Surveyor requested all hospice documentation from Nursing Home Administrator (NHA)-A. Included in the documentation were the following signed orders, dated 4/21/23: - Morphine Concentrate 20 mg/ml (milliliter) oral - give 1 ml every 4 hours. - Lorazepam 2 mg/ml liquid - give 0.25 ml every 6 hours. On 6/14/23, Surveyor reviewed R6's medical record, including Certified Nursing Assistant (CNA) charting, Treatment Administration Record (TAR), Medication Administration Record (MAR), and vital signs. CNA charting did not include documentation that incontinence cares and repositioning were completed on the 4/14/23, 4/17/23, 4/18/23, and 4/21/23 night shifts. In addition, CNA charting did not contain any documentation regarding the completion of oral cares. R6's MAR indicated one dose of morphine sulfate 7.5 mg was administered on 4/21/23 at 5:20 PM by Licensed Practical Nurse (LPN)-G for a pain rating of 8 out of 10. R6's MAR and TAR did not indicate any other comfort medications were administered by facility staff. R6's pain assessments indicated pain was to be monitored each shift. Staff completed the following pain assessments using the numeric scale (0-10 out of 10) versus the Pain Assessment in Advanced Dementia (PAINAD) unless otherwise specified: 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, and 4/22/23 Night shifts - 0 4/15/23, 4/18/23, and 4/22/23 AM shifts - not assessed 4/16/23 AM shift - 0 (PAINAD); 4/19/23, 4/20/23, and 4/21/23 AM shifts - 0 4/15/23, 4/16/23, and 4/17/23 PM shifts - not assessed 4/18/23, 4/19/23, 4/20/23, and 4/22/23 PM shifts - 0 4/17/23 AM shift - 2 (PAINAD) 4/21/23 PM shift - 8 R6's medical record contained the following respiratory assessments: 4/16/23 at 12:58 PM: O2 sat (oxygen saturation level) 91% on oxygen (did not indicate how many liters); Respiratory Rate (RR) 16 (normal range is 12-20 breaths per minute (bpm)). 4/17/23 at 10:57 AM: O2 sat 89% on oxygen (did not indicate how many liters); RR 22 bpm 4/17/23 at 3:52 PM: O2 sat 89% on oxygen (did not indicate how many liters); RR 22 bpm 4/20/23 at 8:05 AM: O2 sat 90% on oxygen (did not indicate how many liters); RR 20 bpm R6's medical record did not contain any additional assessments or vital signs. On 6/14/23, Surveyor reviewed R6's hospice visit notes which contained the following information: 4/14/23 - Hospice Admission Visit 12:35 PM: Hospice Registered Nurse (HRN)-J noted R6 was breathing heavily and had wet sounding respirations with O2 sat of 81% on 5 liters (L). HRN-J opened medication from a comfort pack and administered atropine drops as ordered. HRN-J noted R6's tongue was extremely dry and cracking in several spots and provided oral and incontinence care. HRN-J assessed R6, obtained vital signs and then administered a second dose of atropine drops. R6's respirations went from 26 to 21. HRN-J educated facility staff on the need for repositioning and oral cares every 2 hours. 4/15/23 - Hospice Nurse Visit 12:00 PM: HRN-K spoke with NHA-A regarding R6's dry oral mucosa, including thick sloughing layers of dry tissue on (R6's) tongue, lips, and inside of cheeks. HRN-K also informed NHA-A that an unknown facility CNA stated oral care, incontinence care, and repositioning was not being done every two hours. NHA-A stated the concerns would be addressed. HRN-K asked NHA-A how R6 took medications due to concerns about R6's ability to swallow. NHA-A was unable to provide the information and HRN-K was unable to find a facility nurse to discuss the concern. At 3:43 PM, HRN-K called the facility and spoke with LPN-R who stated R6 took medications without concern. HRN-K instructed the facility to contact hospice with any concerns related to comfort/swallowing. 4/17/23 - Hospice Nurse Visit 12:00 PM: HRN-L noted R6 felt short of breath. R6's RR was 22 and O2 sat was 80% on 6 L. R6's pain was assessed as 4 (moderate pain) out of 10 using the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Pain Scale. 4/20/23 - Hospice Nurse Visit 10:45 AM: HRN-M noted R6 had a RR of 44. HRN-M requested R6's morphine. LPN-F stated the facility did not have R6's comfort medications. HRN-M verified R6's comfort pack was delivered on 4/14/23. LPN-F found R6's medications after approximately twenty minutes. LPN-F crushed and administered one 1/2 tab of morphine with water in a syringe. R6 began to cough and R6's O2 sat dropped to 72% on 8 L. HRN-M instructed LPN-F to stop when LPN-F tried to administer additional water via syringe and educated LPN-F on the proper administration of R6's crushed medication. HRN-M requested R6's atropine drops when R6 became restless. LPN-F stated the facility did not have atropine drops. HRN-M again verified all medications in the comfort pack were delivered on 4/14/23. LPN-F found the atropine drops after approximately 15 minutes. HRN-M administered two doses of lorazepam, three doses of morphine, and one dose of atropine to bring R6 back to baseline. HRN-M instructed LPN-F to administer comfort medications every four hours and as needed. 4/21/23 - Hospice Nurse Visit 4:40 PM: HRN-L and LPN-G reviewed R6's comfort medications and why they were not administered since hospice's visit on 4/20/23. LPN-G stated the medications were tablets. HRN-L educated LPN-G on how to administer crushed comfort medications with a small amount of water in a syringe. HRN-L noted R6 had labored breathing and a RR of 48 with an O2 sat of 75% on 10 L of oxygen. HRN-L obtained orders for liquid morphine and liquid lorazepam so facility staff would feel comfortable administering medications. HRN-L instructed LPN-G to administer morphine 7.5 mg and lorazepam 0.5 mg with a small amount of water. Hospice sent orders for liquid comfort medications to the pharmacy to be delivered the following day. 4/22/23 - Hospice Nurse Visit 11:30 AM: HRN-N arrived at the facility with liquid morphine and liquid lorazepam. LPN-I signed and accepted the medications. 4/23/23 - Hospice Nurse Visit 7:35 AM: HRN-O arrived after the facility reported R6 passed away. HRN-O asked facility staff how R6's night went, when R6 received the last dose of medication(s) and when staff last rounded on R6. RN-Q stated R6 did not receive any medications during the night. HRN-O asked why the liquid morphine and liquid lorazepam orders were not transcribed or administered after they were delivered on 4/22. RN-Q stated RN-Q did not know. On 6/14/23 at 9:55 AM, Surveyor interviewed Hospice Director (HD)-P who verified several hospice staff reported concerns regarding R6's condition and the fact facility staff did not provide comfort medications. HD-P stated R6 likely had a very rough end of life. HD-P stated that (named hospice company) chose to no longer work with the facility due to poor communication and lack of follow through on hospice orders/treatments. On 6/14/23 at 2:20 PM, Surveyor interviewed Regional Director (RD)-C who verified medication orders should be transcribed and administered as ordered. On 6/14/23 at 3:05 PM, Surveyor interviewed NHA-A who could not recall any concerns regarding R6, including any concerns expressed by hospice staff. Surveyor noted the grievance binder contained no concerns related to R6. On 6/15/23 at 9:31 AM, Surveyor interviewed CNA-D who worked with R6 on the 4/15/23 AM and PM shifts and the 4/20/23 PM shift. CNA-D stated R6 appeared to be in pain because R6 moaned when R6 was repositioned and appeared to have labored breathing. On 6/15/23 at 9:35 AM, Surveyor interviewed RN-E who was the charge nurse on the 4/14/23 AM shift. RN-E verified staff had to assess R6 for pain because R6 could not verbally report pain. RN-E confirmed RN-E did not administer any comfort medications due to R6's swallowing concerns. On 6/15/23 at 9:42 AM, Surveyor interviewed LPN-F who worked with R6 on 4/19/23 and 4/20/23 AM shifts. LPN-F stated the last time LPN-F worked with R6, R6 appeared to be in respiratory distress as evidenced by the use of accessory muscles, gasping, and low O2 sat. LPN-F stated LPN-F administered comfort medications under the direction of hospice staff. On 6/15/23 at 9:49 AM, Surveyor interviewed LPN-G who worked with R6 on the 4/19/23, 4/21/23, and 4/22/23 AM shifts and the 4/21/23 PM shift. LPN-G verified R6 appeared restless and uncomfortable. LPN-G stated R6 could not verbally report pain and staff had to determine R6's pain level via assessment/non-verbal scale. On 6/15/23 at 12:47 PM, Surveyor interviewed HRN-N who verified both liquid medications and a copy of the signed orders were delivered to LPN-I during R6's hospice visit on 4/22/23. HRN-N told LPN-I the medications were scheduled and R6 needed them right away. On 6/15/23 at 10:04 AM, Surveyor interviewed LPN-I who verified HRN-N delivered the medications in the early afternoon. LPN-I stated LPN-I put the medications (in their original bag) in the 400 wing medication cart and added them to the narcotic book. LPN-I stated LPN-I assumed R6 already had orders for the medications and did not look in the medication bag for orders. 18815 2. On 6/13/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility with diagnoses to include hemiplegia/hemiparesis following a cerebrovascular accident, morbid obesity and seizures. R5's Quarterly MDS assessment, dated 4/28/23, documented R5's cognition was 15 out of 15 (the higher the score, the more cognizant). R5 did not ambulate, was dependent on staff for transfers with a full-body lift, and required extensive assistance of two staff for bed mobility. R5's plan of care, initiated 7/27/21, stated R5 was at risk for altered nutrition related to current condition, alcohol abuse, and history of weight gain. Weights to be obtained per orders. A progress note, dated 5/12/23 at 1:47 PM, indicated R5's physician was notified that R5 had four (4) plus edema to the left foot. New orders were obtained to weigh and notify the physician. A physician order, dated 5/12/23, stated daily weights to start on 5/13/23 on the day shift. A progress note, dated 5/12/23 at 5:06 PM, indicated R5 was to be administered 20 mg of Lasix every day with daily weights. Lasix 20 mg was administered as ordered. R5's weight summary indicated R5 weighed 345.6 pounds on 5/3/23. R5 was weighed on 5/15/23 and weighed 357.8 pounds (a weight gain of 12.2 pounds). Surveyor noted that was the only documented weight after the physician ordered daily weights to start on 5/13/23. R5 had a physician order, dated 5/23/23, for compression stockings to lower extremities-measure and fit, on in AM, off in PM, every day and evening shift. R5 also had a physician order, dated 5/23/23, for facility to supply wedge to R5-place at foot of bed to elevate legs or allow to use own (wedge). R5 did not have a plan of care or a CNA Kardex (modified care plan used by nursing staff) related to compression stockings or the use of a wedge. R5 had a physician order, dated 5/31/23, to send R5 to the emergency department (ED) per family request due to concerns of increased edema and a question of possible sepsis. A progress note, dated 5/31/23 at 5:55 PM, indicated R5 was sent to the ED to be evaluated per family request for increased edema and possible sepsis. R5 was evaluated at the ED on 5/31/23 at 6:29 PM. The chief complaint was increased edema and shortness of breath. Morbid obesity was an ongoing problem. R5's weight was obtained. R5 weighed 390.88 pounds. R5 was prescribed compression socks, but R5 stated the facility did not provide compression wraps. R5 was diagnosed with dependent edema, 40 mg = 4 milliliters was administered to R5 intravenously (IV) at the ED. R5 was discharged back to the facility on [DATE] at 8:02 PM with an order to increase Lasix to 40 mg daily as the ED physician suspected the ongoing edema was likely due to R5's weight, immobility and a prior left leg deep vein thrombosis (DVT). The ED physician indicated to please apply compression stockings to both legs as prescribed. On 6/13/23 at 12:50 PM, Surveyor observed R5 in bed with stretched out (loose) Tubigrips (not compression stockings) on both legs, and without a wedge to elevate R5's legs. R5 stated staff do no put on R5's compression stockings and verified the Tubigrips were loose. R5 also stated staff do not elevate R5's legs with the wedge, but should do so because of R5's edema. Additionally, R5 stated R5 was not weighed in a long time. On 6/13/23 at 1:02 PM, R5 requested CNA-S and CNA-T put compression stockings on R5's legs and elevate R5's legs with the wedge in R5's room. CNA-S stated R5 did not ask for and did not wear compression stockings for the entire nine (9) months CNA-S worked at the facility. CNA-T stated R5 refused to wear compression stockings because the stockings were too tight. R5 stated R5 wanted to wear the compression stockings, but there was not a pair of stockings in R5's room. R5 then asked for the wedge under R5's legs. CNA-S and CNA-T placed the wedge under R5's legs, but did not feel the wedge was safe to use because it did not look comfortable or safe and R5 ordered the wedge on R5's own. CNA-T removed the wedge from under R5's legs and stated CNA-T would ask therapy if R5 could use the wedge. CNA-T verified the compression stockings and wedge were not on R5's plan of care or CNA Kardex. CNA-T left R5's room to get compression stockings and discuss the use of the wedge R5 ordered with therapy. On 6/13/23 at 1:27 PM, CNA-T returned to R5's room with brown and white compression stockings. R5 declined the brown stockings, but allowed CNA-T to put the white stockings on. CNA-T also elevated R5's legs. On 6/14/23 at 4:05 PM, Surveyor interviewed LPN-G regarding R5's weights, compression stockings and wedge. LPN-G verified R5 had an order for daily weights indefinitely, but stated the order should have been for daily weights times three (3) days and update the physician. LPN-G confirmed the only weight documented was on 5/15/23. Additionally, LPN-G verified R5 had a physician order for compression stockings to be placed on R5's legs daily and R5 had an order to use R5's own wedge to elevate legs while in bed. LPN-G verified R5 should be offered the stockings and wedge. LPN-G stated if R5 refused, the nurse should be notified so the physician could be notified.

Based on staff and resident interview and record review, the facility did not ensure dressing changes were completed as ordered for 1 Resident (R) (R2) of 2 residents reviewed. R2 had a physician order to change a central line dressing every 72 hours. The dressing was not changed for 11 days. On 4/27/23, R2 was transferred to the emergency room (ER) with signs of infection and was prescribed antibiotic treatment. Findings include: The facility's Catheter Insertion and Care: Central Venous Catheter Dressing Changes policy, revised July 2011, contained the following information: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .Dressing changes will include: removal of the old dressing, observation and evaluation of the catheter-skin junction and surrounding tissue, cleansing with an approved antiseptic solution, replacement of any stabilization device, and application of a sterile dressing .Apply sterile transparent dressing to area .label with initials, date and time. R2 was admitted to the facility on [DATE] with diagnoses to include femur (hip) fracture, osteomyelitis (bone infection), diabetes, and depression. R2's most recent Minimum Data Set (MDS) assessment, dated 3/31/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2's most recent care plan, dated 3/31/23, stated R2 had the potential for infection/complication related to intravenous (IV) use via central line and contained a goal that R2 would remain free from signs and symptoms of infection. Care plan interventions included: Change IV tubing, dressings, and caps according to order or more frequently as needed; Monitor site for signs and symptoms of infection: redness, inflammation, drainage, irritation to the vein. On 5/9/23, Surveyor interviewed R2 regarding R2's central line dressing changes. R2 verified staff missed some of R2's dressing changes before R2 was transferred to the hospital on 4/27/23. R2 stated the area became infected a few weeks ago and was very painful to the touch. On 5/9/23 at 12:29 PM, Surveyor noted R2's central line dressing was clean and intact; however, the dressing did not contain initials or a date. On 5/9/23, Surveyor reviewed R2's medical record, including physician orders, Treatment Administration Record (TAR) and hospital notes. R2 had a physician order, dated 4/10/23, to change the central line dressing every 72 hours. Per R2's TAR, the treatment was completed on 4/10/23, 4/13/23, 4/16/23, 4/19/23, and 4/25/23. R2's TAR did not contain initials or indicate the treatment was completed on 4/22/23. On 5/10/23 at 10:15 AM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should date and initial dressings when applying a new dressing. DON-B was not aware of any concerns related to R2's central line dressing changes, but verified R2 was treated for an infection at the central line site. A nursing progress note, dated 4/27/23 at 7:53 AM, indicated R2's central line was red and warm around the site and stated R2 had pain even when blankets touched the site. A nursing progress note, dated 4/27/23 at 8:22 AM, contained the following information: (R2) complaining of pain in right chest where central line is placed. Area is red, warm to the touch and an angry red orders to send to the ER to evaluate and treat. An ER visit note, dated 4/27/23, contained the following information: Central line dressing not intact. Gauze underneath saturated with yellow drainage. Skin around site is reddened and excoriated (skin damage). Appears dressing has not been changed since 4/16/23. On 5/11/23 at 7:02 AM, Surveyor interviewed ER Registered Nurse (RN)-H who stated upon R2's arrival to theER on [DATE], R2's central line dressing was dated 4/16. RN-H stated the central line site was infected and R2 was prescribed Clindamycin (antibiotic) 450 mg (milligrams) three times daily for five days. On 5/11/23 at 7:42 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who initialed the central line dressing change in R2's TAR on 4/19/23. LPN-F stated LPN-F had never done a dressing change on R2's central line, but recalled assessing the area around the dressing. LPN-F verified LPN-F did not complete R2's central line dressing change on 4/19/23. On 5/11/23 at 9:26 AM, Surveyor interviewed LPN-G who initialed the central line dressing change in R2's TAR on 4/25/23. LPN-G stated LPN-G could not recall ever completing a central line dressing change for R2.

Based on observation, staff interview and record review, the facility did not ensure 1 Resident (R) (R54) of 1 resident reviewed for accidents and supervision received adequate supervision to prevent elopement. R54 had a history of elopement from the facility. After R54's most recent elopement on 12/5/22, R54's location and attire were to be checked every 15 minutes by staff. Surveyor observed checks were not completed in 15 minutes increments and all staff working with R54 did not know to check R54's attire. In addition, staff documented 15 minute checks were completed when they were not. In addition, prior to R54's elopement on 12/5/22, R54 was on 30 minute checks. Documentation of 30 minute checks was inconsistent and missing information, including staff initials to indicate who checked R54 prior R54's elopement. The facility's failure to implement safety interventions and adequately supervise a resident with a history of elopement created a finding of Immediate Jeopardy that began on 12/5/22. Regional Field Operations Supervisor (RFOS)-UU notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy on 12/14/22 at 4:30 PM. The Immediate Jeopardy was removed on 12/13/22; however, the deficient practice continues at a scope/severity level D (Potential for Harm/Isolated) as the facility continues to implement its action plan. Findings include: The facility's Elopement policy reads as follows: 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 .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . On 12/12/22, Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis/immobility of one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following unspecified cerebrovascular disease (a variety of medical conditions that affect the blood vessels of the brain, often resulting in what is commonly known as a stroke) affecting right dominant side and aphasia (an inability to comprehend or formulate language because of damage to specific brain regions). R54's Minimum Data Set (MDS) assessment, dated 11/1/22, contained a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R54 was severely cognitively impaired. R54's medical record contained Court Ordered Guardianship and Protective Placement documents, dated 3/7/22, that indicated R54's Guardian was responsible for R54's healthcare decisions. R54's medical record contained Elopement Evaluations, dated 2/17/22, 4/7/22, 5/6/22 and 8/16/22 that indicated R54 was at risk for elopement. The 4/7/22, 5/6/22 and 8/16/22 Elopement Evaluations each indicated .History of or attempted leaving the facility without informing staff . R54's medical record also included prior elopements on 6/20/22 and 8/6/22. R54's medical record contained a Social Service Care Plan Meeting note, dated 2/24/22, that stated, .(R54) seems to lack the insight of what is going on/happening or what exactly happened to (R54) .The stroke has affected the brain cognitively--language and understanding; (R54) is not able to communicate effectively verbally . On 12/13/22 at 8:43 AM, Surveyor interviewed NHA-A who confirmed R54 eloped through R54's window on 12/5/22 and a staff who was not in work status found R54 walking on a sidewalk that was .7 to 1 mile from the facility. Surveyor requested the facility's investigation of R54's elopement. On 12/13/22 at 8:45 AM, Surveyor reviewed R54's care plan which stated: 1 on 1 supervision will add what (R54) is wearing and where (R54) is at .Window 4 inch stops modified to prevent (R54) from removing and opening the window independently (initiated 12/5/22) .When I am noted to have blue jeans, tennis shoes, and a baseball hat, I am more prone to wanting to leave and require increased supervision (initiated 6/21/22) . R54's medical record included the following progress notes regarding R54's elopement on 12/5/22: 12/5/2022 at 3:15 PM: Writer spoke with POA (Power of Attorney) and caseworker to update that (R54) did elope and is on 15 minute checks as well as (1 on 1 supervision). No concerns or changes at this time and will update as needed. Writer also faxed (physician) to update. 12/5/2022 at 3:56 PM: Writer heard the code for a missing resident and went looking. A staff member not working today had called and let the facility know that (R54) was in town walking by self. (R54's) window was open in their room. (R54) did come back to the building. All windows checked for the 4 inch clearance. (R54) continues to be on 15 (minute) checks and is on 1:1 as of now. 12/6/2022 at 1:03 PM: Skin Only Evaluation: Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. No current skin issues noted at this time. Right knee 2 cm (centimeter) x 4 cm blister with right shin scrape superficial left open to air 1 cm x 5 cm. Surveyor reviewed facility-provided check forms that staff utilized to confirm R54's checks were completed. A form, dated 12/5/22, stated R54 was to have 30 minute checks completed. The form included columns for the time (pre-filled in 15 minute increments), R54's location, activity/observations and staff initials. A staff entry at 6:00 AM noted R54 was in bed and included staff initials. Surveyor noted there was a line drawn down each column until 7:45 AM in which the same staff's initials noted R54 was in R54's room eating breakfast. The same initials noted at 8:00 AM that R54 was on R54's bed. Surveyor again noted a line drawn down each column until 10:00 AM when the form indicated R54 was in bed; however, the 10:00 AM entry was not initialed. The form contained a line drawn down the columns to 11:30 AM; however, there was no documentation at 11:30 AM where the line ended. The next row with a time of 11:45 AM was left blank. The 12:00 PM row contained a short line drawn through (R54's) location block only; the activity/observations and staff initials column were blank (no line drawn). There was no documentation of R54's whereabouts at 12:00 PM except for the short line drawn in the location column. The 12:15 PM row read: Got out, Code Green and was initialed by Certified Nursing Assistant (CNA)-N. The columns/rows were then blank until 2:00 PM. On 12/13/22 at 10:55 AM, Surveyor noted R54's room door was approximately one-fourth open. R54 could be seen in R54's bed when looking in the cracked door. No staff were noted in the hallways. There was a nurse within an enclosed nurses' station which was several rooms away and not within sight of R54 or R54's doorway. At 11:06 AM, Surveyor observed staff transport residents to the dining room in the hallway prior to R54's room. Staff were not within visual contact of R54 or R54's doorway. At 11:22 AM, Surveyor observed a CNA deliver R54's lunch tray. Surveyor noted no staff checked on R54 during the observation time of 10:55 AM to 11:22 AM which was a total of 27 minutes. On 12/13/22 at 12:14 PM, Surveyor observed R54 on R54's bed. R54's door was approximately one-third open. Surveyor was able to see R54 when looking through R54's door. Surveyor did not observe staff in the hallway on the unit. Surveyor remained outside R54's door until 12:37 PM which was 23 minutes. When Surveyor departed the area, Surveyor noted there were no staff in the unit hallway and no staff checked on R54 during that time frame. On 12/13/22 at 1:27 PM, Surveyor interviewed Social Worker (SW)-P who was unsure if R54 was on 15 minute checks or 1 on 1 supervision at the time of the interview. When asked how staff knew how to supervise R54, SW-P stated there would be an end date on R54's care plan if 1 on 1 supervision was discontinued. Surveyor reviewed R54's care plan with SW-P who confirmed there was not an end for 1 on 1 supervision. When asked about the intervention related to R54's clothing, SW-P stated in the past, R54 stated if R54 was wearing jeans and tennis shoes, then R54 was leaving. SW-P stated staff were supposed to watch and redirect R54. SW-P stated staff check on R54 at least every 15 minutes. On 12/13/22 at 1:43 PM, Surveyor interviewed NHA-A who stated R54's 1 on 1 supervision was discontinued on 12/12/22 and R54 was currently on 15 minute checks. NHA-A confirmed the care plan still indicated 1 on 1 supervision and indicated R54's care plan should be updated to 15 minute checks. NHA-A stated staff are to observe R54's attire and document it on the check forms. NHA-A stated R54's attire was monitored as a potential elopement red flag because R54 usually wore sweatpants and no shoes. NHA-A stated R54 made comments in the past that if R54 was wearing jeans, tennis shoes and a hat, R54 may plan to leave the facility. NHA-A stated there was a form on the unit for staff to document the time, R54's location and R54's attire. When asked NHA-A's expectation of 15 minutes checks, NHA-A stated NHA-A expected staff to walk by R54's room, check if R54 was in bed and check if R54 was safe. During the same interview, NHA-A stated residents' windows contained screws to prevent them from opening fully, but they are old screws. NHA-A located the window screws in R54's dresser drawer following R54's elopement on 12/5/22 and stated, (R54) took (the screens) out. NHA-A stated Maintenance staff (MS)-Q installed longer screws in R54's window frame after the 12/5/22 elopement so they were harder to get out. NHA-A stated NHA-A believed R54 hit the smaller screws previously installed in the window and loosened the screws. NHA-A also stated staff indicated R54 opened the window in the past wide enough to place a can of soda in the opening and R54 must have worked on (the window) for a couple days. NHA-A stated MS-Q checked other facility windows after R54's elopement and noted not all windows needed installation of the longer screws. NHA-A stated NHA-A was made aware of R54's elopement of 12/5/22 when NHA-A heard an overhead page on the loud speaker that stated, (R54) (named Doctor) is here to see you. NHA-A stated the page was the facility's code for an elopement or elopement drill. NHA-A stated, I jumped up and thought, I did not know we were having a drill. I went to the back parking lot (to conduct a search). NHA-A stated the facility then received a call from Hospitality Aide (HA)-S who saw R54 walking down a street in town. NHA-A G googled the location and noted it was .7 miles from the facility. NHA-A was unsure if the weather was documented; however, NHA-A recalled it snowed on the morning of 12/5/22. NHA-A stated the direction R54 was headed was the direction to the highway to get to (town where R54 resided prior). NHA-A stated, Another 1.5 miles, (R54) would have been almost to the highway. NHA-A stated facility staff knew R54 exited R54's window because there was a foot mark in the mud outside the window. NHA-A indicated\ R54 was wearing jeans, tennis shoes, a hat, a sweatshirt and a flannel when found. NHA-A verified R54 was on 30 minute checks at the time of the elopement. NHA-A believed R54 returned to the facility between 1:30 PM and 1:40 PM on 12/5/22; however, NHA-A verified it was not documented when R54 returned or how long R54 was gone. NHA-A stated there was coaxing done to get R54 to return and that took some time. NHA-A stated NHA-A reviewed the check-off document for 30 minute checks and noted R54 was checked on at 12:15 PM. NHA-A stated CNA-N was the last staff to see R54 during the 30 minute checks and indicated CNA-N last checked on and visualized R54 when CNA-N picked up lunch trays. NHA-A stated upon R54's return to the facility, management began education with staff which included the prior intervention regarding what to do when R54 was wearing jeans, tennis shoes, etc. NHA-A stated an emergency care conference was held because R54 had no skilled need, NHA-A also stated the facility was trying to place R54 at another facility since R54's last elopement. NHA-A provided Surveyor with the facility's investigation related to R54's elopement. A Grievance/Concern Form stated, (R54) elopement out window: Date of Occurrence: 12/5/22. Individual completing form: Acute Care Unit (ACU) Director, Registered Nurse (RN)-R. Description of Concern: (R54) removed screws from window and crawled through the window leaving facility. Investigation Findings: Was blank. Summary of Investigation: Was blank. Resolution: (R54) placed on 15 minute checks, 1 on 1 staff, emergency care conference. All windows checked for the 4 inch clearance. Two 3 inch long screws placed to restrict window from opening all the way preventing (R54) from exiting facility through window. SW (Social Worker) put in a call to psychologist. The form was signed by NHA-A and Director of Nursing (DON)-B on 12/6/22. NHA-A stated there was a soft file which included staff education for what to do when R54 was wearing jeans, tennis, shoes, etc. Educations documents provided to Surveyor included staff signatures on educational post-tests related to R54's supervision, including how often staff were to review care plans (before their shift), how often care plans should be updated (when there was a change in orders, treatment or condition), what to do if staff saw R54 in jeans, a baseball hat and tennis shoes (notify the ACU Director), that windows are not required to open completely and the importance of documentation. On 12/13/22 at 2:39 PM, Surveyor noted R54's door was opened approximately 1 foot. Surveyor was not able to see into R54's room without opening the door further to look inside. Surveyor observed one staff on the opposite end of the hall who took a resident into the shower room and was not seen afterward. Surveyor observed CNA-U enter the unit, but noted CNA-U did not go down R54's hallway. At 2:55 PM, Surveyor observed Administrator-in-Training (AIT)-GG enter the unit and interact with staff. Following the interaction, two staff members walked directly to R54's room. Prior to staff entering the room, Surveyor noted R54 was not checked for 16 minutes. On 12/13/22 at 3:00 PM, Surveyor interviewed CNA-CC who verified staff were to check on R54. CNA-CC stated staff were to check R54's location and if R54 needed anything. When asked if staff were to check anything else, CNA-CC stated, No. When asked if staff should check R54's attire, CNA-CC said, That (clothing) does not matter because (R54) changes own clothing. We check if (R54) needs anything and where (R54) is. CNA-CC verified CNA-CC worked the unit on which R54 resided the day prior (12/12/22) as well. On 12/13/22 at 3:11 PM, Surveyor interviewed RN-O who started work at 2:00 PM. When asked the location of R54's 15 minute check form, RN-O stated, Well, there was question if they were going to do them. RN-O stated RN-O was recently off work and was not sure if R54 was still on 15 minute checks. Medication Tech (MT)-J, who was in the nurse's station at that time, stated, (R54) is 15 minute checks. We are seeing if (R54) went in (R54's) room and that (R54) didn't climb out the window. RN-O then stated, Oh, and then we look for a certain outfit (R54) likes to wear. Apparently (R54) wore jeans and tennis shoes when (R54) escaped out the window. RN-O also stated R54 was observed pushing the window back and forth prior to 12/5/22 and that was likely how the screw became loose enough to remove. On 12/13/22 at 3:30 PM, Surveyor reviewed the 15 minute check forms for 12/13/22 which contained documentation for the above-noted times when Surveyor's observations confirmed staff did not check on R54 within 15 minutes. The observation time from 10:55 AM to 11:22 AM contained documentation at 11:00 AM that R54 was in R54's room eating and wearing sweats, tee (T-shirt) and socks. (Of note, R54's lunch tray was not delivered until 11:22 AM). There was a line drawn from the 11:00 AM entry to an 11:45 AM entry. During the observation time of 12:14 PM to 12:37 PM, staff documented a check was completed at 12:15 PM and R54 was watching TV in room and wearing sweats, tee and socks. Documentation at 12:30 PM indicated the same. There were no staff initials for those checks. On 12/14/22 at 8:04 AM, Surveyor interviewed MS-Q who stated MS-Q looked at every window in the facility following R54's elopement on 12/5/22. MS-Q stated R54's window was the only window that had a machine screw installed in the window track to restrict the window from opening more than 4 inches. MS-Q stated the machine screw had minimal threading, was non-tapered and easy-out (meaning easier to get out than a threaded screw). MS-Q stated the rest of the windows in the facility had sheet metal screws in the window tracks. MS-Q installed a 3 inch screw in R54's window track as a means to restrict the window from opening more than 4 inches and stated, It would take days for (R54) to get (the screw) out. Surveyor noted the screw in R54's window track was different than other screws observed in other resident' windows. The screw in R54's window had a head with a straight line in both directions that formed an X. All other windows observed in residents' rooms had hex-head screws placed in the window tracks. On 12/14/22 at 8:12 AM, Surveyor interviewed HA-S who verified HA-S found R54 walking on a sidewalk in town on 12/5/22. HA-S stated HA-S was off work that day and saw R54 quite a ways from (the facility) while driving down the street. HA-S stated staff were not sure which path R54 took to get where R54 was found. HA-S lived near the area in which R54 was found and stated it took HA-S 20 minutes to walk from home to the facility. HA-S stated it would have taken R54 at least 45 minutes to get that far. HA-S stated R54 was wearing a pull-over sweatshirt, jeans and green tennis shoes. HA-S indicated R54 was shaky and unsteady and walking with one shoulder slumped more than usual. HA-S lowered R54 down to the sidewalk to sit and gave R54 HA-S' sweatshirt when R54 would not get in the car to warm up. HA-S stated the weather was cold and rainy like today but with less wind. (The temperature on 12/14/22 was approximately 30 degrees, damp air, misting with wind). HA-S stated HA-S then called the facility and spoke with Medical Records Clerk (MR)-EE to ask if R54 was supposed to be released from the facility. MR-EE stated, No. HA-S stayed with R54 until staff arrived. HA-S believed HA-S found R54 between 12:30 PM and 1:00 PM. HA-S stated MR-EE and RN-R picked up R54 approximately 15 minutes later. HA-S verified R54 complained about getting in the car, but got in without delay. HA-S stated HA-S was not interviewed by NHA-A or management after the incident and was not asked what time R54 was found. On 12/14/22 at 8:27 AM, Surveyor interviewed MR-EE who confirmed MR-EE received a call from HA-S on 12/5/22. MR-EE thought MR-EE received the call at approximately 12:00 PM. MR-EE said HA-S stated, I think I (saw) (R54). Can you go to (R54's) room and check? MR-EE checked R54's room with RN-R and noted R54 was not in the room. MR-EE stated CNA-N and CNA-U were working on the unit and both stated R54 was there for lunch. MR-EE stated R54 was likely served lunch around 11:00 AM because R54 had a room tray and was served lunch from the first meal cart that went out. At the time of the interview, Central Supply Clerk (CS)-FF was in the same office as MR-EE and stated that was when CS-FF called an elopement code via the paging system. MR-EE and RN-R then met HA-S in town and picked up R54. MR-EE stated R54 was wearing tennis shoes, a sweatshirt and a baseball cap. MR-EE stated R54 seemed agitated; however, RN-R talked to R54 and then R54 got in the car. MR-EE confirmed MR-EE and RN-R told CNA-N and CNA-U that R54 was not in R54's room and a building search was initiated. MR-EE stated no one noticed R54 went out the window at that time. Upon R54's return, staff saw R54's curtain pulled out the open window and a foot print outside the window in the dirt. MR-EE stated, If (R54) wants to get out, (R54) will keep finding a way to get out. On 12/14/22 at 8:53 AM, Surveyor interviewed CNA-N who confirmed CNA-N and CNA-U were the last to see R54 on 12/5/22 prior to R54's elopement. CNA-N stated CNA-N and CNA-U were assisting with lunch when they discovered R54 eloped. CNA-N stated RN-R entered the dining room and let CNA-N and CNA-U know R54 was missing. CNA-N stated CNA-N and CNA-U told RN-R they did not see R54 come out of R54's room. CNA-N could not recall the time but stated, We had picked up (R54's) tray after R54 was done eating. CNA-N stated CNA-N last saw R54 wearing a T-shirt and sweatpants. When asked if CNA-N was the last to see R54, CNA-N stated, We (CNA-N and CNA-U) were both going back and fourth within the time of meals to see (R54). When asked if CNA-N and CNA-U completed a check and visualized R54, CNA-N said, It wasn't me that saw (R54) last. (CNA-U) (saw) (R54) last. CNA-N verified R54 was currently on 15 minute checks. When Surveyor stated Surveyor observed three instances of missed checks the day prior (12/13/22), CNA-N responded, Yes, it gets busy, especially during meals and getting people up in the morning. On 12/14/22 at 9:18 AM, Surveyor interviewed NHA-A who stated NHA-A did not have written statements or documented interviews with CNA-N or CNA-U. NHA-A confirmed not all staff were educated to check R54's attire during 15 minute checks, including CNA-CC. The failure to adequately supervise a resident with a history of elopement resulted in the resident leaving the facility through a window and created a reasonable likelihood for serious harm for R54 which led to a finding of Immediate Jeopardy. The facility removed the Jeopardy on 12/14/22 when it completed the following: 1. Reviewed all residents for elopement risk score and appropriate care plans. 2. Elopement education for staff, including the importance of completing checks. 3. All residents' windows were checked and secured to prevent them from opening more than 4 inches.

Based on observation, staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being in accordance with professional standards of practice for 2 Residents (R) (R24 and R14) of 2 sampled residents. R24 had a diagnosis of type 2 diabetes mellitus (adult-onset diabetes characterized by high blood sugar and insulin resistance) with diabetic neuropathy (weakness, numbness and pain from nerve damage usually in the hands and feet). The facility did not monitor and assess R24's feet according to R24's plan of care and the facility's foot care and wound management policies which resulted in a scheduled surgical amputation of the second toe on R24's left foot. Failure to monitor and assess a diabetic resident's feet created a finding of Immediate Jeopardy that began on 10/28/22. Regional Field Operations Supervisor (RFOS)-UU notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy on 12/15/22 at 3:43 PM. The Immediate Jeopardy was removed on 12/16/22; however, the deficient practice continues at a scope/severity level D (Potential for Harm/Isolated) as the facility continues to implement its action plan. The facility did not monitor, assess or notify the physician timely when R14 complained of a cough on 11/28/22. Findings include: The facility's undated Wound Management policy states: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse . 5. Treatments will be documented on the Treatment Administration Record .7. The effectiveness of treatments will be monitored throughout ongoing assessment of the wound. The facility's Skin Integrity-Foot Care policy, dated 10/1/22, states: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot. Policy Explanation and Compliance Guidelines: 1. The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical conditions .b. If necessary, the facility will assist the resident in making appointments with a qualified person and arranging for transportation to and from such appointments. 2. Assessment of Risk: a. Licensed nurses will conduct pressure injury risk assessments and skin assessments in accordance with facility policy for those assessments c. The comprehensive assessment will include an assessment of the feet for disorders which may require treatment, including, but not limited to, corns, neuromas, calluses, bunions, hammertoes, heel spurs, and nail disorders .d. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .3. Interventions for Prevention and to Promote Healing. A. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and assessment of any foot ulcers (e.g., impaired sensation, immobility, foot deformity, wound characteristics) .iii. Referrals to podiatrists, vascular or orthopedic surgeons, or wound care physicians will be made when appropriate. The facility will arrange for transportation to and from any appointments .4. Modifications of Interventions: a. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any foot ulcers, or any changes in a resident's medical condition. B. Interventions will be modified in a resident's plan of care as needed. The facility's Notification of Changes policy, with an implementation date of 3/1/19, states: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the representative, according to their authority, and reported to the attending physician to delegate. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. R24 was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease (a chronic kidney disease causing the kidneys to no longer work), dependence on renal dialysis (requiring dialysis to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform those functions naturally), other abnormalities of gait and mobility and venous stasis dermatitis (when blood pools in the lower legs and puts pressure on the skin leading to skin discoloration, pain, itching and sores). R24's Quarterly Minimum Data Set (MDS) assessment, dated 10/20/22, documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 was cognitively intact. The MDS further indicated R24 required partial/moderate assistance for activities of daily living (ADLs). The MDS also indicated R24 was at risk for pressure injuries and had one stage two pressure injury. R24's plan of care stated Focus: Assessment of skin condition weekly by licensed nurse. Apply skin moisturizer as needed for dry, itchy skin, initiated 4/13/22 due to alteration in kidney function due to End Stage Renal Disease (ESRD) .Conduct weekly skin inspection, initiated 4/13/22. Diabetic foot monitoring, initiated 04/13/22. Skin assessment to be completed per (facility policy), initiated 5/16/22. Treatment completed as Medical Doctor (MD) ordered followed by wound nurse as appropriate, initiated 5/6/22. On 12/12/22 at 2:40 PM, Surveyor observed R24 in bed with bare feet and both heels directly in contact with the mattress. Surveyor observed an undated bandage on the bed next to R24's left foot. R24 did not know when the bandage was applied. R24 stated dressings were sporadically changed by Director of Nursing (DON)-B and other nurses. The bandage was soaked with what appeared to be brownish, yellow dry drainage. Surveyor noted R24's left second toe contained what appeared to be yellow and black crust around the tip of the toe as well as in between the toe. Surveyor also noted the appeared be encrusted with black eschar (dead tissue) around the circumference of the tip and approximately mid-toe in length. R24 stated R24 asked Nurse Practitioner (NP)-II to look at the toe since no one had looked at the toe for a while. R24 was sent to the Emergency Department (ED) on 10/27/22 due to sudden onset of black discoloration of the toe. R24 had no recollection of a toe injury. R24 reported no pain in the toe or foot due to neuropathy. R24 stated to Surveyor the whole experience really frightened me and still does. R24 was unsure of the treatment plan for the toe wound and trusted the nurses with care of the toe. Surveyor also noted R24's right and left feet had visibly cracked and peeling/flaking dry skin. R24 stated nursing staff did not regularly apply lotion to R24's feet as they should. On 12/12/22 at 2:26 PM, Surveyor informed Anonymous Staff (AS)-F that R24's bandages were removed from the left heel and left second toe by NP-II. AS-F stated AS-F would inform DON-B. On 12/12/22 at 2:57 PM, Surveyor interviewed DON-B who verified R24's left second toe wound was discovered on 10/27/22 during weekly care for R24's left heel pressure injury. DON-B was unsure when the toe wound originated despite the fact R24 received scheduled wound care for the pressure injury, weekly skin assessments and bathing. DON-B stated MD-JJ was notified of the toe wound on 10/27/22. MD-JJ ordered staff to send R24 to the ED and follow-up with MD-JJ upon R24's return. DON-B stated DON-B believed the toe injury went undiscovered because DON-B and nursing staff did not remove R24's sock during wound treatments to the left heel. DON-B stated, You just don't always pull the whole sock off, not saying that is right, just playing devil's advocate. DON-B stated the toe wound contained eschar that was resolving because R24's left second toe was all black. On 12/12/22 at 3:07 PM, Surveyor observed DON-B complete wound care for R24's left second toe. Surveyor observed DON-B remove an old dressing that was around R24's left ankle. R24 stated the dressing slid off and was unsure when that occurred. During wound care, DON-B did not cleanse the wound. DON-B stated cleansing the would cause more harm than good because we don't know what is under it. DON-B then stated DON-B was not a doctor the wound needed to be looked at by a podiatrist. DON-B used gloved hands to pick dried, crusty drainage from in between R24's toes. Surveyor noted blood and drainage coming from the wound which was verified by DON-B. DON-B stated DON-B did not want to manipulate the drainage and crust. DON-B applied iodine to the wound edges and wrapped the toe with Kerlix (a woven gauze used in wound care). DON-B stated DON-B wanted to leave the eschar open to air. On 12/12/22 at 3:30 PM, Surveyor interviewed DON-B who stated DON-B completed wound rounds on Wednesdays, unless otherwise ordered in residents' treatment plans. DON-B stated the facility had an agency Wound Registered Nurse (WRN)-KK who previously completed wound rounds; however, WRN-KK no longer worked in the facility. DON-B verified R24's plan of care did not contain treatment orders for the left second toe. DON-B stated DON-B was doing the best with what (DON-B) had and had not touched (R24's toe wound) for some time. DON-B confirmed DON-B observed the wound and believed the wound was improving; however, DON-B did not document the observations or wound treatments. DON-B verified DON-B was not wound care certified, but stated DON-B can care for any wounds and is just not able to make up treatment plans. DON-B verified NP-II observed the wound on 12/12/22 and ordered a STAT (immediate) appointment with podiatry. DON-B stated the facility was awaiting further treatment orders. DON-B acknowledged R24's plan of care included daily checks of the left heel, foot checks, weekly skin assessments and orders for ointment to R24's feet. On 12/12/22 at 4:00 PM, Surveyor reviewed a faxed copy of an order, dated 12/12/22 and by signed by NP-II, that stated, (R24) Referral to .Podiatrist (MD-LL) STAT. DX (diagnosis) L (left) 2nd toe wound. Increase wound care to daily to L 2nd toe. On 12/12/22 at 4:03 PM, Surveyor reviewed R24's electronic health record (EHR) and found the following progress notes regarding R24's left second toe: 10/27/22 at 3:43 PM: Writer updated (MD-JJ) and (resident representative) .in regard to BLE (bilateral lower extremities) needing possible further medical attention. (MD-JJ) agreed and was ordered to update when (R24) returned if needed. 10/27/22 at 4:08 PM: (R24) great toe and second toe ruddy in color with absence of pedal pulse to palpation with +3 weeping edema noted at foot. (MD-JJ) called with orders received to send (R24) to hospital. (R24) stated it doesn't hurt if second toe has some black eschar 0.2 cm (centimeters) in circumference. 10/27/22 at 9:50 PM: (R24) returned from hospital in stable condition. NNO (no new orders) at this time. Continue with wound care. 10/28/22 at 8:27 AM: Writer placed call to (MD-JJ) for wound consult/referral. Writer informed (MD-JJ) out for the day. Writer left message with nursing staff. Writer informed will deliver message to have (MD-JJ) call back upon return. Progress note selected to display on 24 hour and shift report. R24's EHR contained the following orders: 1. Ointment (Emollient): Apply to bilateral feet topically every day and evening shift for skin concerns, dated 4/12/22. 2. Complete COMS (Core Outcome Measurement Set) skin evaluation weekly on shower day every day shift every Friday, dated 4/13/22. Surveyor reviewed documentation for R24's COMS skin evaluations and noted the last weekly skin review was completed on 9/12/22. Surveyor reviewed R24's Treatment Administration Record (TAR) and noted an order, dated 4/11/22, to check R24's heels on the evening shift, every evening shift. R24's TAR indicated the heel checks weren't completed on 10/15/22, 10/19/22, 10/21/22, 11/5/22 and 12/2/22. Surveyor noted R24's EHR and TAR contained no treatment orders for R24's left second toe. Surveyor reviewed R24's weekly wound impairment and wound evaluations, dated 11/2/22, 11/9/22, 11/17/22, 11/23/22, 11/25/22, 12/3/22 and 12/7/22. The wound evaluations indicated R24 had a left heel wound identified on 4/17/22. R24's wound/skin impairment was documented as improving. The evaluations stated R24 did not have any other skin or wound impairments that needed evaluation. On 12/13/22 at 10:36 AM, Surveyor reviewed R24's EHR for updated orders, treatments and care plan interventions. Surveyor noted R24's care plan was updated on 12/13/22 at 9:29 AM with the following intervention: Left foot second toe to be assessed for skin integrity to begin on 12/13/22. R24's TAR was also updated and contained the following interventions: Paint second toe on left foot with iodine every Monday, Wednesday and Friday one time a day related to End Stage Renal Disease, dated 12/13/22; Skin assessment daily on second toe on Left foot monitor for increase in redness, drainage and smell if any changes (notify) (NP-II). Complete in the afternoon related to End Stage Renal Disease, dated 12/13/22. On 12/13/22 at 12:27 PM, Surveyor again interviewed R24 who again stated nursing staff did not apply lotion or check R24's feet daily. R24 verified R24 had an appointment with podiatry on 12/14/22. R24 stated R24 was still nervous, afraid of losing the toe and hoped the wound be resolved. On 12/13/22 at 2:38 PM, Surveyor interviewed DON-B regarding documentation of treatments completed by WRN-KK for R24's left second toe. DON-B stated DON-B spoke with (named contracted wound care agency) several times regarding documentation of care provided to R24's toe. DON-B stated (named contracted wound care agency) verified R24's left second toe was not assessed or treated by WRN-KK and there was no documentation of wound care assessments or treatments. On 12/14/22 at 8:45 AM, Surveyor reviewed R24's Treatment Administration Record (TAR) and noted the following new order: Change the bandage on the left foot 3 times per week. Apply Betadine-soaked gauze directly to the wound bed/incision site. Cover the wound with dry gauze. Wrap the foot with rolled gauze can incorporate heel bandage. Secure with tape, avoiding directly on the skin. Complete in the evening every (Monday), (Wednesday), (Friday) for wound care, dated 12/14/22. Surveyor also reviewed documentation in R24's TAR for completion of the following intervention: Skin assessment daily on second toe on left foot monitor for increase in redness, drainage, and smell if any changes (notify) (NP-II) . On 12/3/22, Surveyor noted RN-OO documented 7 and initialed the treatment as completed. Surveyor reviewed the TAR key chart codes/follow up codes and noted code 7 is listed as Other/See Nurses Notes. Surveyor reviewed R24's EHR which contained no documentation related to the code 7 on 12/3/22. On 12/14/22 at 9:07 AM, Surveyor interviewed NP-II. NP-II stated NP-II completed a routine visit with R24 on 12/12/22 and advised Surveyor to view the visit note contained in R24's medical record. Surveyor noted the visit note was not in R24's EHR at the time of the interview. NP-II stated R24 asked NP-II to look at R24's left second toe. NP-II stated NP-II removed bandages from R24's left heel and left second toe. NP-II verified NP-II was not aware of R24's toe wound. NP-II verified NP-II notified MD-JJ who ordered R24 be sent to the ED. NP-II stated that was the last communication the facility had with NP-II and MD-JJ regarding R24's toe wound. NP-II stated NP-II provided verbal orders to DON-B immediately after viewing R24's toe and faxed orders to the facility. NP-II stated NP-II expected the facility to follow-up with orders after R24 returned from the ED. A visit note, dated 12/12/22 and signed by NP-II, stated R24 requested NP-II look at R24's second toe. The note stated (R24) thought the wound developed approximately a month ago and stated no one looked at R24's foot for a few days now. The note further stated, Staff denies any concerns regarding (R24) .Exam: skin: 2nd toe dry crusted with serosanguineous drainage (drainage containing either blood or clear liquids), foul smelling gauze removed from 2nd toe Skin ulcer of toe of left foot with necrosis of muscle .No dressing/monitoring orders in (R24's EHR) for left toe area .Plan: Emergent referral to (named podiatry clinic) placed. Left second toe to be painted with iodine M-W-F. Skin checks daily-update (NP-II) with any increase in drainage, redness, worsening. If access to podiatry an issue, needs wound clinic or (named podiatry clinic) podiatry (appointment) (as soon as possible) .Note from ER visit on 10/27/22 (attached to visit note): Wound to left second toe. Patient is receiving wound care for heel wound to this foot. Today sock was fully removed and wound noted. Toe is reddened, purulent drainage, no nail to toe noted .Examination of left lower extremity: nail avulsion over left second toe but no signs of infection. No red streak or warmth .(X-ray) toes left (10/27/22). Findings: Degenerate changes in the forefoot .Medical decision making: Patient stable for discharge at this time and encouraged close follow-up with primary care. Patient will return to the ED with new or worsening symptoms .Assessment and Plan: Toenail avulsion. Ordered: Discharge patient .Patient instructions: Return for redness, swelling or pain over affected toe. On 12/14/22 at 11:32 AM, Surveyor interviewed R24 regarding foot care. R24 stated nursing staff did not apply lotion, cleanse wounds or check either foot on 12/13/22. R24 stated R24 informed DON-B that nursing staff did not completed foot care and DON-B stated DON-B would get to it. R24 stated foot care and checks were last completed on 12/12/22. R24 stated this whole ordeal of having to go to the hospital in an ambulance scared R24 and R24 was fearful of losing the toe since the toe was completely purple in color. On 12/14/22 at 1:12 PM, Surveyor interviewed agency RN-OO. RN-OO stated RN-OO did not know what code 7 meant on R24's TAR documentation for 12/13/22. RN-OO verified through the TAR chart/follow-up codes that code 7 indicated See Other Notes/Nurses Notes. RN-OO verified R24's EHR did not contain a note for the treatment. RN-OO verified RN-OO did not complete R24's foot care on 12/13/22, but marked the treatment as completed. RN-OO stated RN-OO intended to complete the treatment; however, RN-OO did not do so. RN-OO stated R24's toe was kinda rotten. RN-OO also stated prior to the treatment orders initiated on 12/12/22, RN-OO cleansed the wound with normal saline and rebandaged the wound when R24's dressing was soiled. On 12/14/22 at 1:13 PM, Surveyor again interviewed NP-II. NP-II stated if the facility would have updated NP-II after R24's ED visit, NP-II would have seen R24 in person or referred R24 to wound care or podiatry. NP-II stated R24's toe wound was not infected, but contained necrosis/eschar and NP-II was waiting for results from R24's podiatry appointment on 10/24/22. On 12/14/22 at 1:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-CC regarding bathing and weekly skin observations for R24. CNA-CC stated the process was to take a warm towel in a bucket and clean R24's body, including R24's feet. CNA-CC stated CNAs do not remove dressings during bathing or skin observations and if there is a soiled dressing, they inform the nurse. On 12/14/22 at 1:34 PM, Surveyor interviewed CNA-PP regarding R24's foot care. CNA-PP stated lotion was applied to R24's feet in the morning and at night and was unsure if R24 had foot wounds. On 12/14/22 at 1:24 PM, Surveyor interviewed CNA-I regarding R24's foot care. CNA-I stated CNA-I completed R24's foot care daily. CNA-I stated CAN-I never removed bandages as bandages stayed on during foot care and were only removed by nurses. On 12/14/22 at 2:12 PM, Surveyor observed DON-B complete wound care for R24's left second toe. DON-B cleansed the wound, applied Betadine to the tip of the toe and then bandaged the wound. Surveyor observed crust around the sides of the toe. DON-B measured the wound and recorded the following dimensions: 2.7 cm (centimeters) (length) by 1.6 cm (width) by 6.7 cm (circumference). On 12/15/22 at 9:10 AM, Surveyor reviewed a note from R24's podiatry appointment on 12/14/22. Surveyor noted the progress note contained new orders for pre and post op amputation of R24's left second toe. The failure to monitor and assess a diabetic resident's feet resulted in a scheduled surgical amputation of the second toe on the left foot and led to serious harm for R24 which created a finding of Immediate Jeopardy. The facility removed the Jeopardy on 12/16/22 when it completed the following: 1. Conducted a skin sweep of all residents. 2. Educated staff on notification of changes in condition, skin assessments, wound prevention and treatment and documentation. 3. Daily documentation audits and review of the wound log with facility staff and weekly review of the wound log with regional staff. 43361 2. R14 was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with diabetic chronic kidney disease, congestive heart failure, atrial fibrillation and history of COVID-19. R14's Minimu Data Set (MDS), dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R14 was cognitively intact. R14 did not have an activated decision maker. On 12/14/22, Surveyor reviewed a facility grievance, dated related to a concern from R14's family that the facility was not doing anything about R14's cough. The grievance contained a timeline by Director of Nursing (DON)-B that stated: ~On Monday 11/28, DON-B spoke with R14 regarding R14's cough over the weekend. DON-B spoke with an unnamed nurse and asked them to call R14's physician and get an order for cough syrup. R14's cough was dry at that time. DON-B left the facility for a personal matter after the conversation and was out of work the remainder of the week. On 12/14/22, Surveyor reviewed R14's medical record which did not contain progress notes or monitoring for R14's cough between 11/28/22 and 12/3/22. R14's medical record also did not contain an order for cough syrup or documentation of physician notification regarding the cough on or around 11/28/22. Progress notes indicated: ~12/3/2022 at 12:04 PM, Received call from (R14's family member) concerned about (R14's) breathing. Assessed VS (vital signs): BP (blood pressure): 152/74, (O2 saturation): 93-90, P (pulse): 82, T (temperature): 97.4, R (respirations): 20. LS (Lung Sounds): Wheezes Bilaterally T/O. Called on call: Ordered CDB (cough deep breathing) Q (every) shift. If (O2 sats) go below 89% on RA (room air), call back. ~12/3/2022 at 5:09 PM, (R14) cleared upper bilateral airway with CDB. Sats 93% on NC (nasal cannula). 3 LPM (liters per minute). ~12/4/2022 at 11:57 AM, (R14) continues with cough today although states that it seems much better today. (R14) alert and oriented per usual. O2 sat 92-94% on check today. Will continue to monitor. ~12/4/2022 at 1:27 PM, (R14) called stating feeling worse this afternoon than this (AM) .has had a few fits of coughing .isn't feeling SOB (short of breath) currently, but states is SOB with activity. LS are diminished with some rhonchi scattered that clear some with coughing. VS obtained and stable at this time. Encouraged po (oral) fluids. Will continue to monitor. Call bell in reach. ~12/4/2022 at 8:01 PM, (R14) alert/oriented x 3. Skin warm and dry. No SOB. No resp(iratory) distress. No cough noted. VSS (vital signs stable). Fluids encouraged. Will continue to monitor this shift. ~A chest X-ray was ordered on 12/5/22 at 3:29 AM. ~~12/5/2022 at 9:28 PM, (R14) cont(inues) to complain of not feeling well. Plan to have CXR (chest X-ray) tonight. Has not been having as much coughing noted. Will (continue) to monitor. ~12/6/2022 at 10:35 AM, R14 had a chest X-ray and the results were reported at 12:03 PM. Findings of the chest X-ray included: Left basilar airspace disease and small left pleural effusion (pleural effusion occurs when fluid builds up in the space between the lung and the chest wall. This can happen for many reasons, including pneumonia or complications from heart, liver, or kidney disease). Clinical correlation, recommend follow-up examination to confirm resolution of findings. ~12/6/2022 at 9:30 PM, (R14) requested to go to the hospital because was coughing a lot and was concerned about X-ray. On-call gave order to send out. 911 called. Came and picked (R14) up to take to the ED. On 12/14/22, Surveyor reviewed R14's vital signs and noted oxygen levels were documented from 2-4 times per day throughout that time period; however, Surveyor noted R14's temperature, respiration rate, heart rate, and blood pressures were documented intermittently. ~Temperature - 11/30 and 2 times on 12/4/22 - all were within normal range ~Blood Pressure -11/30 and 2 times on 12/4/22 - all were within R14's historical ranges ~Heart Rate - 11/30 and 2 times on 12/4/22 - all were within normal range ~Respirations - 11/30 and 2 times on 12/4/22 - all were within normal range On 12/14/22 at 3:09 PM, Anonymous Staff (AS)-F stated AS-F frequently worked with R14. AS-F stated every shift report AS-F participated in during that time frame, AS-F stated R14 needed something for R14's cough. AS-F stated the cough was noticeable and not normal for R14. AS-F stated there was nothing done initially; however, days and days later something was finally done. On 12/14/22 at 11:28 AM, DON-B stated on 12/5/22 when DON-B returned to work, DON-B checked on R14 who stated R14 was not good. DON-B confirmed there was no monitoring of R14's cough, no order for cough syrup and no physician contact between 11/28/22 (when DON-B was aware of the cough) and 12/3/22 when the physician was notified and ordered coughing and deep breathing every shift. DON-B verified things were missed during the week DON-B was off and stated the facility used a lot of agency staff. DON-B also stated prior to 11/28/22 when DON-B spoke with R14 and discovered R14 had a cough over the weekend, DON-B expected weekend staff to note a cough and contact the physician or DON-B. DON-B acknowledged that vital sign documentation was missing and stated DON-B told staff if it's not documented, it did not happen. DON-B stated DON-B expected vital signs be completed more frequently for a resident who didn't feel well. 47248 Resident #24 FTag Initiation

Based on record review and interviews, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 Resident (R) (R2) of 3 sampled residents. On 2/17/22, R2 was admitted to the facility and was assessed to be at risk for elopement. On 6/20/22, the facility was made aware of R2 leaving facility without staff knowledge when local Police informed the facility that R2 was found several blocks away from the facility crawling on the ground. The facility did not provide supervision to prevent R2 from eloping from the facility on 8/16/22. The facility did not have a system for routinely monitoring R2's whereabouts even though staff knew that R2 refused to wear a Wanderguard bracelet. Furthermore, the facility failed to ensure staff responsible for monitoring the front door knew how to alarm the door when leaving the area. The facility's failure to implement safety interventions to prevent elopement created a finding of Immediate Jeopardy (IJ) (situation has caused or is likely to cause serious injury, impairment or death) that began 6/20/22. NHA (Nursing Home Administrator)-A was notified of the IJ on 9/15/22 at 11:33 AM. The IJ was removed on 8/19/22; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility provided an undated policy titled Elopement, which stated, 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 .'Elopement' occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . On 9/14/22, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] (paralysis/immobility of one side of the body) and [CONDITION(S)] (muscular weakness or partial paralysis restricted to one side of the body) following unspecified [CONDITION(S)] disease (a variety of medical conditions that affect the blood vessels of the brain, often resulting in what is commonly known as a stroke) affecting right dominant side and [CONDITION(S)] (an inability to comprehend or formulate language because of damage to specific brain regions). R2's Minimum Data Set (MDS) assessment, dated 8/1/22, stated R2's Brief Interview for Mental Status (BIMS) score was 00 out of 15 which indicated R2 had severe cognitive impairment. R2's medical record contained Court Ordered Guardianship and Protective Placement documents, dated 3/7/22, that indicated R2's Guardian was responsible for R2's healthcare decisions. R2's medical record contained an Elopement Evaluation, dated 2/17/22, that indicated R2 was at risk for elopement. R2's medical record contained a Social Service Care Plan Meeting Note, dated 2/24/22, that stated, .[R2] seems to lack the insight of what is going on/happening or what exactly happened to [R2] .The stroke has affected the brain cognitively--language and understanding; [R2] is not able to communicate effectively verbally . R2's medical record contained an Elopement Evaluation, dated 4/7/22, that indicated R2 had a .History of or attempted leaving the facility without informing staff . Although there was no documented elopement attempt on or in the few days prior to 4/7/22, the following documentation was noted: ~ 4/7/22 at 12:40 AM: Resident had no behavior issues on PMs (evening shift) or NOC (night) shift staff monitoring location of resident at all times no attempt to elope either shift will continue to monitor. ~ 4/7/22 at 12:18 PM: Writer spoke with resident about the concern of [R2] leaving the facility without informing staff and staffs (sic) concern for [R2's] safety. Resident does enjoy being out side (sic) and with (sic) offer resident, when the weather is nice, to be outside with staff. Discussed placement of a Wanderguard on resident and [R2] firmly refused. Did explain the rationale as well as the risks/benefits for wearing one and [R2] continued to refuse. Resident has made no attempts to exit the facility today. ~ 5/2/22 at 4:53 PM: Social worker took resident to MD (physician) appointment this AM (morning), when reentering the facility social worker realized residents (sic) Wanderguard wasn't on resident's ankle, while writer tried to replace Wanderguard resident got very upset and walked down to social workers (sic) office, resident and social worker talked, resident got upset a few times and raised voice with foul language although finally agreed to have Wanderguard placed to right ankle. ~ 5/4/22 at 9:38 PM: Behavior Charting Describe Behavior/Mood: removed [R2's] w/g (Wanderguard) times 2 (twice) this pm. Replaced and heard resident yelling and swearing about it being on. What was the resident doing prior to or at the time of behavior/mood; sitting in room. Staff gave shower and noticed it was not on ankle. Found in dresser drawer. Was another one there as well smashed. Interventions attempted; 1:1 (one on one monitoring) Effectiveness of the interventions: ineffective and would not allow back on. Was yelling loudly and swearing so staff left off and note placed in DON (Director of Nursing) mailbox. ~ 5/5/22 at 2:36 PM: Did not find Wanderguard on resident. Notified Director of Nursing [DON,] stated to leave Wanderguard off of resident at this time. ~ 6/20/22 at 4:50 PM: Social Service note: this writer spoke with the resident's guardian to inform [Guardian] of the situation where the resident left the facility and had police intervention. [Guardian] was made aware as well by the police department. It was noted that the intervention is to move the resident to the secured ACU (Alzheimer's Care Unit)--explained that unit to the guardian. [Guardian] was alright with whatever we needed to do. [Guardian] asked to be kept up to date with the current situation. ~ 6/20/22 at 9:25 PM: writer made aware of resident elopement @ (at) 1545 (3:45 PM) and was found by Police/EMS (Emergency Medical Services). resident had POA (power-of-attorney) paperwork, driver's license and small amount of money ($1.50 or so). [R2] was found lying on the ground a few blocks from facility. Resident was last seen by CNA (Certified Nursing Assistant) at 1500 (3:00 PM) while [R2] was in [R2's] room. Resident unable to explain where [R2] was going or what [R2] was doing. Resident was very upset and yelling at staff. MD office was updated at 1650 (4:50 PM) w/msg (with message) left with [named MD office staff] of details .resident was given cold water and encouraged to drink as it was very hot outside today. Staff attempted to place WG (Wanderguard) on resident, but [R2] refused several times. No injuries noted. Skin intact. Resident was placed on 15 minute checks .at 2200 (9:00 PM) Wanderguard was placed to right ankle. Resident much calmer and resting in [R2's] room with no further outbursts noted. ~ 6/21/22 at 10:32 AM: Reviewed incident 6/20 around 1700 (5:00 PM) with DON, NHA, SS (Social Services), RDO (Regional Director of Operation) and RDCO (Regional Director of Clinical Operations). Suggestion to move to ACU (secured unit) as resident has refused/removed Wanderguard in the past. Resident with unclear speech and increased frustration/agitation when not understood- Communication with ACU residents would be a trigger for resident-also residents in ACU could be at risk if resident would become aggressive with the communication issues. Plan is 15 minute checks and attempt to place Wanderguard and to update guardian. ~ 6/22/22 at 9:35 PM: resident was found outside of front of building at 1900 (7:00 PM). resident easily redirected back into building. DON updated and resident to continue on 15 minute checks. ~ 8/13/22 at 6:41 PM: Writer informed by staff resident noted going outside and being redirected by caregiver from ACU back into bldg. (building). Writer was entering bldg for shift start, when noted regular smoker resident exiting bldg to go out to smoke. Alarm sounded and was in place. Kitchen staff may have reset the alarm to front door but possible did not confirm. Caregiver from ACU saw resident through the window and proceeded to get resident back into bldg. Writer and peer went out to assist caregiver but they were on their way back to bldg. Resident obtained no injuries. Alarms were check and reset. Writer updated DON and MD on call ([named physician]). Resident put on 24 hour board for monitoring. ~ 8/16/22 at 10:45 AM: [R2] was brought back to the facility without incident and was placed on 1:1. No injury occurred and [R2] was wearing a t-shirt, sweatpants, tennis shoes and a baseball cap which was weather appropriate. The facility was not able to provide Surveyor with evidence the facility investigated R2's elopement on 6/20/22. The current facility administration and regional staff were unable to find any documentation of elopement details other than the entries above. R2's care plan for elopement risk was initiated on 4/11/22 and stated, At risk for elopement related to: Resident states 'I want to go home' as well as perseverates on [R2's] guardianship paperwork . R2's care plan was revised on 6/21/22 to state, When I am noted to have on blue jeans, tennis shoes, and a baseball hat, I am more prone to wanting to leave and require increased supervision. R2's medical record did not indicate what increased supervision meant. On 9/14/22, Surveyor reviewed a facility-provided Investigation Report, dated 8/16/22, that stated, Resident left building unattended. Dietary staff member was driving into work, and saw resident walking down a sidewalk away from the facility. Dietary staff member asked resident to get into their car. [R2] got into their car and was brought back into the facility without incident .Resident noted to have eloped from building and brought back to facility by dietary aide. External temperature at the time resident was found and brought in was 65 degrees and partly sunny. Resident was assessed and no injuries were observed from the time resident had been out. Resident had on appropriate clothing at the time - tee shirt, sweatpants, shoes and a baseball cap. Investigation revealed resident had walked out following transport company driver while staff who was supposed to be [NAME] desk had walked down the hall to get resident who was going out on appointment. Resident's previous notes show that though [R2] was noted to be an elopement risk, [R2] did not have on a Wanderguard (the facility's alert system for residents who are elopement risks) because [R2] cut them off in the past and would not leave any on. Timeline reveals resident was gone for about 20 minutes before [R2] was seen and brought back to the building. Resident's assessment post-elopement showed resident to not have any injury while out of the building. During close observation period while resident was on 1-on-1 monitoring and then downgraded to Q15 minutes monitoring, resident did not verbalize wanting to leave facility. Resident was moved to the secured unit with physician and responsible party approval, with 1-on-1 monitoring re-instituted through a 72-hour adjustment period. Resident adjusted well to secured unit through this time and got recently downgraded to Q30-minute monitoring, which indicated no mention of attempting to elope as resident fully adjusted to this new unit . On 9/14/22, Surveyor reviewed a hand-written statement by a dietary staff member, dated 8/15/22, that stated, I was driving to work on Roller Ave (by [named] Construction) and saw [R2] walking so I asked [R2] to come for a ride with me and [R2] said ok but didn't want to go home. But I convinced [R2] to come with me. [R2] recognized me so [R2] got in. I drove [R2] right to work .time: 10:38 On 9/14/22 at 12:53 PM, Surveyor interviewed RDCO-C who verified R2 was not moved to the secure unit until after R2's elopement from the facility on 8/16/22. RDCO-C indicated RDCO-C had asked facility administrative staff employed at the time of R2's elopement on 6/20/22 about moving R2 to the facility's secure unit. RDCO-C indicated the DON and Social Worker at the time felt R2's move to the secure unit would be detrimental and thought R2 would exhibit behavior that would be dangerous to other secure unit residents. Surveyor questioned RDCO-C about what R2's behavior had been like since R2's move to the secure unit. RDCO-C indicated R2 had adjusted to the secure unit without incident. On 9/14/22, Surveyor reviewed facility-provided documentation from R2's medical record to show the facility conducted 15-minute checks on R2 starting at 3:45 PM on 6/20/22 through all of 6/21/22 and 6/22/22. On 9/14/22, the facility provided no documentation to explain why 15-minute checks were discontinued or what else was done to keep R2 safe beyond 6/22/22. On 9/14/22 at 2:56 PM, Surveyor interviewed RDCO-C who verified the facility had no documentation to show the facility had conducted an investigation regarding R2's elopement on 6/20/22. RDCO-C verified R2's care plan did not address when R2's Wanderguard use was initiated or discontinued. RDCO-C indicated R2's medical record did not contain documentation as to why 15-minutes checks were stopped after R2's 6/20/22 elopement. RDCO-C indicated RDCO-C would expect resident medical records to contain documentation detailing reasons for decreasing supervision of a resident who had eloped from the facility and what specific interventions were put into place to keep the resident safe. On 9/14/22 at 3:54 PM, Surveyor interviewed NHA-A who indicted NHA-A could not locate in R2's medical record why the 15 minutes checks in June 2022 were stopped and what else was put into place to keep R2 safe. NHA-A verified R2's care plan was not updated to reflect R2's move to the secure unit on 8/19/22 or the 30-minute checks facility staff were conducting since R2's move to the secure unit. NHA-A verified R2's care plan should reflect current interventions in place for R2's safety. On 9/14/22 at 4:36 PM, Surveyor reviewed a map of [NAME] Dam, WI with NHA-A. Roller Avenue was located on the map and NHA-A stated, I was told it (the location R2 was found on 8/16/22) was about 5 blocks from facility. The map showed S Spring St/Highway G between the location of the facility and the location where R2 was found on 8/16/22. NHA-A verified R2 had to cross what looks like a busy main street (S Spring St/Highway G) to reach Roller Avenue. On 9/14/22 at 5:00 PM when Surveyor exited the facility, Surveyor noted Roller Ave was 0.7 mile from the facility according to a Global Positioning System (GPS). Surveyor drove to the intersection of Roller Ave and [NAME] Dr where [named] Construction was located. [NAME] Dr was a residential area which included houses and apartment buildings. There was a one-block stretch on the left of an open mowed field with a wooded area beyond. There was a stop sign at the intersection of [NAME] Dr and S Spring St/Hwy G. Surveyor had to wait for two cars to pass on S Spring St/Hwy G before crossing over. Surveyor could visualize two other cars on S Spring St/Hwy G in the distance while crossing the intersection. Roller Ave was a residential area. [Named] Construction was partially enclosed by a metal fence containing large construction equipment. [Named] Construction's building was not behind the fence. On the map referenced above, the [NAME] Dam River was located approximately one block beyond where R2 was found on 8/16/22, in the general direction R2 was heading. On 9/15/22 at 7:58 AM, Surveyor contacted the [NAME] Dam Police Department for a copy of the police report from R2's 6/20/22 elopement. The [NAME] Dam Police did not complete a formal police report but emailed Surveyor a Dispatch Report, dated 6/20/22, that indicated at 3:34 PM on 6/20/22, a call came from a person at an address on S Spring St/Hwy G indicating a [gender] subject in front of [person's] house, was on the ground, and is now walking toward S Lincoln (Street) and elderly [gender] with florescent Nike shoe, blue jeans, wearing a hat, was on the ground crawling, but then got up. EMS sent, responded on scene at 3:41 PM, R2's name listed. At 3:46 PM, the report stated, not a resident at [named Assisted Living facility]. At 3:49 PM, the report stated, [R2] is a resident at 410 [NAME] Court (facility's address), they will be sending their social worker to come pick [R2] up. They were unaware that [R2] had escaped and never set off the alarm. At 4:00 PM, the report stated, [R2] picked up by social worker and taken back to facility. On 9/15/22, Surveyor reviewed facility-provided documents to include a Teachable Moment Form, dated 8/23/22, that stated, I noticed you walked away from the desk to go get a resident from the hall - without getting a replacement or arming the door. This could result in safety issues, such as residents who are elopement risks walking out and away from the building unattended. Was there a good reason for you to handle the situation the way you did? What do you think you could have done differently to get a better result? I was filling in & (and) I was not shown how to alarm the door. I was only shown how to answer the phone. The taxi --> (handwritten arrow sign) From now on, I would like you to call or page for help and get a replacement at the desk when needing to leave or secure the door so it is locked and alarmed . On 9/15/22, Surveyor reviewed facility provided documents to include R2's Medication Administration Records (MARs) for June, July and August 2022 which included the order Monitor Q (every) shift and document on Mood and behavior and any attempts to leave the facility which started on the evening shift of 6/22/22 and continued through 8/31/22. The documents did not indicate how frequently in a shift staff were to monitor and check R2's location and safety. On 9/15/22, Surveyor reviewed facility-provided documents to include Follow Up Question Reports for the time frame of 6/20/22 through 8/19/22 which indicated CNAs documented approximately each shift every day whether or not R2 exhibited any behavior symptoms. The documents did not indicate how frequently in a shift staff were to monitor and check R2's location and safety. The facility's failure to provide supervision to prevent R2 from eloping, develop a system for routinely monitoring R2's whereabouts when R2 refused to wear a Wanderguard bracelet, and ensure staff understood how to monitor/engage the door alarm, created a finding of Immediate Jeopardy. The facility removed the jeopardy on 9/19/22 when it had completed the following: ~Provided R2 with 1:1 monitoring until R2 was moved to a secure unit. ~Continued 15 minute checks thereafter to monitor R2's behavior. ~Educated all staff regarding the elopement policy and door alarm functioning. ~Reviewed the policy and procedure to ensure regulatory requirements were met. ~Updated the elopement binder and careplans for residents at risk for elopement. ~Conducted an elopement drill.

Based on interview, record review, and observation, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents reviewed (Resident 2). The facility was informed, prior to Resident 2's admission, of Resident 2 requiring increased monitoring due to wandering. Resident 2's Guardian hired an outside agency to stay with Resident 2 on a one-on-one basis from 9/25/15 - 10/1/15 to assist with adjustment to placement. Resident 2 ambulates and transfers independently. The facility assessed Resident 2 to be an elopement risk upon admission. Resident 2's care plan indicated the facility placed a Wanderguard bracelet on Resident 2's left wrist, would redirect Resident 2 when Resident 2 is exit seeking, and would provide one-on-one PRN (as needed) as tolerates. Resident 2 paced and wandered the Alzheimer's Care Unit (ACU) since he was admitted to the unit, wandering into other resident rooms, exit seeking and pacing the hallway. On 10/3/15 at 8:00 AM Resident 2 exited the ACU when a housekeeper opened doors and proceeded toward an exit at the end of the opposite hall. Resident 2 attempted to exit and activate the fire alarm. Resident 2 was redirected back to the ACU. No new interventions were put in place and Resident 2 was not put on a one-on-one as his care plan indicated would happen. At 12:46 PM Resident 2 exited the ACU exit by the lounge, Certified Nursing Assistant (CNA) J was the only caregiver on the unit to assist 12 residents. Resident 2 was found a block away, in an assisted living facility. Resident 2 refused to leave the assisted living facility with staff; the police were called and accompanied Resident 2 back to the facility. Resident 2's Wanderguard bracelet was found in his shirt pocket when he returned to the facility. On 10/3/15 Resident 2 exited the ACU unit through an exit door; staff immediately followed Resident 2 and redirected him back into the facility. Failure to ensure systems were in place and that Resident 2 received adequate supervision to prevent accidents created a finding of immediate jeopardy. The immediate jeopardy began on 10/3/15. Nursing Home Administrator (NHA) A was officially notified of the immediate jeopardy on 11/3/15. The facility removed the immediate jeopardy on 11/2/15, however, the deficient practice continues at a scope/severity level D as the facility continues to implement its removal plan. Evidenced by: Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. Resident 2 also has a PEG tube for supplemental tube feedings. Resident 2 is one of 12 residents who reside on the facility's Alzheimer's Care Unit (ACU). This is a secured unit with 2 alarmed exit doors that go to the outside and 1 alarmed double door that goes onto to the 100 unit of the facility. There are a total of 17 residents in the facility assessed to be at risk for elopement; 12 of the residents at risk reside on the ACU unit. Resident 2's hospital discharge summary, dated 9/24/15 includes the following: The patient appears to have recovered fairly well with his physical disability; however, the patient does not require anymore assistance on ambulation and bed to chair transfer; however, the patient's mentation appeared to have reached a plateau. The patient is currently still requiring zone restriction because of patient's sporadic wandering and being up and about. The patient also at times appears to be incoherent with conversation. Resident 2's Admission Clinical Health Status Assessment, dated 9/25/15, included the following: Cognitive Communication: Level of Consciousness: Alert: self and wife. Short-term memory: Memory problem. Long-term memory: Memory problem. Cognitive skills for decision-making: not answered. Behavioral symptoms: HX (history) of wandering, verbally abusive, socially inappropriate/disruptive, resists cares. Risk for Elopement: 1. Is resident physically able to leave the building on their own? Yes. 2. Is the resident cognitively impaired? Yes. 3. Does the resident have impaired decision making skills? Yes. 4. Does the resident make repetitive statements about going home? No. 5. Is there a history of wandering or elopement? If yes, implement Elopement IPOC (Immediate Plan of Care) Yes. 6. Experience a recent move in room or facility? Yes. 7. Wanders aimlessly about facility and/or exhibits night wandering? Yes. 8. Has a recent change in medication? No answer. If YES is marked for #1 & 2 and any other (#3 - 8), consider a prevention plan of care for elopement. Resident 2's Immediate Plan of Care, Elopement Risk, dated 9/25/15, Problem includes the following: At risk for elopement related to: *Persistent anger with self, anger at placement in nursing. *Wandering with no rational purpose seemingly oblivious to safety needs. * Resident states I am leaving or is angry with placement. The Immediate Plan of Care, Elopement Risk includes the following interventions initiated on 9/25/15: *Evaluate need for wandering management program. *Take picture of resident upon admission, and alert front desk of elopement risk. *Encourage family to bring in personal possessions. *Implement your LC's (Living Center's) system for identifying residents. *Involve resident in Living Center actives of their liking. *Introduce resident to other residents in the building. *Wandering management program initiated: Wanderguard L (left) wrist, (check) function and placement per policy. *Brightstar 1:1 (one-on-one) to assist with adjustment to placement. (D/C (discontinue) 10/1/15) *Evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings. *Communicate with resident to determine reason for the behavior. *Involve the resident in decision making regarding daily choices. *1:1 PRN (as needed) as resident tolerates. *When resident is exit seeking staff are to redirect. The following interventions were added: 10/3/15, Validate res. (resident) feelings/frustrations. Offer re-assurances. 10/3/15, 1:1 PRN/close supervision when restless. 10/3/15, BrightStar companion services to assist (with) adjustment to new environment. (D/C, no date) 10/3/15, Encourage family and friends to visit frequently, assist with adjustment as able. 10/5/15, Wife educated on Project Life Saver. Resident 2's ACU Psychosocial Assessment, dated 9/30/15, includes the following: Cognitive and Mental Status: Cognitive assessment difficult to complete. Resident is very angry and irritable, becomes easily frustrated with questions and can be verbally abusive. Has poor long and short term memory. Knows self, knows wife. Recognizes staff members throughout day, however does not remember them day to day. Poor decision making skills, poor problem solving abilities, unable to make safe and sound choices. Guardianship obtained, wife is legal guardian. Resident unable to comprehend situation, resulting in poor judgment. Had always been a very independent man, used to being in charge and giving orders. Emotional Status, Mood and Behavior Patterns: Resident unable to deal with current situation, as he does not perceive anything is wrong. Does not understand why he cannot be at home. He presents withdrawn, will intentionally ignore others. He wanders about unit, can be intrusive to others property and personal space, however is easily redirected. Can be verbally aggressive, potentially to be physically aggressive towards staff when they are attempting to assist resident. Can reject cares and medications, decline meals. Is social with peers for very short periods of time, does not stay in same place long. Psychosocial Well-Being, Social Skills and Current Relationships: . resident has declined all offers of group programming. Resident is easily distracted, quickly annoyed/angered, with extremely short attention span. Currently, resident can be demeaning and angry at staff, telling them to leave him alone. Repeated states he is going home, will wander about unit. Noted to exit seek on one shift, however staff able to redirect. Resident 2's Progress Notes include the following entries: 9/25/15, 13:54 (2:54 PM), . provide 1:1 as needed during adjustment periods Resident wandering about unit frequently, exploring new surroundings. Per wife and hospital, resident can be resistive to cares, at risk for elopement. Wandergard placed to left wrist. 9/25/15, 22:19 (10:19 PM), Resident admitted today, settling in, resident up and around in room rearranging sheets on bed several times, very agitated when a person enters room. CNA (Certified Nursing Assistant) from Bright Star here, she noted he is ok with 1 person in room, but if more enter he gets agitated. 9/28/15, 02:58 (AM), Resident up pacing halls during first half of shift. Resident resistive to care. Up pacing floor and refusing to sleep this shift. Anxious when approached by staff. Attempted to use door to exit, also wandering into other resident's rooms. Resident is 1:1 care with agency aide not available due to had to leave for family emergency. Golden living aide scheduled for ACU monitored 1:1 as best possible along with caring for other residents. Writer monitored resident 1:1 while aide did rounds. Resident swearing at staff and swinging arms at times. Finally at 2:45 (AM) resident laid down in bed and is sleeping at this time. Will continue to monitor 1:1 care as best as possible. 9/28/15, 15:38 (3:38 PM), Resident adjusting fairly well. Wandering about unit, socializing with peers. Care staff report resident slept poorly last night. Writer, care staff and wife review behaviors, agree to give resident more freedom in wandering, allowing him to explore unit ad lib with distant supervision. Resident does not need 1:1 intervention at all times. 9/29/15, 15:25 (3:25 PM), Resident up wandering about unit throughout day, irritable and restless, verbal aggression. No exit seeking, . Wife, writer and Bright Star discuss continued supervision, all agree that supervision needs to be at a distance, allowing resident opportunity to have alone/quiet time as well as allow chance to explore new surrounding. 9/29/15, 18:29 (6:29 PM), Alert, disoriented, contrary with cares and feedings. Currently requires 1 on 1 supervision due to contrariness and wandering. 9/30/15, 06:04 (AM), . Sitter in room also attempted to allow feed and talking to resident without success. At that point resident talking about how he had to feed the animals and became very anxious started pacing in hall. Came to nurses station door x (times) 2 trying to exit. At one point wanted to talk with aide from 100 wing saw in nurses station and demanded to know the police phone number. Talked to resident explained it was too early to call police. Resident continued to pace hall and then laid down on couch in lounge resting. 9/30/15, 15:31 (3:31 PM), . Resident up wandering about unit today, declined all offers of cares, meals, medications. Continues to wander, staff redirect as needed, however give him room to wander and explore unit as he is safe, supervising from a distance. Does not require 1:1 supervision. Is typically easily redirected when needed from wandering and intrusive to others. No physical aggression shown today. Message left for wife to discuss continued companionship offered by Bright Star and pro vs cons of continuing their services. 9/30/15, 16:13 (4:13 PM), . Wandering about unit. 10/1/15, 13:06 (1:06 PM), . Some exit seeking noted, stating he needed to get back to Hartland Aurora. Easily redirected away from doors. Also discussed Bright Star, family will be canceling their services today. Resident adjusting to unit, able to find room, socializes mostly with peers. Seems to becoming accustomed to some staff, pleasant with certain care givers. 10/2/15, 04:51 (AM), . Awake about 3:30 (AM) up and about did enter other residents rooms and redirected by aide. Will continue to monitor mood. 10/2/15, 13:32 (1:32 PM), . resident has wandered unit majority of shift . 10/3/15, 03:10 (AM), Describe Behavior/Mood: . At 2:30 (AM) resident up and about wandering into other residents rooms. What was resident doing prior to or at the time of behavior.mood: Was sleeping in bed. Interventions attempted: Attempted to redirect resident. Resident yelling at CNA when attempting to be redirected. Resident stated this is his building. Effectiveness of the interventions: Resident left room when he saw that residents were sleeping. Resident continues to walk up and down hallway looking in resident's rooms. 10/3/15, 14:25 (2:25 PM), At about 08:00 (AM) resident exited ACU when housekeeping opened doors and proceeded toward exit at end of opposite hall. Once there, writer blocked exit and fire alarm as resident was attempting to activate alarm. Another staff member was able to redirect resident back to unit. At 12:46 (PM) writer was on lunch break and alerted by staff that resident could not be located. Writer checked alarm and determined resident had exited ACU lounge. Writer instructed staff to call ED (Executive Director) and DON (Director of Nursing) and pursued resident to about ½ block away and had entered an assisted living facility. Once in the facility, police were called to assist in helping resident back to GLC (Golden Living Center). Resident removed wandergard from wrist between breakfast and noon unawares and had pocketed in shirt pocket so alarm was still activated upon exit. Resident decline majority of medications and both feedings after multiple approaches. Voice mail was left for wife to call for an update and MD (Medical Doctor) was updated. 10/3/15, 14:07 (2:07 PM), Writer walked up to building to find staff outside looking for resident at approximately 1250 (PM). Writer turns to start looking when care staff report resident at assisted living across street. Writer enters assisted living to find resident speaking to director of assisted living and our facility RN (Registered Nurse). Resident calmly stating that he needs to get to the apartment building and that he is waiting for the police. ALF (Assisted Living Facility) director states she has called the police. BD (Beaver Dam) police arrive approx. (approximately) 1300 (1:00 PM), resident sees police pull up and leaves ALF to speak to police. Police address resident, resident clearly states, I need you to get to the apartment building, they are destroying it. Police ask resident to get into police car to talk it over. Resident climbs in to back seat of police car without incident. Police and writer speak, writer updates on resident from Alzheimer's unit at GLC. Officer states he will talk to resident and meet us in front of GLC. Writer walks back to facility, officer meets at facility with resident, gets out of vehicle and informs writer that resident believes he owns an apartment building in Hartford and that someone is vandalizing it. He also believes that his wife let some kids into my bar to remodel and that they destroyed it. Resident also informed officer that his wife is in Fond du Lac, our son was in an accident, however per officer resident was unconcerned about son. Officer let resident out of police car, writer, officer and resident enter building without incident. Officer accompanies resident back into unit and into room, sits with resident and talks. Officer encourages resident to stay in facility, to let the police handle things at the apartment building. Resident seemed to settle after officer reassured resident he would contact the Washington County Sheriff to check out the apartment building and bar. Resident walked officer to door then turned and went back to room. Officer encouraged staff to call if they could be of further assistance. Writer returns to unit to find resident visiting with male peer, no irritability or anxiety, no exit seeking at this time. Writer updates ED ad DNS, education to staff started. Writer updates care plan. Message left for wife to call facility. 10/3/15, 18:30 (6:30 PM), . At 15:45 (3:45 PM) wife stepped out, resident pushed open outside door walking out of building. CNA followed immediately and redirected resident back in. Wife sitting with resident in room, wife has been trying to contact Bright Star agency to resume supervision care of resident. 10/3/15, 21:25 (9:25 PM) Resident sleeping, wanderguard applied to left ankle, wife leaving for home, states she won't take his cutting outbursts to her personally, and she will call Bright Star for services ASAP. 10/4/15, 14:10 (2:10 PM), . resident has made multiple statements this shift about busting down the door . 10/4/15, 10:33 (8:30 PM), Resident very agitated, pacing, looking at fire alarms, and CNA reported he did attempt to pull a fire alarm in middle of hallway but CNA intervened. 10/8/15, 21:59 (9:59 PM), Resident up and around in room and hall, was less contrary after the Lorazepam cream, . 10/9/15, 04:26 (AM), Describe Behavior/Mood: Resident wandering into other resident's room. What was the resident doing prior to or at the time of behavior/mood: Resident was in his room. Interventions attempted: Resident was redirected. Effectiveness of the interventions: It was helpful at times but then resident would go back into other resident's room. 10/12/15, 15:41 (3:41 PM), Resident up per normal, wandering about unit, . 10/12/15, 16:50 (4:50 PM), Alert, oriented to self, very agitated contrary man, wanders hallways, often refuses cares, meds, food or tube feedings. Staff must use caution when approaching resident due to often swinging clenched fists at staff. Lorazepam cream being used, however resident tries to wipe it off after application. 10/13/15, 04:09 (AM), Resident awakened when applying topical lorazepam by lifting covers. At 4:00 A swinging and hitting at writer swearing at writer. 10/15/15, 14:23 (2:23 PM), Care Plan Note, . is typically irritable, angry non-cooperative. Wanders, will at times exit seek, at high risk for elopement. 10/16/15, 01:26 (AM), Describe Behavior/Mood: Wakened to inquire about giving scheduled midnight Lorazepam administering and resident became agitated due to being awakened. Resident up in halls walking into other residents rooms. In room of peers #11-1 trying to awaken resident while she was sleeping. Stop sign was up on entrance way and resident went underneath to get in room. Resident also becomes upset and anxious with trying to check wandergards to ankle. What was resident doing prior to or at the time of behavior/mood: Sleeping. Interventions attempted: Tried repeatedly to redirect out of other residents rooms and he would refuse to leave. Left him in room and eventually after time he came out. Effectiveness of the interventions: Resident refused to be redirected and come out of room, Refused medication. Charted as such. 10/18/15, 09:18 (AM), . NOC (night) CNA reports that resident was in another resident's room standing over her bed, leaning on bed, which frightened other resident who was screaming in fear. The NOC CNA firmly redirected this resident out of room w/o (without) further incident. This resident is friendly towards other residents and it seems unlikely that he was trying to harm her based on his history. Following incident a stop sign was placed across resident's doorway. During this shift resident was observed trying to remove the stop sign but was redirected. 10/18/15, 20:53, (8:53 PM), Resident up in room and halls, CNAs noted resident went into (room 11), taking down the STOP sign. CNA asked resident to leave her room as he was standing at her bedside and she was motioning with her arm for him to go. Resident replied he was taking her with him. CNA asked him to leave again, and then he did walk out her door. 10/20/15, 04:33 (AM), Resident sleeping most of shift. Was found going into room 11 across the hall and requested he come back out which he did after a few seconds. 10/21/15, 14:36 (2:36 PM), Resident up for short period of time per normal, wandering about unit, visiting with peers. 10/23/15, 06:40 (AM), First half of shift resident up and going into room 11 pulling on peer in that room trying to pull out of bed per aide. 3 times was in room 11 before 2:00 AM. Resident in room 11 screaming out. 10/23/15, 13:45 (1:45 PM), Resident up per normal wandered about unit for short periods of time, visiting with multiple peers. 10/24/15, 12:49 (PM), Resident up per normal. Approached staff early this AM requesting assistance with getting down to the bar. Easily redirected. Pleasant with peers, and with staff today. Approached care staff again prior to lunch, stating I think it is getting time to go. Care staff replied, Do you want a shower first?, to which he agreed. 10/25/15, 03:49 (AM), Describe Behavior/Mood: Aide walking through hall and noted resident up in hall. Aide walked past resident and then noted that resident entered room 11. When aide turned to try to assist, resident pushing on door from inside room 11 to prevent aide from entering. Resident eventually let go of door and went to stand at bedside of room 11. Aide trying with gentle persuasion to have resident come out of room. Peer in room 11 awake and afraid but aide reassured and managed to escort resident out of room at which time he went back to bed. What was the resident doing prior to or at the time of behavior/mood: Sleeping. Interventions attempted: Not confronting resident when originally walked past in the hall. Tried to persuade resident to come out of room by gentle redirect. Effectiveness of the interventions: Eventually did come out of room 11 and went back to bed, ACU stop sign placed and peer in room took down. 10/25/15, 21:14 (9:14 PM), Resident pacing through halls before supper, attempting to figure out codes on doors and anxious to leave. 10/26/15, 01:50 (AM), Up and wandering throughout halls. Pushing on doors insisting that he owns the building and can't find his keys, redirected several times. Continues with exit seeking. 10/26/15, 12:40 (PM), Resident has been up since 0200 this am, resident has been pacing and trying to leave facility, pounding on doors and windows, wanting to call police, gait has been a little unsteady at times noted by ACU director, writer has not noted this, . Has been opening fire extinguisher box and pacing around unit. He gave order for prn (as need) lorazepam, . 10/26/15, 13:20 (1:20 PM), Resident up all day, pacing unit, banging on windows, attempting to open door. Has been unsteady in ambulation, words are slurred at times, has been increasing confused and restless. Has been pleasant with peers and staff, however with multiple complaints and delusions on needing to leave. Conversation quickly changes, difficult to follow. Upset about Bill & Roberta and the car, needing to load all the furniture in the truck, believing his son is moving and it is costing me $15,000, needing to see the Credentials for the repair Rex made on the recorder going nuts, and the sale ending and now I am out $3500. Continues pacing, packing up belongings, looking for car. Continues pleasant towards staff, asking them for assistance, accepting of staff's inability to help him get out. Was pulling on the fire alarm outside office, stating that will get the Brookfield fire department here. When asked why he needed the fire department, stated well only the sheriff. Writer and RN offer to help resident call the sheriff, however resident quickly declined offer and moved onto new topic. Continues kind towards peers. Currently pacing about unit, starting to sit for a few minutes at a time, looking quite tired. Staff continue to encourage resident to rest. Will continue to closely supervise at this time. Proceed per plan of care. 10/26/15, 15:10 (3:10 PM), Resident sitting with male peer in room (number), pleasant, much calmer. Will visit for short time, then fall asleep for short time. No active exit seeking or talk of leaving in past hour. Will continue to closely supervise. Proceed per plan of care. 10/27/15, 14:26 (2:26 PM), Resident irritable much of day, declining all offers of cares, meals, medications. Rude towards staff, calling care staff stupid and idiots. Minimal exit seeking, would state he was leaving, however no attempts to open doors. No aggression, wandering about unit, socializing with peers, continues kind and compassionate towards peers. Will continue to re-approach as needed. Proceed per care plan. 10/28/15, 13:59 (1:59 PM), Resident continues to wander about unit, minimal exit early this AM, rude towards staff. 10/28/15, 06:39 (AM), After 2:15 resident up in hall exit seeking very forcibly pushing on doorways. Resident going into other peers room. Went into every other resident's room except for 11. Did wake up residents in room 9 and room 12. Asked resident if he was hungry and his response was yelling yes, but not your pussy. Resident very vocal swearing and using obscene words. Aide and writer monitoring residents wandering not interfering until resident was in room 4 and closed door. Holding handle so we could not open. Eventually did open door and allowed us to enter. Encouraged resident to come out of room 4. Did come out for a few minutes then resident went back in and was sitting on the bed with resident in bed 4-1. Again encouraged him to come out. We did not enter room but stayed out distance in the hall. Resident got up and came to the doorway closed door again and we were unable to open door. Eventually trying handle pushed door open enough to discover that resident had barricaded door with chair in the room. When writer tried to remove chair from room resident became angrier and while standing in the door way of room made a fist and took a swing at writer. Called to (Nursing Home Administrator (NHA) A) regarding actions. Later resident wandered into room 8 and sat in chair continued to monitor and he fell asleep. After about 45 minutes Aide came and said she could not find him. Searching every room. Found in room 8 aide had missed him due to he had laid in bed and was all covered up. Left sleeping and monitored. Once we needed to round on peer in room 8 resident awoke and exited room. Continued to walk hall and wandering into other resident's room 2nd aide assisted with monitoring where abouts until end of shift. 10/29/15, 01:20 (AM), Describe Behavior/Mood: No behavioral this shift. Resident was walking in hallway but then went back to bed. Will continue to monitor. 11/1/15, 04:24 (AM), Resident up pacing in hallway x (times) 2 during the night. Did look through doorways but not trying handles. After about 30 minutes went back to room and back to sleep. 11/2/15, 16:29 (4:29 PM), Resident up wandering about unit for short periods of time today per normal, no exit seeking noted. On 11/2/15 at 2:00 PM Surveyor interviewed Certified Nursing Assistant (CNA) J. Surveyor asked CNA J to describe what happened with Resident 2 on 10/3/15, when he eloped. CNA J stated she was the only staff on the ACU. Shortly after lunch she was assisting another resident and did not hear the door alarm until after she left the room of the resident she was assisting. CNA J stated she went to the lounge to find the door alarming, she searched the ACU hall and counted heads and noticed Resident 2 was not on the unit. CNA O and Cook P then came onto the unit to assist CNA J with the search. CNA J stated the alarm was still sounding. CNA J stated she went outside to search, walked around the building. When CNA J got to the front of the building, she told another staff member that she was going to get her car and search for Resident 2. The staff member told CNA J that 911 was being called. CNA J stated when she got to her car another staff told her that Resident 2 was at the Assisted Living with Registered Nurse (RN) L. CNA J stated Resident 2 now has a Life Saver Project on his ankle, a tracking device, so if he gets out the police can track him. CNA J stated Resident 2 continues to wander. CNA J stated on 10/26/15 Resident 2 was hitting on the exit door, trying to open the door and exit the building. On 11/2/15 at 4:20 PM Surveyor interviewed Registered Nurse (RN) L. RN L stated on 10/3/15 Resident 2 had left the unit at 8:00 AM following the housekeeper off the unit. RN L stated she was on the 100 wing and blocked him from exiting the building. RN L stated she did not make any changes to Resident 2's care plank after he left the unit. RN L stated staff were monitoring his presence. RN L stated it would have been nice to have staff one-on-one with Resident 2 after he left the unit, however there was no staff available. RN L stated Resident 2 continued to actively exit seek, all doors are alarmed and he did have a wandergard on. RN L stated she was on lunch break on 10/3/15 when she was informed that Resident 2 had eloped from the building. RN L stated she went to the front door, she could see Resident 2 walking down the sidewalk, walk across the street from corner to corner, jaywalk, and walk up another half block to the Assisted Living on the next block. RN L stated there was no traffic. RN L stated she did not think that Resident 2 would understand how to safely cross the street if there was oncoming traffic. RN L stated she followed Resident 2 to the Assisted Living. RN L stated the police had to be called to get Resident 2 to return to the facility. RN L stated the police officer helped to calm Resident 2 down. RN L stated when Resident 2 returned to the facility she noticed his wandergard was no longer on his wrist, the wandergard bracelet was found in his shirt pocket. On 11/2/15 at 4:45 PM Surveyor interviewed Alzheimer's Director (AD) M. AD M is the Alzheimer's Care Unit Director. AD M stated the staff should have made changes to Resident 2's care plan when he eloped off the unit on 10-/3/15 at 8:00 AM. AD M stated she would expect staff to observe Resident 2 one-on-one whenever he is agitated and actively exit seeking. The facility's failure to prevent Resident 2 from eloping from the facility created an Immediate Jeopardy. The facility removed the Immediate Jeopardy on 11/2/15 by implementing the following interventions: *On 10/3/15 staff was immediately educated to respond immediately to alarms, checking the alarm panel to see which alarm is going off, making sure the doors are re-activated when walking away. *On 10/3/15 Resident 2's care plan updated to include redirection when exit seeking, 1:1 PRN as tolerates. *On 10/3/15 implementation use of walkie talkies with staff. *On 11/2/15 began in-service for staff that if resident anxious or restless 15 minute checks will be implemented. If resident threatening to leave or actively attempting to open or exit exit doors 1:1 supervision which is keeping resident in line of vision. Do not awake resident when sleeping. Allow resident to dictate his own sleep pattern allow to eat, take medications as resident wishes. Care plan updated 11/2/15 with interventions. *Will ensure all residents at risk of wandering have appropriate interventions on their care plan and staff are following care plans *Education started immediately and will be completed with all staff prior to starting their shift.

Based on interview and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident 1) reviewed. The facility failed to monitor Resident 1's weights, failed to ensure RN assessment of his change in condition, failed to closely monitor, to include vital signs when appropriate, did not inform the physician of the x-ray results until 5.5 hours later and LPN E failed to report clinically accurate information. Resident 1's condition worsened and he died two days later at the hospital. These failures created a finding of Immediate Jeopardy that began on [DATE]. On [DATE] the nursing home administrator was formally notified that an Immediate Jeopardy situation existed on [DATE]. The Immediate Jeopardy situation was removed [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's weight was documented as 128.9 on the Hospital discharge, dated [DATE]. Resident 1's physician orders [REDACTED].>Metroprolol [MEDICATION NAME] tablet 25 mg Give 25 mg by mouth two times a day for Heart. Daily weights times 3 days every day shift for 3 prescriber days. Weekly Weights times 4 weeks every evening Wed (Wednesday) evening for 4 weeks. [MEDICATION NAME] 40 mg (Milligram) give 40 mg by mouth one time a day for Excess fluid, Resident 1's Treatment Administration Record (TAR) indicates that Resident 1's weights were documented as follows: [DATE] - 136 [DATE]- 136.6 [DATE]- 136.4 [DATE] this box was left blank where Resident 1's weight should have been recorded. [DATE]- this box had the number 7 in it, which the legend indicates means Other/see Nurse Notes. This was documented by Licensed Practical Nurse (LPN) E. There was no documentation in the nurses indicating the reason the weight was not obtained. There is no weight documented after [DATE]. The facility did not monitor Resident 1's weight as had been ordered by the physician. Resident 1's comprehensive care plan Impaired Cardiovascular status related to: Hypertension dated [DATE], includes the following interventions: Observe and report signs of chest pain, [MEDICAL CONDITION], and SOB. Observe for abnormal vital signs and report. Observe for change in condition. Goals include: Will not have a decline in cardiac function. Resident 1's Comprehensive care plan Potential for alteration in Hydration related to [MEDICAL CONDITION], Diuretic use, End Stage [MEDICAL CONDITION] dated [DATE], includes the following interventions: Administer diuretic per physician orders. Check vital signs and auscultate breath sounds as needed, more frequently if indicated. Monitor weight per physician order, Notify physician of weight gain/loss. The goals include: remain free of s/sx (Signs and symptoms) fluid excess, [MEDICAL CONDITION], sudden weight gain and tachypnea. Resident 1's Clinical Health Status admission assessment dated [DATE] at 3:15 PM, includes Respiratory Function, Experience difficulty breathing- this box is marked No. Experience shortness of breath- this box is marked No. Lung sounds-indicates Clear lung sounds left and right upper and lower lobes. To be noted there was not a weight obtained on the date of admission. The area to record the weight on the assessment was left blank. Progress notes [DATE]-[DATE] document oxygen saturations ,[DATE]% on Room Air (RA). Progress notes dated [DATE] documented by Licensed Practical Nurse (LPN) H state, SPO2 (Estimate of arterial oxygen saturation) was below 88%. O2 (Oxygen) started at 2L (Liters) per nasal cannula. Resident stated he has an occasional cough. No complaints of shortness of breath. Resident SpO2 89%-90% with O2 on. Resident takes his O2 off and becomes upset when staff attempt to put back on the O2. Will have Night RN (Registered Nurse) check resident when she comes in at 2:00AM. Nurse Manager updated at 06:30 AM. TPR (Temperature, Pulse, Respirations) 98XXX[DATE]- B/P (Blood Pressure) ,[DATE]. Progress note, by night RN (Register Nurse) G at 5:05 AM, on [DATE] state in part, (Resident) noted to have crackles to right lung field and lower left lung. O2 85% on RA (Room air) put PRN (as needed) oxygen on at 2 L which resident left on for a short while then removed. Resident assisted to recliner to sitting position to assist with breathing. Continued to monitor and encourage oxygen via nasal cannula which would only stay on short times then resident would remove. Will request chest X-ray for day shift to contact MD with report. Progress note on [DATE] at 11:08 AM, by RN F states in part,O2 sat 84% Pt (Patient) HOB (Head of Bed) elevated 90 Degrees in recliner. (On call MD N) notified and new orders noted for chest x- ray, titrate O2 ,[DATE] L n/c (nasal cannula), and [MEDICATION NAME] TX's (Treatments). O2 applied 3L n/c and sats up to 92%. Medication Administration Record [REDACTED]. A physician's telephone order dated [DATE] at 11:04 AM, includes Chest x-ray one time only for 1 day. Physician's telephone order dated [DATE] at 11:06 AM, include Duo-Neb Solution 0.5mg-2.5mg (3) MG/3ML (Milligram/Milliliter) ([MEDICATION NAME]-[MEDICATION NAME]) 1 vial inhale orally every 4 hours as needed for [MEDICAL CONDITION]. The chest x-ray results were faxed to the facility on [DATE] at 3:55 PM. The conclusion indicates Modest [MEDICAL CONDITIONS] vs atypical infection. A Physician's telephone order dated [DATE] at 6:32 PM, includes, [MEDICATION NAME] 40 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time only for [MEDICAL CONDITION]. (MD D) on call for (MD C), updated on chest x-ray. Give a total of 80 mg one time only on [DATE]. Progress note on [DATE] at 9:23 PM, by LPN E indicates that Resident 1's x-ray completed, MD D on call NO (New Order), extra 40 mg [MEDICATION NAME] morning of [DATE]. (The date should have read [DATE].) It should be noted there is no documentation of resident's condition. LPN E continues to fax an update to primary MD to update him on the changes made by the on call physician. To be noted there are no documented vital signs for Resident 1 between 11:08 AM on [DATE] until 1:57 AM on [DATE] except noting O2 sats of mid 80's to low 90's. The facility only gave one [MEDICATION NAME]. Additionally, there was not a documented lung assessment. A progress note, dated 10/ ,[DATE] at 2:42 AM, documented by LPN E indicates, Situation: Resident stated he did not feel well to the aid (sic) using accessory muscles to breath. Background: Hx (History) of Alzheimer's, [MEDICAL CONDITIONS], adult failure to thrive. Assessment: Resident vitals as follows ,[DATE], 80%, 89 bpm (Beats per minute), 97.8, 18, using accessory muscles to breath, very SOB (short of breath). Response: Called to receive order from on call of (MD C), (MD D) to send to ER. (emergency room ). Transported per ambulance. A physician's telephone order, dated [DATE] at 2:36AM, includes send to the ED (Emergency Department) one time only for SaO2 below 80%. On [DATE] at 5:30 PM, Surveyor received the EMS (Emergency Medical Service) Prehospital Care Report that indicated on [DATE] the EMS received a call at 2:35 AM for a male patient with breathing difficulty. Facility staff stated this patient has been having problems for past couple of days. EMS arrived at the facility at 2:42 AM and noted Resident 1 was semi- fowlers (Patient lying in bed in a supine position with the head of bed at approximately ,[DATE] degrees) in bed with audible breath sounds. Auscultation revealed crackles bilaterally. (Resident) did have some active coughing and was on 4L of O2. O2 sat was 85%. Neb treatment was immediately set up and administered. EMS was told by facility staff (LPN E) that a chest x-ray was done today that was negative for pneumonia and patient was diagnosed with [REDACTED]. Pt was also given orders for [MEDICATION NAME] for fluid retention and (LPN E) stated, We didn't give it because we didn't want him up peeing all night. On [DATE], Resident 1's vital signs documented by EMS include: At 02:50 AM BP ,[DATE], P 80, R 24 labored, Sat 85% Room air. At 03:07 AM, BP ,[DATE], P80, R 24 labored, Sat 88% Med O2 (Medicated oxygen). The Prehospital Care Report indicated due to the prolonged breathing issues and close proximity to the ER it would be in the Pt's best interest to get him to the ER where RT (Respiratory Therapy) was waiting. IV access and IV meds were deferred to save time. O2 was given at 8 L during transport and follow up vitals were obtained. On [DATE] at 4:30 PM, Surveyor reviewed Resident 1's ER information: ER Nurses Notes dated, [DATE] at 3:15 AM, general assessment states in part, [MEDICAL CONDITION] 2+ (Plus) to BLE (Bilateral lower extremities), Breath sounds are coarse bilaterally. Breathing with crackles, wheezing bilaterally. Vital signs: BP ,[DATE], P 81, R 24, T 98.4, Sat 79% RA, Weight 157.85 To be noted, Resident 1's weight was up 21.45 pounds from the facility weight on [DATE] and a 28.95 pound increase from the weight noted on [DATE] from the VA Hospital. ER MD notes dated [DATE] at 3:34 AM, [DIAGNOSES REDACTED]. Resident 1 left the local ER to transfer to the VA Hospital in Madison at 10:00 AM on [DATE]. To be noted, Resident 1 passed away on [DATE]. On [DATE] at 11:40 AM, Surveyor interviewed MD (Medical Doctor) C who is the facility Medical Director regarding Resident 1's order for additional [MEDICATION NAME]. MD C stated, I would have expected it (the [MEDICATION NAME]) to be given based on symptoms. If short of breath it would be appropriate. MD C stated, I would have given the order to give in AM if there were not any symptoms and if it was late at night. MD C stated, If the patient is having signs and symptoms of distress the ordered dose of [MEDICATION NAME] should have been given. On [DATE] at 1:05 PM, Surveyor interviewed MD D who was on call for MD C on [DATE]. MD D indicated that he remembered getting called with the chest x-ray report noting [MEDICAL CONDITION] for Resident 1. MD D stated, I ordered [MEDICATION NAME] 40 mg which would be an extra dose. I was told by the nurse (LPN E) that the resident was 'not that bad'. MD D indicated that he Ok'd the order to give 80 mg total the next day. MD D again indicated, I was told he didn't look that bad, so clinically it would be ok to wait until the next day. MD D indicated he was called again in the early morning, the same nurse (LPN E) reported that the resident's 'sats were dropping; he was very short of breath and hypoxic. MD D indicated he gave the order to send to the ER. MD D indicated that he was not aware of Resident 1's full condition, to include new orders for Duo neb, low oxygen sats, the need to sit in a chair to assist with his breathing and abnormal lung sounds. On [DATE] at 2:30 PM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 1's weights. DON B indicated that the facility obtained the 3 day admission weights. DON B stated, We should have obtained the weight on [DATE]. Surveyor interviewed DON B regarding Resident 1's lung sound crackles that were documented on [DATE] at 5:05 AM, and if the MD should have been contacted. DON B stated, Yes, the MD should have been notified as it was a change of condition. DON B indicated the nurses did not document the actual time when the assessments were done. Surveyor asked DON B if she would expect the nurse to contact the MD with the chest x-ray report when it was available at 3:55 PM, on [DATE]. DON B stated, Yes, when it is respiratory related. I would have expected that they call the MD at the time of x-ray result, get orders, and initiate them. They should have called right away. Surveyor asked DON B about the additional [MEDICATION NAME] that was ordered. DON B stated, She (LPN E) probably should have given it to him right away. DON B indicated that she was not made aware of the chest x-ray. Surveyor asked DON B if LPN E had an RN assess Resident 1. DON B indicated that she could not produce any documentation to indicate that RN F, who was also working in the building, was notified of the x-ray results, and new orders received for Resident 1. DON B stated, LPN E should have had an RN assess Resident 1. Surveyor asked DON B if she was notified when LPN E documented the SBAR and the need to send Resident 1 to the hospital. DON B stated, There were no RN's in the building and I was not called. I did not find out until Monday AM. DON B indicated she is on-call ,[DATE]. (Twenty four hours a day/seven days a week.) Surveyor asked DON B if an LPN can make an assessment. DON B stated, They would have to if they are the only one in the building. DON B indicated that they would have to update an RN on call. DON B stated, I was never called. DON B stated, There could have been a better outcome if the [MEDICATION NAME] was given; could have prevented the transfer to the ER. DON B indicated that she would have expected more documentation. LPN E wanted to get Resident 1 out of the building instead of calling me. DON B stated, There was an RN here until 9:00 PM and the RN never assessed Resident 1. DON B indicated she was not sure why the [MEDICATION NAME] was not given as they have it in house. DON B indicated the ordered dose was never given. DON B stated, I would have called the MD back and ask to give the [MEDICATION NAME] right away. (LPN E) was over stepping her boundaries as an LPN. On [DATE] at 5:00 PM, Surveyor interviewed LPN E regarding Resident 1's chest x-ray results. LPN E stated, I called the MD around 5 ish. LPN E stated, I told the on call MD the vital signs and sats were nothing I was concerned about. I was not concerned at all. Surveyor interviewed LPN E regarding Resident 1's order for [MEDICATION NAME]. LPN E stated, The MD said to give it in the AM otherwise he will be up all night peeing. Surveyor asked LPN E if she updated the on call MD with Resident 1's need for a duo-neb this morning, decreased oxygen sats, and need to be sitting in a chair to breath. LPN E stated, I did not tell the on call MD about the duo-neb, dyspnea, or decreased sats from earlier today. LPN E indicated she didn't think she contacted DON B. LPN E indicated she usually would call the DON. LPN E stated, I didn't feel this was life threatening. If I had felt it was life or death I would have called. LPN E indicated she thinks she may have called DON B after he was transported but was not sure of the time. Surveyor interviewed LPN E regarding the information given to the EMS. LPN E indicated she told the EMS that Resident 1's vital signs and sats were decreasing. LPN E stated, He had a change in condition. I sent the x-ray along, and said there was a new [DIAGNOSES REDACTED]. LPN E stated, I think I told them about the [MEDICATION NAME], no other information about the [MEDICATION NAME]. LPN E indicated at the start of her shift at 2:00 PM Resident 1 was fine except for taking his oxygen off. LPN E indicated Resident 1 took his medications at 3:00 PM. Surveyor asked LPN E if Resident 1 had any [MEDICAL CONDITION]. LPN E indicated that she didn't think he was swollen. LPN E stated, I didn't notice any [MEDICAL CONDITION]. If [MEDICAL CONDITION] was a concern for him I would have monitored. LPN E indicated that Resident 1 appeared his normal self. LPN E stated, Later in the night, I thought maybe his he was mottled. Slight purple noted on his feet. Surveyor asked LPN E why Resident 1's weight was not obtained as LPN E documented a 7 meaning other, see note. LPN E stated, It didn't get done. Maybe he was asleep. Surveyor asked LPN E if the weight should have been obtained. LPN E stated, Yes, it should have been done. I should have made sure it was done. According to webmed's Heart Failure Health Center, Sometimes your symptoms may get worse very quickly. This is called sudden heart failure. It causes fluid to build up in your lungs, causing congestion. (This is why the problem is often called [MEDICAL CONDITION] <http://www.webmd.com/heart-disease/guide-heart-failure>.) .Sudden heart failure is an emergency. You need care right away. <http://www.webmd.com/heart-disease/heart-failure/tc/heart-failure-symptoms> Similarly, according to the article Shortness Of Breath Without Chest Pain Can Signify The Presence Of High Risk [MEDICAL CONDITION], .researchers at Cedars-Sinai Medical Center have found that patients with shortness of breath can have a higher risk of dying from [MEDICAL CONDITION] than patients without symptoms, and even than patients with typical cardiac pain . shortness of breath was a significant predictor of death from cardiac causes, as well as death from any cause . patients without known [MEDICAL CONDITION] who had shortness of breath were four times more likely to suffer death from a cardiac cause than asymptomatic patients and twice as likely as patients who had chest pain that is considered to be typical cardiac pain. <http://www.sciencedaily.com/releases/[DATE].htm> The facility removed the jeopardy on [DATE] when it began implementing the following: 1. All licensed nursing staff educated on notifying RN on duty or on call immediately with any change of condition. 2. All licensed nursing staff must review policy for COC and notification of change of resident health status. MD is informed of all changes for resident to ensure MD is fully aware current status of resident. 3. Chart audit will be completed to ensure all residents who had a change in condition had proper notification of MD. 4. Chart audit will be completed to ensure all weights are obtained as ordered. And care plans followed in regards to weight and [MEDICAL CONDITION]. 5. Education started immediately and will be completed with all staff prior to starting their shift. Cross reference F157 and F281

Based on interview and record review the facility did not ensure that care was provided to meet professional standards of quality for 1 of 6 residents reviewed (Resident 1). The facility failure created an Immediate Jeopardy situation when LPN E did not ensure that an RN assessed Resident 1 when Resident1's condition changed to include difficulty breathing, crackles in the lungs and when x-ray results confirmed [MEDICAL CONDITION]. With no RN assessment the LPN informed the physician of the x-ray results 5.5 hours later, she failed to report clinically accurate information. Resident 1's condition worsened and he died two days later at the hospital. . These failures created a finding of Immediate Jeopardy that began on [DATE]. On [DATE] the nursing home administrator was formally notified that an Immediate Jeopardy situation existed on [DATE]. The Immediate Jeopardy situation was removed [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Evidenced by: In section N7.03(1)(g) Wis. Adm. Code, the Board of Nursing cites as negligence, offering or performing services as a licensed practical nurse or registered nurse for which the licensee or registrant is not qualified by education, training or experience. Facility policy titled, Clinical Health Status - Change of Condition Guidelines dated [DATE], states in part, Change of condition-SBAR. The process for identification of change of condition includes gathering objective data and documenting assessment findings, resident /patient response, and physician and family notification. Communication both written and verbal, are integral part of actions needed for change of condition. The SBAR process assists in coordinating change of condition information for concise communication with the Physician/Physician Extender. Background - Pertinent and brief information related to the situation. Assessment - Subjective and Objective Assessment of the situation. What does the physical assessment reveal? Recommendation - What action of recommendation if needed to correct the problem? Monitoring/ Compliance - Vital signs are recorded for all residents / patients with change of condition. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's nursing notes include: On [DATE] into [DATE] between 10PM-2 AM (time frame estimated per Director of Nursing (DON) B as the time stamp on the nursing note by LPN H were not indicated as the events took place), SpO2 (Estimate of arterial oxygen saturation) was below 88%. O2 (Oxygen) started at 2L (Liters) per nasal cannula. Resident stated he has an occasional cough. No complaints of shortness of breath. Resident 's SpO2 89%-90% with O2 on. Resident takes his O2 off and becomes upset when staff attempt to put back on the O2. Will have Night RN (Registered Nurse) check resident when she comes in at 2:00AM. Nurse Manager updated at 06:30AM. TPR (Temperature, Pulse, Respirations) 98XXX[DATE]- B/P (Blood Pressure) ,[DATE]. There was no RN assessment of Resident 1 at this time and no immediate consultation with the physician. To be noted there are no documented vital signs for Resident 1 between 11:08 AM on [DATE] - 01:57 AM on [DATE] except for an O2 sat at of mid 80's to low 90's 01:57AM. Progress note, by night RN (Register Nurse) G at 5:05 AM, on [DATE] states in part, (Resident) noted to have crackles to right lung field and lower left lung. O2 85% on RA (Room air) put PRN (as needed) oxygen on at 2 L which resident left on for a short while then removed. Resident assisted to recliner to sitting position to assist with breathing. Continued to monitor and encourage oxygen via nasal cannula which would only stay on short times then resident would remove. Will request chest X-ray for day shift to contact MD with report. On [DATE] at 2:30 PM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 1's crackles that were noted [DATE] at 5:05AM, and if the MD should have been contacted. DON B stated, Yes, the MD should have been notified as it was a change of condition. On [DATE] at 3:55 PM, the chest x-ray report, which had been ordered by the physician, indicated Modest [MEDICAL CONDITIONS] vs atypical infection. On [DATE] at 9:23 PM, nursing notes by LPN E indicate that Resident 1's x-ray completed, MD D on call NO (New Order),extra 40 mg [MEDICATION NAME] morning of [DATE]. (DON B indicated the date should have read [DATE]). Fax sent to MD C to update. The nurse did not promptly notify the physician of the findings from the x-ray but, instead, delayed consulting with the physician for 5 ,[DATE] hours. On [DATE] at 2:30 PM, Surveyor asked DON B if she would expect the nurse to contact the MD with the chest x-ray report when it is available. DON B stated, Yes, when it is respiratory related. I would have expected that they call the MD at the time of x-ray result, get orders, and initiate them. On [DATE] at 1:05 PM, Surveyor interviewed MD (Medical Doctor) D who was on call for MD C on [DATE]. MD D indicated that he remembered getting called with the chest x-ray report [MEDICAL CONDITION] for Resident 1. MD D stated, I ordered [MEDICATION NAME] 40 mg which would be an extra dose. I was told by the nurse (LPN E) that the resident was not that bad. MD D indicated that he Ok'd the order to give 80 mg total the next day. MD D again indicated, I was told he didn't look that bad, so clinically it would be ok to wait until the next day. Although LPN E contacted the physician at 9:23 PM with the x-ray results, she did not give a complete description of Resident 1's symptoms, leaving MD D with the impression that Resident 1 was not that bad and that it would be OK to give the [MEDICATION NAME] in the morning. MD D indicated he was called again in the early morning, the same nurse (LPN E) reported that the resident's 'sats were dropping; he was very short of breath and hypoxic. MD D indicated he gave the order to send to the ER. MD D indicated that he was not aware of Resident 1's full condition, to include new orders for Duo neb, low oxygen sats, the need to sit in a chair to assist with his breathing and abnormal lung sounds. A physician's telephone order, dated [DATE] at 2:36AM, includes send to the ED (Emergency Department) one time only for SaO2 below 80%. On [DATE] at 5:30 PM, Surveyor received the EMS (Emergency Medical Service) Prehospital Care Report that indicated on [DATE] the EMS received a call at 2:35 AM for a male patient with breathing difficulty. Facility staff stated this patient has been having problems for past couple of days. EMS arrived at the facility at 2:42 AM and noted Resident 1 was semi- fowlers (Patient lying in bed in a supine position with the head of bed at approximately ,[DATE] degrees) in bed with audible breath sounds. Auscultation revealed crackles bilaterally. (Resident) did have some active coughing and was on 4L of O2. O2 sat was 85%. Neb treatment was immediately set up and administered. EMS was told by facility staff (LPN E) that a chest x-ray was done today that was negative for pneumonia and patient was diagnosed with [REDACTED]. Pt was also given orders for [MEDICATION NAME] for fluid retention and (LPN E) stated, We didn't give it because we didn't want him up peeing all night. Resident 1 died at the hospital on [DATE]. On [DATE] at 2:30 PM Surveyor asked DON B if an LPN can make an assessment. DON B stated, They would have to if they are the only one in the building. DON B indicated that they would have to update an RN on call. DON B stated, I was never called. DON B stated, There could have been a better outcome if the [MEDICATION NAME] was given. Could have prevented the transfer to the ER. DON B indicated that she would have expected more documentation. LPN E wanted to get Resident 1 out of the building instead of calling me. DON B stated, There was an RN here until 9:00 PM and the RN never assessed Resident 1. DON B indicated she was not sure why the [MEDICATION NAME] was not given as they have it in house. DON B indicated the ordered dose was never given. DON B stated, I would have called the MD back and ask to give the [MEDICATION NAME] right away. (LPN E) was over stepping her boundaries as an LPN. On [DATE] at 5:00 PM, Surveyor interviewed LPN E regarding Resident 1's chest x-ray results. LPN E stated, I called the MD around 5 ish. LPN E stated, I told the on call MD the vital signs and sats were nothing I was concerned about. I was not concerned at all. Surveyor interviewed LPN E regarding Resident 1's order for [MEDICATION NAME]. LPN E stated, The MD said to give it in the AM otherwise he will be up all night peeing. Surveyor asked LPN E if she updated the MD on call MD with Resident 1's need for a duo-neb this morning, decreased oxygen sats, and need to be sitting in a chair to breath. LPN E stated, I did not tell the on call MD about the duo-neb, dyspnea, or decreased sats from earlier today. LPN E indicated she didn't think she contacted DON B. LPN E indicated she usually would call. LPN E stated, I didn't feel this was life threatening. If I had felt it was life or death I would have called. LPN E indicated she thinks she may have called DON B after he was transported but was not sure of the time. Surveyor asked LPN E what information was given to the EMS. LPN E indicated she told the EMS Resident 1's vital signs and sats were decreasing. LPN E stated, He had a change in condition. I sent the x-ray along; there was a new [DIAGNOSES REDACTED]. LPN E stated, I think I told them about the [MEDICATION NAME], no other information about the [MEDICATION NAME]. LPN E indicated at the start of her shift at 2:00 PM Resident 1 was fine except for taking his oxygen off. LPN E indicated Resident 1 took his medications at 3:00 PM. Surveyor asked LPN E if Resident 1 had any [MEDICAL CONDITION]. LPN E indicated that she didn't think he was swollen. LPN E stated, I didn't notice any [MEDICAL CONDITION]. If [MEDICAL CONDITION] was a concern for him I would have monitored. LPN E indicated that Resident 1 appeared his normal self. LPN E stated, later in the night, I thought maybe his he was mottled. Slight purple noted on his feet. The failure to ensure that nursing care was provided in accordance with accepted standards of nursing practice created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time it had begun implementing the following: The facility removed the jeopardy on [DATE] when it began implementing the following: 1. All licensed nursing staff educated on notifying RN on duty or on call immediately with any change of condition. 2. All licensed nursing staff must review policy for COC and notification of change of resident health status. MD is informed of all changes for resident to ensure MD is fully aware current status of resident. 3. Chart audit will be completed to ensure all residents who had a change in condition had proper notification of MD. 4. Chart audit will be completed to ensure all weights are obtained as ordered. And care plans followed in regards to weight and [MEDICAL CONDITION]. 5. Education started immediately and will be completed with all staff prior to starting their shift. Cross Reference F157 and F309

Based on review of a facility investigation, record review, and interviews, the facility did not promptly consult with the physician when there was a significant change of condition and a need to significantly alter treatment for 1 (Resident 1) of 6 sampled residents. The facility failed to immediately consult with the physician when Resident1's condition changed to include difficulty breathing, crackles in the lungs and when x-ray results confirmed [MEDICAL CONDITION]. When the LPN informed the physician of the x-ray results 5.5 hours later, she failed to report clinically accurate information. Resident 1's condition worsened and he died two days later at the hospital. These failures created a finding of Immediate Jeopardy that began on [DATE]. The NHA was notified on [DATE]. The facility removed the immediate jeopardy on [DATE], however, the deficient practice continues at a scope/severity level of D as the facility continues to implement its action plan. This is evidenced by: The facility's policy, Notification of Change in Resident Health Status dated [DATE], states in part, Guideline Statement: To ensure that proper notifications are made when a resident has a change in health status. The center will consult the resident's physician, nurse practitioner, or physician's assistant, and if there if known notify the resident's representative or an interested family member when there is: (B) Acute illness or significant change in the resident's physical, mental, or psychological status (i.e. deterioration in health, mental , psychosocial status in either life-threatening conditions or clinical complications.) Criteria: Appropriate notification time, immediate. Nursing judgment is an integral part of the skilled care provided in this Living Center; therefore such judgment must be applied in a case by case basis in keeping with acceptable nursing practice. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. On [DATE] between 2:00 AM - 6:00 AM (per DON B as the time stamps were not indicated as the events took place) the nursing notes by RN G state in part, (Resident) noted to have crackles to right lung field and lower left lung. O2 85% on RA (Room air) put PRN (When necessary) oxygen on at 2 L which resident left on for a short while then removed. Resident assisted to recliner to sitting position to assist with breathing. Continued to monitor and encourage oxygen via nasal cannula which would only stay on short times then resident would remove. Will request chest X-ray for day shift to contact on with report. RN G did not promptly consult with the physician at the time she noted crackles and difficulty breathing. 2. On [DATE] at 15:55 PM, the chest x-ray report indicated Modest [MEDICAL CONDITIONS] vs atypical infection. On [DATE] at 21:23 PM, nursing notes by LPN E indicate that Resident 1's x-ray completed, MD D on call NO (New Order),extra 40 mg [MEDICATION NAME] morning of [DATE]. (DON B indicated the date should have read [DATE].) Fax sent to MD C to update. The nurse did not promptly notify the physician of the findings from the x-ray. On [DATE] at 2:30 PM, Surveyor asked DON B if she would expect the nurse to contact the MD with the chest x-ray report when it is available. DON B stated, Yes, when it is respiratory related. I would have expected that they call the MD at the time of x-ray result, get orders, and initiate them. 3. On [DATE] at 1:05 PM, Surveyor interviewed MD D who was on call for MD C on [DATE]. MD D indicated that he remembered getting called with the chest x-ray report noting [MEDICAL CONDITION] for Resident 1. MD D stated, I ordered [MEDICATION NAME] 40 mg which would be an extra dose. I was told by the nurse (LPN E) that the resident was 'not that bad'. MD D indicated that he Ok'd the order to give 80 mg total the next day. MD D again indicated, I was told he didn't look that bad, so clinically it would be ok to wait until the next day. Although LPN E contacted the physician at 9:23 PM with the x-ray results, she did not give a complete description of Resident 1's symptoms, leaving MD D with the impression that Resident 1 was not that bad and that it would be OK to give the [MEDICATION NAME] in the morning. MD D indicated he was called again in the early morning, the same nurse (LPN E) reported that the resident's 'sats were dropping; he was very short of breath and hypoxic. MD D indicated he gave the order to send to the ER. MD D indicated that he was not aware of Resident 1's full condition, to include new orders for Duo neb, low oxygen sats, the need to sit in a chair to assist with his breathing and abnormal lung sounds. A physician's telephone order, dated [DATE] at 2:36AM, includes send to the ED (Emergency Department) one time only for SaO2 below 80%. On [DATE] at 5:30 PM, Surveyor received the EMS (Emergency Medical Service) Prehospital Care Report that indicated on [DATE] the EMS received a call at 2:35 AM for a male patient with breathing difficulty. Facility staff stated this patient has been having problems for past couple of days. EMS arrived at the facility at 2:42 AM and noted Resident 1 was semi- fowlers (Patient lying in bed in a supine position with the head of bed at approximately ,[DATE] degrees) in bed with audible breath sounds. Auscultation revealed crackles bilaterally. (Resident) did have some active coughing and was on 4L of O2. O2 sat was 85%. Neb treatment was immediately set up and administered. EMS was told by facility staff (LPN E) that a chest x-ray was done today that was negative for pneumonia and patient was diagnosed with [REDACTED]. Pt was also given orders for [MEDICATION NAME] for fluid retention and (LPN E) stated, We didn't give it because we didn't want him up peeing all night. Resident 1 died at the hospital on [DATE]. The facility removed the jeopardy on [DATE] when it began implementing the following: 1. All licensed nursing staff educated on notifying RN on duty or on call immediately with any change of condition. 2. All licensed nursing staff must review policy for COC and notification of change of resident health status. MD is informed of all changes for resident to ensure MD is fully aware current status of resident. 3. Chart audit will be completed to ensure all residents who had a change in condition had proper notification of MD. 4. Chart audit will be completed to ensure all weights are obtained as ordered. And care plans followed in regards to weight and [MEDICAL CONDITION]. 5. Education started immediately and will be completed with all staff prior to starting their shift. Cross Reference F 281 and F 309

Based on observations and staff interviews, the facility did not ensure that the resident environment remained as free of accident hazards as is possible, and each resident had not received adequate supervision to prevent accidents. The deficient practice had the potential to affect 9 (resident #18 through #26) of 59 residents residing on unsecured units who were independently mobile and were cognizantly impaired. The facility installed a gas fireplace with a blower on 11/07 in it's main lobby. The fireplace did not have a hearth installed. The glass panel was protected by a safety screen, but the metal strip located at the top of the fireplace where heat was blowing was 165 degrees F (Fahrenheit). The area was not always supervised by staff. Failure to follow the manufacturer's safety directions for the gas fireplace in lieu of the dangerous temperatures of the metal on the top of the unit created a finding of immediate jeopardy, which began on 2/11/14. The Nursing Home Administrator was notified of the immediate jeopardy on 2/11/14. The facility removed the immediate jeopardy on 2/11/14. Findings include: The gas fireplace with blower manufacture's instructions indicated "Read, understand and follow these instructions for safe installation and operation. HOT SURFACES! Glass and other surfaces are hot during operation AND cool down. CAREFULLY SUPERVISE children in the same room as fireplace. High temperatures may ignite clothing or other flammable materials. If you expect that small children or vulnerable adults may come into contact with this fireplace, the following precautions are recommended: * Install a physical barrier such as: * A decorative fire screen. * Adjustable safety gate. Never leave children alone near a hot fireplace, whether operating or cooling down. Consider not using the fireplace when children will be present". At 156 degrees F, hot-water scalding/third-degree burns can occur in less than a second. Similarly, ASTM (American Society for Testing Materials)C 1055 - 99 Standard Guide for Heated System Surface Conditions That Produce Contact Burn Injuries notes at 6 .4 .2, "If the, surface temperature exceeds 70? C (Celsius) / 158 degrees F and the surface is metallic, it may present a hazard regardless of contact duration." It rephrases this by noting, "For extremely high-temperature metallic surfaces > (greater than) 70?C, damage occurs almost instantaneously upon contact." According to www.burnsurgery.org http://www.burnsurgery.org, "A deep dermal burn (third degree burn) will require 4-10 weeks or longer to heal. Since the new epidermis is very thin and not adhered well to dermis, wound breakdown is common. Excision and grafting is the preferred treatment. Dense scarring is usually seen if the wound is allowed to heal primarily." On 2/10/14 at approximately 8:00 a.m., the survey team entered the building. Surveyor # observed a lit fireplace in the facility's main lobby. Two unknown female residents in wheel chairs were noted to be seated facing the fireplace. On 2/11/14 at 10:45 a.m., surveyor # conducted an environmental tour of the facility and noted a lighted gas fireplace in the main lobby. The fireplace did not have a hearth and had a screen over the fireplace glass which was cool to touch. A blower was noted to be activated on the fireplace and was blowing hot air out of the top of the glass. The fireplace had black metal around the glass. The sides and bottom of the metal were cool to touch, but when the surveyor touched the metal on top of the fireplace glass, her hand was immediately retracted due to extreme temperature of the metal. It was noted that hot air was blowing out of the fireplace under this approximately 26 inches long and 2 inches wide metal strip. This strip was approximately waist high. There were no residents in the immediate vicinity of the fireplace and a receptionist was seated at a desk 8 feet away. The surveyor immediately had the receptionist summon MC (Maintenance Coordinator)-N. MC-N verified to the surveyor that the fireplace was activated daily during cool weather and also verified the top metal piece of the fireplace was very hot to touch. MC-N utilized a lazar thermometer and pointed it at the hot metal on the fireplace. The thermometer read 200 degrees F initially, then fluctuated for several seconds and read 165 degrees F. MC-N turned the fireplace off via a switch on the side of the wall by the fireplace and stated, "It wouldn't take long before a burn could occur at that temperature. The manufacturer's instructions say that there is to be other safety things put into place if vulnerable adults would have access to the fireplace. That wasn't done. I wasn't here when the fireplace was installed but someone must not have looked at the directions. The fireplace was installed on 11/07." Once turned off, the surveyor noted that even after 10 minutes, the metal on the fireplace was still too hot to touch. MC-N then placed a sign over the fireplace on/off control panel that indicated not to turn the fireplace on. On 2/11/14 at 11:00 a.m., surveyor # interviewed R (Receptionist)-Q. R-Q stated she worked at the front desk from 7:00 a.m. until 3:30 p.m., but also worked the resident units, had meetings out of the area and took breaks during her shift. R-Q indicated that she was unsure of when the fireplace was turned on and off during the day, but that the main lobby was not always supervised. R-Q also indicated that the fireplace was turned on almost daily basis during cool and cold days because residents would request it be turned on. R-Q also indicated that the NHA (Nursing Home Administrator) or the BOM (Business Office Manager) were usually in their office if she was absent from the front desk. The surveyor observed that neither of the above named staff had full view of the fireplace from their offices. On 2/11/14 at 12:30 p.m., surveyor # interviewed ADON (Assistant Director of Nursing)-P. ADON-P verified to the surveyor that resident #18, #19, #20, #21, #22, #23, #24, #25, and #26 were independently mobile and cognizantly impaired and would have access to the fireplace. ADON-P also verified to the surveyor that up to this point, she was unaware that anyone had sustained a burn from the fireplace. The immediate jeapardy was removed on 2/11/14 at approximately 3:30 p.m., when surveyor # observed MC-N place a lock box around the on/off panel for the fireplace.

Based on observation, interview and record review the facility did not ensure that the environment for 1 of 8 residents (Resident 8) remained free of accident hazards as is possible and that this resident received adequate supervision to prevent accidents. Resident 8 was observed smoking on the public sidewalk right in front of the facility with a tank of liquid oxygen on her wheelchair with oxygen running. The facility was aware as this was Resident 8's normal practice. Failure to ensure that Resident 8's environment remained as free of accident hazards as is possible and to receive adequate supervision to prevent accidents created a finding of immediate jeopardy. The immediate jeopardy began on 8/26/10. NHA A was officially notified of the immediate jeopardy on 9/1/10. The facility removed the immediate jeopardy on 9/1/10, however, the deficient practice continues at a scope/severity level D (potential for harm that is not immediate jeopardy/isolated) because. This is evidenced by the following: Resident 8's "Admission Record", dated 8/26/10, indicates Resident 8 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. On 9/1/10, at 12:45 PM, Surveyor observed Resident 8 outside the facility on the sidewalk in front of the facility. Resident 8 was smoking a cigarette. Resident 8 was seated in a wheelchair with a portable tank of liquid oxygen hanging on the back of Resident 8's wheelchair. The nasal cannula was noted resting in Resident 8's lap. This created a danger for Resident 8 because an oxygen-enriched environment makes the air highly combustible and makes burning more efficient. A spark from a match, a lighter, or a cigarette, within five to six feet from the source of oxygen could cause lit materials to combust and burn more vigorously. About 45 people die each year in the United States, and more than 1,000 are burned from fires fueled by home oxygen equipment, mostly caused by smoking, according to the National Fire Protection Association. On 9/1/10, at 12:45 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, and she indicated she was aware that Resident 8 was smoking with oxygen on the wheelchair. NHA A indicated that Resident 8 was aware of the risks associated with smoking and oxygen use, and that Resident 8 refused to take the oxygen off. NHA A also stated that just prior to the observation by Surveyor , NHA A had reminded Resident 8 about the risk of oxygen and smoking. NHA A stated Resident 8 refused to allow NHA A to remove the oxygen; however, Resident 8 did agree to remove the nasal cannula but would not allow NHA A to turn off the oxygen. NHA A stated this was all care planned for Resident 8. The facility's "Smoke-Free Campus Policy", effective date 7/2010, states "Golden Living Center, Beaver Dam is a smoke free campus. Residents, visitor, and staff are not allowed to smoke in the facility or on the facility grounds. This policy promotes the health and safety of residents, visitors, and staff...3. All new residents will be informed of the Facility's smoke free campus policy prior to admission. Residents will be expected to abide by the policy. New residents will not be permitted to smoke outdoors on the facility grounds. No smoking assistance will be provided to new residents. Receiving this information prior to admission will allow potential residents to make informed decisions regarding whether they will be able to abide by this policy. 4. Resident's are not allowed to keep smoking materials in their room due to safety...5. a. If a resident is non-compliant with this policy, the Executive Director will follow-up with the resident to discuss the smoke free campus compliance exceptions. If the danger or lack of compliance is serious enough, it may warrant discharge in accordance with state and federal law...6. All staff, resident, and visitors are encouraged to report violations of this policy to the Executive Director." On 9/1/10, Surveyor reviewed Resident 8's care plan "At Risk for Smoking Related Injury", dated 8/27/10. The facility identified the problem of "Resident is unable to move to/from smoking area without assistance. Disease or [DIAGNOSES REDACTED]. Presence of oxygen." Interventions include "Facility smoking policy explained to resident and family. Storage of smoking material per facility policy. Location (left blank). Assist to and from designated smoking area. Attempt to remove supplemental oxygen device prior to entering designated smoking area. Observe resident for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Res (Resident) chooses to keep O2 (oxygen) on while smoking despite risk of explosion. (Resident 8) states 'I used to be a respiratory therapist - I know what the risk is.' Encourage (Resident 8) to take (Resident 8's) N.C. (nasal cannula) off while smoking." Resident 8's Physician's Plan of Care, signed 8/26/10, indicates Resident 8 uses 2 liters of oxygen per nasal cannula at all times. Resident 8's "Smoking Safety Assessment", completed on 9/1/10, indicates Resident 8 uses oxygen, is independent and the facility will store tobacco products and fire materials. The "Burned clothing" box is not marked. Resident 8's nursing notes include the following: 8/26/10 2:58 PM - Resident admitted to the facility. "Resident welcomed to facility and was helped to settled (SIC) into room...Resident then went outside with husband to smoke a cigarette. Resident made aware of facility's smoking policy..." 8/26/10 10:29 PM - Oxygen saturation 92% at 3 liters...Resident outdoors to smoke, accompanied by family...On continuous oxygen at 3 liters. 8/28/10 8:40 PM - On continuous oxygen...Smokes outdoors with family. 9/1/10 12:57 PM - "Resident chooses to smoke with (Resident 8's) oxygen on. Writer asks resident if (writer) can turn resident's oxygen off when found smoking on public sidewalk front of building at 12:45 pm. Resident states 'no, I don't want it off, I know the risk. I used to be a respiratory therapist. I'm not going to blow up. Leave it on. I will take this cannula off and leave it in my lap.' Resident then removes (SIC) (Resident 8's) NC (nasal cannula) and places it in (Resident 8's) lap." It should be noted that placing an oxygen cannula running at 2 or 3 liters per minute in her lap increases the oxygen saturation of her clothing, thus, highly increasing the risk of burns if ashes or cigarettes would drop to her lap. On 9/1/10, at 1:05 PM, Surveyor interviewed Resident 8. Resident 8 was outside facility on the sidewalk in front of the facility sitting in a wheelchair smoking with a friend/visitor who was also smoking. Surveyor observed a burn hole in Resident 8's shirt. Resident 8's portable tank of liquid oxygen was observed to be running at 3 liters, the tubing was draped over Resident 8's lap, hanging down the right side of the chair and wrapped around the right front wheel of the wheelchair. Resident 8 stated that smoking can occur anywhere on the sidewalk. Resident 8 stated she usually keeps oxygen tubing and cannula on her lap while smoking. Resident 8 stated she goes outside 5 - 6 times a day to smoke. Resident 8 stated she is a retired Respiratory Therapist and knows you can catch on fire when smoking with oxygen on your wheelchair. On 9/1/10, at 1:10 PM Surveyor observed Certified Nursing Assistant (CNA) C approach Resident 8 outside the facility on the sidewalk in front of the facility. Resident 8 was still smoking and the oxygen was running and the liquid oxygen tank was on the back of Resident 8's wheelchair. CNA C informed Resident 8 that her weight was needed. CNA C saw the oxygen tubing was broken. CNA C stated she was going to get some new oxygen tubing, unplugged the tubing from the top of the oxygen tank, did not turn off the oxygen and went back inside the facility. On 9/1/10, at 1:14 PM, Surveyor interviewed NHA A. NHA A stated that smoking was allowed off property, i.e. sidewalk. NHA A stated staff can not take residents outside to smoke or assist with smoking. NHA A stated Resident 8 has only been in the facility a couple of days. NHA A stated Resident 8 did the same thing during her last admission, April thru May 2010. NHA A stated Resident 8 went outside with oxygen on and smoked. NHA A stated at that time there was also a problem with Resident 8 not smoking in the designated smoking areas. On 9/1/10, at 1:23 PM, Surveyor interviewed Resident 8 again. Resident 8 was sitting in the doorway to her room with smoking materials on her lap. Resident 8 stated she keeps the smoking material in her room, either in a personal pocket or unlocked drawer. This is contrary to facility policy. Resident 8 stated her roommate does not attempt to take the cigarettes. On 9/1/10, at 2:40 PM, Surveyor interviewed CNA D. CNA D stated the nurse keeps Resident 8's smoking materials. CNA D stated Resident 8 goes outside whenever Resident 8 wants to, independently. CNA D stated staff are not allowed to take residents outside to smoke or assist with smoking. CNA D stated staff can take residents for walks on the sidewalk where Resident 8 smokes but can not take residents out there to smoke or off grounds. CNA D stated activity staff can take residents outside for walks and can go around the block on the sidewalk. On 9/1/10, at 2:44 PM, Surveyor interviewed Activity Director (AD) E. AD E stated Resident 8 goes outside to smoke independently. AD E stated staff are not allowed to take residents outside to smoke or assist with smoking. AD E stated activity staff can take residents off property and do take residents for walks around the block with a radio or to the corner and back. AD E confirmed that staff take residents for walks and pass the area where Resident 8 smokes. Allowing Resident 8 to smoke with the oxygen tank on her wheelchair with the oxygen running created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 9/1/10 when they removed Resident 8's smoking materials and placed them at the nursing station and informed Resident 8 that she was not allowed to smoke with the liquid oxygen tank on her wheelchair. The facility trained their staff that Resident 8 was to have her oxygen tank removed and kept in the facility prior to Resident 8 going out of the building to smoke. All staff were to be inserviced on the new procedure prior to beginning their next shift of work.