Every finding on record at Benedictine Manor of LaCrosse

Based on interviews, observations, and record reviews, the facility failed to ensure that 2 of 3 residents (R5 and R40) reviewed for pressure injuries out of a total sample of 21, received care to prevent the development of pressure injuries and/or promote the healing of existing pressure injuries.R5 had a chronic left heel ulcer and was at risk for the development of additional pressure injuries. The facility implemented a Rooke Boot but did not include interventions for staff to follow related to removal of the boot. Staff interviews found that staff did not consistently remove the boot and/or did not complete a thorough skin inspection with cares. R5 developed a stage 4 pressure injury to the left calf. When the pressure injury showed signs of worsening, the physician was not consulted to determine if there was a need to change treatments. Observations found that R5 would lie on his back with the left calf resting directly on the mattress without pressure relieving devices in place. In addition, wound care was not completed in a manner that would promote the healing of the pressure injury.These failures created a finding on immediate jeopardy that began on 4/28/26. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 6/4/26 at 1:07PM. The immediate jeopardy was removed on 6/5/26, however the deficient practice continues at a scope/severity of G (actual harm/isolated) based on the following example:R40 was admitted to the facility without pressure injuries. While at the facility, R40 developed avoidable pressure injuries. Weekly wound assessments were not completed and R40's mid upper back pressure injury worsened to an unstageable pressure injury and required antibiotics. Evidenced by:The facility's policy and procedure dated 9/1/18 includes, .A resident centered care plan is implemented/updated for skin risk with interventions based on areas of risk, resident assessment, Braden evaluation score of 15 or less, clinician assessment/evaluation, resident preferences. Members of the care team are notified and consulted as necessary. Skin integrity is monitored and abnormal findings are documented. Skin is observed daily with cares.Weekly skin audits are performed by a licensed nurse.Evaluate current pressure reduction interventions and revise resident centered care plan.Notify the attending provider.if the pressure injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate.The NPIAP (National Pressure Injury Advisory Panel) classifies a PI as follows: 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.Deep Tissue Pressure Injury (DTPI): 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 reveals a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the extent of tissue injury, or many resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury. (Unstageable, Stage 3 or Stage 4). 1) R5 was originally admitted to the facility in January 2020 and readmitted to the facility on [DATE] with diagnoses of disease of spinal cord, type 2 diabetes, and diabetic neuropathy.R5's MDS (Minimum Data Set) assessment, dated 2/3/26 indicates R5 has moderate cognitive impairment, has upper and lower extremity impairments on both sides, and is dependent on staff for bed mobility. The MDS also indicates R5 is at risk for pressure injuries, and had 1 unstageable pressure injury.R5's care plan, dated 1/24/20 included a focus area of skin impairment. Interventions included:~Observe for alteration in skin integrity and report to care provider. Skin inspected by licensed staff weekly on bath day. (1/24/20)~CNAs (Certified Nursing Assistants) to observe skin with cares and report abnormalities to the nurse. (1/24/20)~Followed by wound nurse weekly. (7/22/25)~Float heels off bed. (7/22/25)~Encourage laying down between meals. (3/20/26)R5's care plan, dated 6/13/25 included a focus area of dependent on staff for bed mobility, transfers. Interventions included:~Staff to ensure call light in in Resident's reach.(6/13/25)~Staff to assist with doors, elevators, inclines, and tight spaces as needed. (6/13/25)~Assist with repositioning every 2-3 hours and as needed. Assist of 2 for bed mobility. (2/9/26)On 2/9/26, a Braden Scale was completed with a score of 15. This indicates R5 is at risk for pressure injuries.A progress note on 4/14/26 at 2:47 a.m. states, Wound to left calf noted when completing heel TX (treatment). Wound has a small amount of sanguineous drainage which was noted dried onto his boot as well as on the pillow that supports the resident's leg. Wound edges are not approximated; skin surrounding is reddened. Inner wound bed has seemed to have scabbed over, however the outside wound bed has split from the healthy skin and appears to have some sloughing. Resident expressed pain to the area.A progress note from wound rounds on 4/14/26 at 11:40 a.m. states, .Resident has new area to left calf measuring 4.5x6cm (centimeters). Necrotic/slough tissue to wound bed. Has foul smelling odor.new orders include: Dakins gauze to area, Vaseline to peri wound, wrap with ABD (abdominal pad) and Kling. Complete BID (twice a day). Change Rooke boots back to green offloading boots. Orders carried and dressing complete.There is no documentation indicating when the Rooke Boot was implemented. There were no approaches related to the care staff were to provide to R5 in relation to the Rooke Boot including how often it should be removed and the need to complete skin inspections.On 6/3/26, DON B (Director of Nursing) brought Surveyor a Rooke Boot. The inside of the boot was made of soft material. Surveyor could feel a straight hard backing that ran down the back of the boot from the ankle to the top edge.On 4/15/26, PA-U (Physician Assistant) documented, .updated on rounds.that a new wound was noted to R5's calf.CNA reports R5 has been having more leg pain, though it was assumed this was related to his chronic left heel ulcer.He is at risk for poor wound healing and wound complications due to complete immobility, frailty, diabetes, and poor nutritional status. Left posterior calf with necrotic, foul smelling ulcer, with moist tan periwound tissue. Mild surrounding erythema. Area is very painful for R5.Pressure ulcer of left leg.Wound is currently unstageable, though it appears it will be a stage 4 wound.I recommend getting a new pair of Rooke Boots or switch back to green boots.4/15/26 11:37 a.m. Wound Management Detail Report for R5's left calf includes 4.5cm x 1 cm, light serous exudate, foul odor with necrotic tissue in the wound bed.4/15/26 physician's order included, left calf treatment: cleanse. Apply Vaseline to periwound. Dakins 0.125% to gauze on wound bed. Cover with ABD. Secure with Kling. Change BID and PRN (as needed).On 4/16/26, R5's skin integrity care plan was updated to include interventions of, Treatment to left calf per MD (Medical Doctor) order.Green multi podous [sic] boot on at all times to bilateral lower extremities.4/22/26 wound rounds documentation at 1:08 p.m. states, .Resident's ulcer to left calf measures 5 x 2x 0.5 cm. Foul smell and continues to have necrotic tissue. Dressing completed.continue dressing changes at this time.4/22/26 Wound Management Detail Report for R5's left calf includes 5 x 2 x 0.5, light serous exudate, foul odor, necrotic tissue, surrounding skin with erythema/blanchable.R5's wound has gotten larger and the skin surrounding the wound has changed since the 4/15/26 assessment.A 4/24/26 progress note states, IDT (Interdisciplinary Team) review of chronic pressure injuries to left heel and left calf. Resident changed from rooke boots back to pressure relieving boots, DC (discontinue) elevated foot pillow. Resident encouraged to alternate between bed and chair.On 4/24/26, a physician's order was added, Remove pressure relieving boots and observe skin. Document if adverse findings. This was to occur each morning. Prior to this order, there were no directions to staff on removal of a device and inspection of the skin under the device. On 4/29/26, R5 enrolled in hospice care.4/29/26 wound round notes state, Continues to have necrotic ulcer to left calf and mepilex applied. Continues to have necrotic ulcer to left calf measuring 4.5x1x.5. Depth can be measured now. Foul smell noted. Dressing was changed. Area was review with PA, no new orders at this time.4/29/26 Wound Management Report documents 4.5 x 1 x 0.5 cm, light serous drainage, foul odor present, Stage 4, necrotic tissue, surrounding skin pink/normal.5/4/26, Braden Scale was completed with a score of 11, indicating R5 is at high risk for pressure injury development. R5's previous score was 15 or high risk for pressure injury development.5/6/26 wound round note for R5's left calf states, .continues to have necrotic area to left calf and heel.left calf is declining, measuring 6x2x.5. Necrotic tissue with redden skin around wound bed. Mild drainage noted to old dressing.No new treatment orders at this time.5/6/26 Wound Management Detail Report indicates R5's left calf wound to be 6 x 2 x.5, light seropurulent drainage, foul odor, stage 4 necrotic, surrounding skin pink/normal.R5's pressure injury has increased in size, and the drainage is no longer clear, but contains pus. Despite this change, there is no indication that the physician was consulted.R5's 5/13/26 Wound Round note states, Resident continues to have necrotic areas to left calf and heel. Treatments completed. Left calf is stable, measuring 7x2x1cm. Necrotic tissue with slough in wound bed, with reddened skin around wound bed. Mild drainage note to old dressing. No s/sx (signs or symptoms) of infection. No new orders at this time.5/13/26 Wound Management Detail Report indicates R5's calf wound is 7cm x 2cm x 1cm, moderate seropurulent drainage, foul odor, unstageable-deep tissue.R5's left calf pressure injury has increased in size and depth and has increased drainage. The staff completing this documentation has documented that this is an unstageable deep tissue injury; however, that is incorrect as it was previously documented as a stage 4. Despite the increasing size and depth and increasing drainage, there is no evidence the physician was consulted for potential change in treatment.R5's 5/20/26 Wound Round note states, Resident continues to have neurotic areas to left calf and heel. Treatments completed. Left calf is stable measuring 7x2x1cm. Necrotic tissue with slough in wound bed, with reddened skin around wound bed. Mild drainage noted to old dressing.R5's 5/27/26 Wound Round note states, Resident continues to have necrotic areas to left calf and heel. Treatments completed. Left calf is stable, measuring 7x2x.5. Necrotic tissue with slough in wound bed, with reddened skin around wound bed. Mild drainage noted to dressing.5/27/26 Wound Management Detail Report indicated R5's left calf pressure injury is 7 x 2 x 0.5 cm with light serous drainage, with foul odor. Pressure injury is unstageable due to the presence of slough and the surrounding skin is pink/normal.On 6/3/26, Surveyor observed R5's wound treatment performed by WCN V (Wound Care Nurse) who was assisted by RN C (Registered Nurse). Upon entering R5's room, Surveyor observed R5 lying on his back in bed. The green boots were in place, however his left calf was lying directly on the mattress without any pressure relieving interventions. RN C removed both the heel and the calf dressing at the same time. (Of note: Current standards of practice recommend that wound care be performed on one wound at a time, from the complete removal of the dressing through thorough cleansing and placement of a clean dressing, before moving to the next to complete the wound care consecutively and concurrently.)While removing the heel dressing, RN C placed a gloved hand directly on R5's soiled left calf dressing causing R5 to say Ow, and groan. RN C did not remove soiled gloves and complete hand hygiene after handling the soiled dressings. WCN V then proceeded to spray wound cleanser on the calf pressure injury and wipe the area with gauze. WCN V then turned the same piece gauze over and used it to wipe the heel wound after spraying it with wound cleanser.(Of note: Cleansing of the wound should be completed with clean gauze with each cleansing and soiled or used gauze should not be reused on another wound.) Surveyor noted a foul odor during the observation and asked if the odor was coming from both the heel and the calf wound. WCN V confirmed the odor was coming from both wounds. WCN V indicated the left calf pressure injury was a large and deep wound with visible slough and beefy red tissue. WCN V did not measure the depth of the calf pressure injury. WCN V indicated that the calf used to be 1 open area, however a bridge of new skin had formed. WCN V then proceeded to place 1 wet dressing over both areas and the bridge of new skin. Placing a wet gauze over intact skin can cause maceration to the newly formed skin creating a potential for skin impairment. On 6/3/26 at 3:59 p.m., Surveyor interviewed WCN V and DON B. WCN V confirmed that she had removed both R5's heel and calf dressings at the same time. WCN V also confirmed that the treatments were also done at the same time and they should have been done consecutively rather than concurrently. WCN V also confirmed that she did use the same piece of gauze to cleanse both wounds but agreed that she should have used a different piece of gauze for each wound. Surveyor asked what the expectation is for someone who touches a soiled dressing. WCN V stated that person should complete hand hygiene. Surveyor asked WCN V if measurements were completed of R5's left calf pressure injury. WCN V stated she did not measure the depth.On 6/3/26 at 1:35 p.m., Surveyor observed R5 sitting up in bed with the left calf resting directly on the mattress.On 6/3/26, Wound management detail report indicates that R5's left calf pressure injury is 8 cm x 3.5 cm x 0.5 cm, with light serosanguineous drainage with odor present. The stage is documented as Unstageable - Deep Tissue with slough and surrounding skin is pink/normal. The pressure injury is currently unstageable because the wound base is obscured by slough; unstageable implies there is full-thickness skin and tissue loss in the affected area.On 6/3/26, NHA A (Nursing Home Administrator) provided Surveyor with their investigation into the development of R5's left calf pressure injury. Witness statements included:~4/24/26: I don't remember seeing it. He did complain of increased pain/discomfort kind of all over. I reported it to my nurse. I usually give him a bed bath on Mondays per his preference.~4/24/26: Couldn't remember why skin check observations were not completed.~4/26/26: I don't remember seeing it. When I take his tubi-grips off, I inspect the front of his legs but not really the back.~4/29/26: R5 doesn't recall how he obtained the area. Resident states his leg hurt all over and not in one specific spot.On 6/4/26 at 8:30 a.m., Surveyor interviewed PA U (Physician Assistant) and asked when she was first made aware of R5's left calf pressure injury. PA U indicated she was notified on 4/15/26 and assessed the wound that day as she was already in the facility. Surveyor shared with PA U the observation of the Rooke Boot and the hard material that ran the length of the boot. PA U indicated she was not aware of that. Surveyor asked PA U if she thought adding pillows or a cushion would have been effective in reducing pressure to R5's calf. PA U indicate that an air mattress would be more effective. On 6/4/26 at 9:00 a.m., Surveyor interviewed DON B and RDCS L (Regional Director of Clinical Services). Surveyor asked what interventions were tried for R5. DON B indicated elevator pillows were tried, but they were uncomfortable for R5. DON B did not share any additional pressure relieving device attempts after the elevator pillows were not effective. The failure to monitor R5's skin condition under a medical device and the failure to consult with a physician when the left calf pressure injury worsened, created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 6/5/26 when it had completed the following:Resident (R5) is no longer a resident of the facility.Residents with medical devices are at risk. This has the potential to impact 14 residents.Residents with pressure injuries are also at risk. This has the potential to impact 6 residents.All licensed nurses will be educated on the importance of inspecting skin daily with removal of medical devices.All licensed nurses will complete education on Preventing Skin Infections (POL_IP093), Hand Hygiene (POL_IP054), and Prevention and Treatment of Skin Breakdown (POL_NS1702). All licensed nurses will be educated on assessing residents for pain pre- and post-treatment.All nursing staff will be educated on ensuring pressure relieving interventions are implemented and/or followed.All education noted above to be completed by next working shift. Any nursing staff who do not complete the education will not be scheduled until completed. Residents who have medical devices will have order set placed to remove device daily and complete skin inspection.Residents with pressure injuries will have order set placed for pre- and post-treatment pain assessment.Residents with medical devices and pressure injuries had care plan interventions reviewed and revised as necessary.The Hand Hygiene and Prevention and Treatment of Skin Breakdown policies were reviewed for accuracy. No revisions were needed.DON or Designee will conduct the following audits daily for 2 weeks, 2x times weekly for 2 weeks, 1x weekly for 8 weeks, and monthly for 3 months:Skin Assessments with Proper Removal of Medical DevicesHand Hygiene with Wound CarePain Assessments Completed Pre- and Post-TreatmentPressure Relieving InterventionsResults of audits will be reported at the facility Quality Council meeting with ongoing frequency and duration to be determined through analysis and review of results if substantial compliance is not met.The facility assessment was reviewed for accuracy as it relates to pressure injuries. No revisions were needed. The deficient practice continues at a scope/severity of a G (actual harm/isolated), based on the following example: 2.) R40 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, adult failure to thrive, epilepsy, type 2 diabetes, and vascular dementia. R40's most recent Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/24/26 indicates R40 has a Brief Interview for Mental Status score of 0 out of 15, indicating severe cognitive impairment. Section GG indicates R40 has lower extremity impairments on both sides and is dependent on staff for rolling left and right in bed. Section M indicates R40 is at risk for developing pressure injuries and has one stage two pressure injury and one unstageable pressure injury. R40's Comprehensive Care Plan states, in part:Problem: Resident needs assist with bed mobility, transfers, ambulation, and locomotion due to impaired mobility, generalized weakness, and impaired cognition. Problem Start Date: 9/17/25.Approach: -Staff assist of 2 with bed mobility. Approach Start Date: 1/6/26.Problem: Resident needs assist with dressing, personal hygiene, and bathing due to impaired mobility, impaired cognition, and generalized weakness. Problem Start Date: 9/17/25.Approach: Assist of 2 for ADLs (Activities of Daily Living).Problem: I am at risk for potential skin integrity issues related to impaired mobility. I have failure to thrive, incontinence, seizure d/o (disorder), weakness, impaired cognition, urinary incontinence, and DMII (Diabetes Mellitus Type 2) which may affect my abilities. Problem Start Date: 3/20/25.Approach: -Staff will observe for alterations in my skin integrity and report these findings to NP/PA/MD as necessary. My skin is inspected by licensed staff on a routine basis. Approach Start Date: 3/20/25-Staff will use a lift sheet to move me in bed. Approach Start Date: 3/20/25.-Apply creams as ordered. Approach Start Date: 3/20/25.-Followed by wound team weekly. Approach Start Date: 12/11/25. On 1/8/26, R40's Care Plan was updated to include the approach: Alternating air mattress from hospice. Call hospice with concerns. On 1/20/26, R40's Care Plan was updated to include the problem: Resident receives hospice services related to cerebral vascular disease from [Hospice Agency Name and Contact Information.] The approach is listed as: Facility will coordinate with hospice providers and reference hospice care plan located in resident's chart. On 2/9/26, a hospice note was written that states in part: . Hospice Integumentary (skin). Issues: decubitus ulcer. Additional Comments: 2/9/26: Red/blanchable hot area to mid spine on bony prominence. Mepilex applied. Q (every) 72hrs (hours) change or if soiled. LDA (Line/drain/airway) and Wound Assessment. midline back pressure injury.Pressure Injury Stage: 1. Base: blanchable; red.Periwound: intact; moist. Encounter Notes. R-Recommendations: -Pillow, repositioning for pressure offloading to back -Mepilex.(Of note: No measurements of the pressure injury were taken at this time. Additionally, this note, along with all other hospice notes, are inaccessible to floor staff. No record of a pressure injury assessment being documented in the facility's electronic medical record.)On 2/13/26, a hospice note was written that states in part: . Hospice Integumentary. Additional Comments: 2/13/26: Wound on back is still red and blanchable, but small gray/black circle noted in middle of the wound. Encounter Notes. -Mepilex changed on back. Red and blanchable [sic]. New gray/black circular area in the center of the redness. R-Recommendations: -Reposition [Resident Name] to deload pressure off middle of back New orders written and/or care plan changes: n/a (not applicable).(Of note: Wound has now declined compared to previous assessment. No measurements or staging is recorded in the note) On 2/17/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging. On 2/25/26, a hospice note was written that states in part: . LDA and Wound Assessment. Active Wound. midline back pressure injury. additional comments: Red blanchable area to mid spine [sic] on bony prominence. Drainage Amount: scant. Encounter Notes. A-Assessment/Observation or issues this visit:. -Dressing changed on her back. New scant drainage. Wound does not appear to be open yet, question if it opened and closed again? .(Of note: No provider notification is documented with the change in drainage and possible opening of the wound) On 3/2/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging. On 3/13/26, a hospice note was written that states in part: . Hospice Integumentary. Additional comments: 3/13/26: Wound on back is changing. periwound no longer red. but middle area is now open/gray, [sic] larger and has drainage with [sic] sloughing skin. LDA and Wound Assessment. Base: gray; red. Gray center looks more pronounced and larger in area, appears open with scant drainage. Sloughing skin noted. R-Recommendations: -Position off center of back.(Of note: this recommendation is not entered into the care plan. Additionally, there is no documentation of a provider notification regarding the changes in R40's pressure injury.) On 3/19/26, R40's Care Plan was updated to include the approach: Encourage repositioning q (every) 2-3 hours and PRN (as needed.) On 3/23/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging. On 3/26/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging. On 3/30/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging. Additionally, there is no documentation regarding the Mepilex dressing change being completed. On 4/3/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging. On 4/7/26, a hospice note was written that states in part: . LDA and Wound Assessment. Dressing Appearance: moist drainageBase: moist; slough. superficial opening, scant serosanguinous drainagePeriwound: moist; redness; warm DrainDrainage Characteristics/Odor: yellowDrainage Amount: scant. Encounter Notes. A-Assessment/Observation. -wound dressing changes. Wound appears to have more yellow drainage with some skin peeling. blanchable redness peri-wound and moist. R-Recommendations: -cleanse wound with dressing changes. New orders written and/or care plan changes: per [Name} NP -utilize anapest for wound cleansing if tolerated.On 4/7/26, a physician order was placed that states: Cleanse wound and apply anasept and Mepilex to bony prominence on back that has blanchable redness. Change every 72 hours or if soiled.(Of note: This is the first time R40's mid upper back pressure injury treatment has changed since its identification on 2/9/26)On 4/9/26, a hospice note was written that states in part: . LDA and Wound Assessment. Base: dry; slough. superficial opening, scant serosanguineous drainage.On 4/20/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging.On 4/13/26, a hospice note was written that does not contain wound bed characteristics, measurements, or staging.On 4/22/26, a hospice note was written that states, in part: . A - Assessment/Observation. - [Resident Name] 's wound on back is gray, slough, serosanguineous drainage. R - Recommendations: - Apply aquacell to wound beds for [Resident Name]'s back and coccyx. New orders written and/or care plan changes: -Per [Name] PA-C, -Apply aquacell to wound bed of back and coccyx wound. Change dressing every other day.On 4/22/26, a note was written by PA U (Physician Assistant) that states in part: . Chief Complaint. Worsening pressure wounds to back and coccyx. Interval Update:. I was updated at [Facility Name] that [Resident Name] had developed a new wound to her coccyx and the pressure area over her mid spine had deteriorated, now with a very dark purple/black wound bed. The area on her spine was being covered with a Mepilex dressing for protection. Z-guard was being used to her coccyx. Physical Exam. Skin. Lower back over spine has an unstageable DTI (Deep Tissue Injury) with about 50% of the wound open with dark tissue in the wound bed. Impression/Plan. 1. Pressure injury of back, unstageable. We will encourage her to lay down between meals and offload side to side. Treatment is changed to Aquacel cut to fit wound beds and cover with Mepilex, changing QOD (every other day) and prn if soiled.(Of note: This is the first note indicating a provider assessed R40's mid-spine pressure injury.)On 4/22/26, a Wound Assessment completed by WCN V included: 2 cm x 1 cm x unable to measure; no exudate; necrotic tissue; pink/normal skin surrounding wound. On 4/23/26, R40's Care Plan was updated to include the approaches: Tx (Treatment) to upper mid back per MD order; and encourage resident to off load side to side.On 4/29/26, a Wound Assessment completed by WCN V included: 1.5 x 1.5 x unable to measure; light serosanguineous exudate; no odor; necrotic tissue; pink/normal skin surrounding wound. On 5/6/26, a Wound Assessment completed by WCN V included: 2 x 1.5 x unable to measure; light seropurulent exudate; no odor; necrotic tissue; pink/normal skin surrounding wound. On 5/7/26, R40's Care Plan was updated to include the approach: When repositioning, ensure shirt is not bunched up in the back.On 5/20/26, a Wound Assessment completed by WCN V included: 2 x 1.5 x unable to measure; no exudate; no odor; Stage unstageable - slough and/or eschar; necrotic tissue; pink/normal skin surrounding wound; healing status declining. On 5/27/26, a Wound Assessment completed by WCN V included: 2 x 1.5 x unable to measure; light serosanguineous exudate; foul odor present; unstageable - slough and/or eschar; necrotic tissue; pink/normal skin surrounding wound; healing status declining. A Progress Note dated 6/1/26 at 17:26 (5:26 PM) states in part: New orders received from [Name] PA-C. Cefadroxil (Antibiotic) 500mg BID x7 days for dx (diagnosis) of cellulitis of back - pressure wound.On 6/3/26, a Wound Assessment completed by WCN V included: 4 x 1.5 x unable to measure; light serosanguineous exudate; no odor; unstageable - slough and/or eschar; necrotic tissue; pink/normal skin surrounding wound. A Progress Note dated 6/3/26 at 16:59 (4:59 PM) states in part: WOUND ROUNDS: resident continues having necrotic area to mid back measuring 4x1.5cm. Resident is being treated with antibiotics for infection of wound. Area around wound is red and swollen. Treatment completed.On 6/3/26 at 10:21 AM, Surveyor observed R40's wound treatment R40's wound treatment performed by WCN V (Wound Care Nurse) who was assisted by RN C (Registered Nurse.) Surveyor observed WCN V don (put on) a glove on her right hand, then use her ungloved left hand to touch and maneuver bedding. WCN V then donned a glove on her left hand without performing hand hygiene and proceeded with the wound treatment. Surveyor observed wound to mid back with tissue that appeared to be black, with some yellow or tan tissue within the darker, black tissue. Surveyor asked WCN V how she would describe the tissue in the wound bed. WCN V indicated she sees necrotic and slough tissue in the wound bed. Surveyor also observed periwound skin to be red and swollen. Surveyor asked WCN V to describe the periwound. WCN V indicated the periwound is more red and swollen than it was during R40's previous assessment last week. Surveyor observed WCN V prepare the Medihoney with Aquacel gauze, hold it up to the wound bed, where Surveyor observed the gauze contact the wound bed. WCN V then removed the gauze, cut it to size, then placed it back on the wound bed.On 6/3/26 at 2:36 PM, Surveyor interviewed CNA O (Certified Nursing Assistant.) Surveyor asked CNA O if CNAs or nurses complete weekly skin checks. CNA O indicated nurses do the weekly skin checks with showers or baths. Surveyor asked CNA O what she does if she notices a resident has a skin change. CNA O indicated she tells a nurse right away. Surveyor asked CNA O how she knows which residents have pressure relieving interventions. CNA O stated the interventions are hard to miss, but I also know if there is an order for barrier cream. It's also on the care plan. Surveyor asked CNA O if there is a way for staff to keep track of when residents are turned when they have a turning / repositioning schedule. CNA O indicated, no, I don't think so. Surveyor asked CNA O what she does if a resident refuses their pressure-relievi

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 5 residents (R21) reviewed for accidents.R21 self-transferred and fell backwards while grabbing for her walker, hitting her head. Subsequently, R21 sustained a laceration to the back of her head that required staples. CNA K (Certified Nursing Assistant) stated to Surveyor that R21 ambulates independently 3-4 times each shift. There is no evidence that risks and benefits associated with self-ambulating have been discussed with R21's APOAHC (Activated Power of Attorney for Health Care.) There is no evidence of increased monitoring to prevent further self-ambulation and potential injuries. Evidenced by:The facility policy and procedure, Integrated Fall Management, undated, documents in part, as follows: Purpose: Fall risk assessment, identification, and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. Policy: Residents are assessed for their risk of falls upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan.Procedure:.3. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment. 4. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist.Definitions: Fall - Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground.Fall with Injury: A fall with injury is when there is any resultant change in resident's physical condition following a fall. This includes skin tears, abrasions, lacerations. R21 was admitted to the facility 2/13/25 with diagnoses including, but not limited to, the following: cerebrovascular disease, vascular dementia, generalized anxiety disorder, osteoarthritis, pain, and weakness.R21's Annual MDS (Minimum Data Set) dated 2/13/26 documents a score of 10/15 on her Brief Interview for Mental Status, which indicates R21 is moderately cognitively impaired. Section J indicates R21 has sustained one (1) fall with no injuries since Admission/Entry/Reentry. R21 has an APOAHC (Activated Power of Attorney for Health Care.) R21's Mobility comprehensive care plan, dated 8/26/25, documents in part, as follows: Resident needs assist with bed mobility, transfers, ambulation, and locomotion on and off unit due to dementia, malnutrition, adult failure to thrive, and osteoarthritis. Has a hx (history) of self-transferring despite staff education and reapproach. Is aware of my risks/benefits.R21's Falls comprehensive care plan, edited 5/27/26 documents: Problem: Resident is at high risk for falling due to confusion, incontinence, medication use, cardiac dysrhythmias (irregular heartbeat,) visual and hearing deficits, hx (history of) falls, and agitation. Goal: (Edited 5/27/26) resident will not have fall related injuries during this quarter.Approach:(Start Date 5/19/26) Keep walker next to resident when in recliner(Start Date 2/23/26) Keep w/c (wheelchair) close to resident when in recliner(Start Date 6/26/25) Offer to toilet between 2-4PM as resident likes to have bowel movement around that time some days(Start Date 5/28/25) Colored call don't fall sign placed in room(Start Date 4/7/25) Resident prefers to have slippers with grippy bottoms(Start Date 3/4/25) I like to self-transfer, keep my walker close to me and remind me to use it(Start Date 3/4/25) Resident to wear grippy socks when up, staff to ensure that grippy is not worn down on socks(Start Date 2/14/25) I require staff to toilet me every 2-3 hours and PRN (as needed) On 12/29/25, R21's Fall Investigation documents in part, as follows:Event Date: 12/29/25 3:24 PMLocation of Fall: Resident BathroomWas the fall witnessed: NoWho was the resident found by: NurseActivity at time of fall: BlankResident Description of Fall: I pooped my pants and was trying to get to the bathroom. (Note: R21 fell while self-transferring)Staff Description of Fall: Sitting against bathroom wall, sitting on top of walker, gripper socks on.Were there any injuries: NoLast time rounding was completed/resident was observed: 3:15 PMLast time resident was toileted: 3:00 PMContributing Physiological Factors: Incontinent Indicate Interventions implemented to prevent future fall/injury: Review toileting needs and adjust toileting plan Evaluation Note: IDT (Interdisciplinary Team) review of fall on 12/29/25. Resident reports she had to use the bathroom and self-transferred. Resident experienced unwitnessed fall without injuries. Resident denies pain/discomfort. No latent injuries noted. Resident has hx (history) of self-transferring. Initial fall intervention not appropriate. Fall intervention: Offer toileting between 2-4:00 PM A progress note for R21 dated 2/13/26 at 7:59 AM documents as follows: Resident had a fall at 7:30 this morning. Writer was outside her room when it happened. She said she was going to go to the bathroom. It appeared that she was using the tray table as her walker and it broke and she fell down. She was laying on the leg of the tray table and she was holding her head up. No injury noted. Resident able to do range of motion with her arms and legs. Neuros and vitals within normal limits. Writer updated provider (name) and the DON (Director of Nursing at that time.) Writer left a message with her POA (Power of Attorney) to call the facility for a non-emergency update. Interventions are to have her wheelchair by her and a sign that says to call don't fall. (IDT review 2/13/26. Resident noted to self-transfer to the bathroom. Resident utilizing tray table over walker. No injuries noted. Intervention: Have w/c (wheelchair) close to resident and call don't fall sign. R21's Fall Investigation dated 2/13/26 documents in part as follows:Event Date: 2/13/26 7:43 AMFall Details: Resident RoomWas the fall witnessed: NoWho was the resident found by: NurseActivity at the time of Fall: BlankResident Description of Fall: was going to go to the bathroom (Note: R21 fell while self-transferring)Staff Description of Fall: Describe the fall details from the staff perspective: BlankWere there any injuries: No Last time rounding was completed/resident was observed: 6:45 AMLast time resident was toileted: 6:45 AMEvaluation: IDT (Interdisciplinary Team) review of fall on 2/13/26, resident noted to self-transfer to the bathroom. Resident utilizing tray table over walker. No injuries noted. No pain/discomfort noted. Fall intervention of have wheelchair close to resident and call don't fall sign. R21's Progress Note dated 2/15/26 at 5:25 PM documents as follows: Fall: Absent s/sx (signs/symptoms) latent fall injury. Staff continue to encourage call-light use. R21's Progress Note dated 2/23/26 at 2:17 PM documents as follows: IDT (Interdisciplinary Team) review of fall on 2/13/2026. Resident noted to self-transfer to the bathroom. Resident utilizing tray table over walker. No injuries noted. No pain/discomfort noted. Fall intervention of have wheelchair close to resident and call don't fall sign. R21's Progress Note dated 3/17/26 at 12:20 PM documents as follows: It was reported to nursing by activity staff that they found resident self-transferring to the bathroom. Call light was within reach. Resident made it to the toilet without [sic] but reminded to call for staff assist with transfers. R21's Progress Note dated 3/25/26 at 7:11 AM documents as follows: Resident was found to be wandering overnight. CNA (Certified Nursing Assistant) staff redirected resident back to room and left resident momentarily to finish resident cares. Resident again wandered and was found to be in an unoccupied resident room. No apparent injuries noted. No skin issues noted. VSS (vital signs stable). On 3/30/26, R21's PT (Physical Therapy) evaluation documents in part, as follows:Precautions: Fall risk, vascular dementia, poor hearingReason for referral: Patient is a long term resident at this SNF (Skilled Nursing Facility) who recently received PT orders to evaluate and treat for safety with transfers.Patient goals: Patient would like to be able to safely ambulate with FWW (front wheeled walker)Plan level of function: Patient requires Ax1 (1 staff assist) for all transfers and ambulation. Requires Ax1 for dressing and ADLs (Activities of Daily Living). CNA staff report patient has been becoming more active and frequently self-transfers indicating PT orders.Previous therapy: Patient has trialed PT services in the past and was able to achieve transfer status of Ax1 with FWW (front wheeled walker.)Therapy Necessity: Patient requires skilled PT to address impairments/deficits which include poor safety awareness when attempt transfers and ambulating tasks requiring cues and guidance to correct. Furthermore, patient has been reported to be self-transferring more frequently putting patient at risk of increased risk of falls and injury. Patient would require skilled PT services to improve balance, safety and independence, and ambulation in order to prevent further self transferring and risk of falling. On 4/16/26, PT documented in part the following:Clinical Impression: Patient demonstrates gradual progress regarding her functional mobility and therapy related goals. At the time of discharge, patient remains Ax1 (1 staff assist) with FWW for all transfers and ambulation. Able to transfer and ambulate safely at an assist of one level. No changes to transfer status at this time.Anticipated Discharge Plan: Recommend patient remain Ax1 for all transfers and ambulation using FWW. Recommend patient attend daily exercise class. R21's Progress Note dated 4/21/26 at 3:22 PM documents as follows: Status: Pt (patient) walked into hallway. Distraught affect. Looking for dentures. Those should never leave my side. Pt had been napping and the dentures were soaking. Writer gave pt her dentures and she put them into her mouth independently.4/23/26 5:33 PM Status: Pt displaying more anxious affect. Several self-transfers to bathroom. Pt upset she can't find her dentures, Someone comes in here and steals them. Dentures were in her mouth. Staff encouraged to play rec therapy game. PT did go and mood improved after activity. R21's Progress Note dated 5/19/26 at 11:22 AM documents as follows: Staff member witnessed resident grab for her walker and she fell backwards, hitting the back of her head, resident is bleeding from the back of her head, unable to see the wound due to the bleeding. Writer received order from provider (name) to send resident to ER (emergency room) for head injury from fall. POAs have been called and messages left that she is being sent out. Ambulance (name) called at 11:25. R21's hospital report dated 5/19/26 at 12:06 PM documents in part as follows: .Presents from facility after a fall. Patient is unable to provide history, and family not present during event, however able to provide collateral information. Patient is wheelchair-bound, family was told as was EMS (ambulance) report that she was moving from a chair to her wheelchair unsure whether assisted by herself when she sustained a fall and hit the back of her head. Patient does have a laceration to the back of the scalp. Although she denies pains anywhere, firm palpation of comprehensive musculoskeletal system performed and patient thankfully does not yelp or complain of any pain nor is there any obvious deformity or bruising.R21's Physical Exam documents in part: Mental Status: Mental status at baseline. She is confused. A CT (Computed Tomography) of R21's head and C-spine obtained with the following impressions:No acute intracranial process.Chronic stroke in the left occipital lobe.Scalp injury posteriorly on the left.Impression:No acute abnormality of the cervical spineMultilevel degeneration changes of the cervical spineDischarge Instructions: .She (R21) did sustain a cut to the back of her head which was repaired with 2 staples. The staples will need to be removed in 7-10 days. Please follow-up with your primary care provider urgent care or the emergency department to have this done. R21's Progress Note dated 5/19/26 at 12:19 PM documents as follows: Attempted to reach POA (name) regarding fall unsuccessfully. Called Alternate POA (name) who stated that his family member (name) had reached him and the POA (name) and family member (name) is attempting to reach (name.) Advised that resident had a fall and hit her head resulting in a laceration to resident's head and that she was transported to ED (emergency department) for evaluation and treatment. R21's Progress Note dated 5/19/26 at 2:48 PM documents as follows: Fall: Pt (patient) returned from hospital. Has staples on her head and roll bandage dressing. Visible blood in hair. Pt denied pain. Vitals and neuros WNL (within normal limits.) Pt self-transferred to toilet x1 this PM. R21's Progress Note dated 5/19/26 at 3:41 PM documents as follows: Immediate fall intervention: Keep walker next to recliner when resident is in recliner chair. R21's Fall Investigation on 5/19/25 documents as follows:Description: Resident fell backwards when attempting to reach for her walker. (Note: R21 fell while self-transferring)Location of Fall: Resident roomWas the fall witnessed: YesActivity at time of fall: Transferring without assistResident description of fall: Resident unable to describe what happened.Staff Description of Fall: Staff witnessed the fall and stated resident grabbed her walker and then she fell backwards, hit her head on the bed and then the floor.Were there any injuries: YesLocation: Back of HeadDoes the resident exhibit signs or complaints of pain related to the fall: YesWhere is pain located: back of her headOn a scale of 0-10, how does resident rate intensity of pain if able or indicated based on observation: 4 - Moderate pain (Distression [sic], Miserable) Range of Motion: ROM (Range of Motion) without pain/limitations in both upper and lower extremitiesPositioning of Extremities: No Rotation/Deformity/Shortening NotedLast time rounding was completed/resident was observed: 10:00 AM*Last time resident was toileted: 8:30 AMWhat footwear did the resident have on at the time of the fall: ShoesPost Fall Actions: cold compress to back of headInterventions: Place walker on left side of recliner when resident is in her recliner.Contributing Environmental Factors: Not applicableContributing Physiological Factors: Not applicableContributing Mental Factors: Impaired MemoryResident's ambulation status: Assist of 1 with deviceLevel of Consciousness: Alert wakefulness - perceives the environment clearly and responds appropriately to stimuli.Facial Muscle Movement: StrongUpper Left Extremity Movement/Grasps: StrongUpper Right Extremity Movement/Grasps: StrongLower Left Extremity Movement: StrongLower Right Extremity Movement: StrongLeft Eye Pupil Size: 3 mm (millimeters)Left Eye Pupil Response/Shape: Round/BriskRight Eye Pupil Size: 3 mmRight Eye Pupil Response/Shape: Round/BriskDoes resident respond to the following: NameDoes resident exhibit or complain of any of the following since the fall: Resident sent to ER (emergency room), unable to answer at this time.Speech: ClearPost-Fall Actions: cold compress to back of headIndicate Interventions implemented to prevent future fall/injury: Other: Place walker on left side of recliner when resident is in her recliner.Evaluation: IDT (Interdisciplinary Team) review of fall on 5/19/26. Resident unable to voice what she was trying to attempt when fall occurred. Laundry aide did observe resident standing, go for walker, and then fall backwards. Resident noted to have bleeding from back of head. Resident was not moved and provider updated with orders to send to ER for eval (evaluation). Resident returned with staples to back of head. Resident offered no complaints of pain discomfort noted r/t (related to) fall. Resident has a hx of self-transferring despite staff reminders and education. Neuros and vitals were within normal limits. Immediate intervention was to keep walker next to resident when in recliner. R21's Progress Note dated 5/20/26 at 10:50 PM documents as follows: Post fall: resident denies pain associated with fall. Resident does have staples to posterior scalp laceration. No bleeding noted. VSS. Neuro checks WDL. IDT (Interdisciplinary Team) review of fall on 5/19/2026: Resident unable to voice what she was trying to attempt when fall occurred. Laundry aide did observe resident standing, go for walker, and then fall backwards. Resident noted to have bleeding from back of head. Resident was not moved and provider updated with orders to send to ER for eval. Resident returned with staples to back of head. Resident offered no complaints of pain discomfort noted r/t fall. Resident has a hx of self transferring despite staff reminders and education. Neuros (Neurological) and vitals were within normal limits. Immediate intervention was to keep walker next to resident when in recliner. (Injury Scalp injury posteriorly on the left - 2 staples) Intervention: Resident has a history of self transferring despite staff reminders and education. Immediate intervention was to keep walker next to resident when in recliner. On 6/1/26 at approximately 9:00 AM, Surveyor spoke with R21. R21 stated she receives help when she needs it. Surveyor asked R21 if she has fallen over the last couple of months. R21 responded no, staff will not let me fall. On 6/3/26 at 2:37 PM, Surveyor spoke with DON B (Director of Nursing) with RDOCS L (Regional Director of Clinical Services) and NHA A (Nursing Home Administrator) also present. Surveyor asked DON B what interventions are in place for R21. DON B stated, staff keep R21's walker next to her recliner and close to her when she's in the recliner, we toilet between 2:00-4:00 PM, have a colored call don't fall sign in her room, and she wears slippers with grippers or gripper socks. DON B added, staff are to make sure the grippers are not worn down, offer toileting every 2-3 hours and PRN (as needed.) Surveyor asked, does R21 self-transfer. DON B stated, yes. Surveyor asked DON B, what is the facility doing to prevent R21 from falling. DON B stated, we put falls interventions in place, R21 can use the call light but does not always remember so we try to anticipate her needs as we can. Surveyor asked DON B, what is the facility doing to prevent R21 from falling? Surveyor asked DON B when R21 is found self-transferring what are staff to do. DON B stated, staff will ask her what her needs are and if she's able to tell them they will assist her with what she was trying to do. Surveyor asked DON B, when staff observe R21 self-ambulating do they increase monitoring. DON B stated, no. DON B stated, therapy is in place, neuros are in place following falls, she is on a busy hall and we monitor her for 3 days following a fall. Surveyor shared concerns regarding R21 self-ambulating with further follow-up needed. On 6/4/26 at 1:08 PM, Surveyor spoke with CNA K (Certified Nursing Assistant) who has worked at the facility for two years. Surveyor asked CNA K, according to R21's care plan, does she need assistance for ambulating. CNA K stated, yes, R21 needs 1 assist for ambulation in her room and hallway. Surveyor asked CNA K, does R21 ambulate independently. CNA K stated, Yes, all the time, it's terrible. Surveyor asked CNA K how often does R21 self-ambulate. CNA K 3-4 times per shift. Surveyor asked CNA K, what do you do when you see R21 self-ambulating. CNA K stated she tells her nurse. Surveyor asked CNA K, do you and other staff do anything different when you observe R21 self-ambulating. CNA K stated, no, we're trying our best. CNA K added, we keep R21's walker and call light near her. CNA K stated, I'm not sure if there's another way to stop her. Surveyor asked CNA K, has R21 had any injuries with falls. CNA K stated, yes, she had a fall 1-2 weeks ago and needed staples to her head. CNA K added, R21 doesn't remember she needs assistance. CNA K added, R21 will say she can do it by herself and should be helping (staff.) CNA K stated, we remind R21 we're here to help her. On 6/4/2026 at 1:50 PM, Surveyor spoke to DON B again. Surveyor asked DON B if the facility has had a conversation with R21 and her APOAHC regarding risks and benefits associated with self-ambulating. DON B stated that the facility does not have a formal risk and benefits sheet. DON B added, we can educate R21. DON B stated, the facility will usually put this education in the care plan. There is no evidence that risks and benefits associated with self-ambulating have been discussed with R21's APOAHC. There is no evidence of increased monitoring (e.g., line of sight or 1:1 supervision is being put in place when R21 is self-ambulating) to prevent further self-ambulation and potential injuries.

Based on observation, interview, and record review, 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 59 residents who reside in the facility.Surveyor observed dust covering the sprinkler heads and suspended from the light fixtures in the facility's stove hood.Surveyor observed staff with facial hair and not wearing hair restraints.Surveyor observed [NAME] J use a dirty alcohol swab to sanitize a thermometer and intervened before the thermometer touched resident food. Surveyor also observed [NAME] J use a dry paper towel to manually dry the thermometer after sanitizing it and before probing food.Surveyor observed 3 mixers to be stored under a plastic covering and unclean.Surveyor observed staff placing wet dishware upside down on trays creating a seal and not allowing the dishware to airdry completely.Evidence by:Example 1Facility policy, titled Cleaning Procedures, undated, includes: Hoods and filters- Clean inside and outside of hood. Wash hood with detergent solution. the interior section of the hood that extend to the roof should be cleaned annually by a commercial hood-cleaning operator.(It is important to note the facility's policy does not include the sprinkler system or light fixtures within the unit's stove hood.On 6/1/26 at 10:50 AM, Surveyor, DM H (Dietary Manager), and [NAME] G observed dust swinging in the changing air, suspended from the light fixtures, inside of the facility's stove hood unit. Surveyor, DM H, and [NAME] G also observed the sprinkler heads inside of the facility's stove hood to be coated in a thin layer of dust. DM H and [NAME] G indicated there is potential for the dust to dislodge and fall into the food being prepared underneath.Example 2Facility policy, titled Employee Health and Personal Hygiene, dated 2019, includes: Keep beards and mustaches neat and trimmed. [NAME] covers are required.On 6/1/26 at 10:50 AM, Surveyor observed [NAME] G and [NAME] F with facial hair, working with food in the facility's kitchen without donning a beard net. DM H (Dietary Manager) indicated they need a beard net and asked [NAME] G to go grab them. [NAME] G indicated he did not know where to find the beard restraints.Example 3Facility policy, titled Cleaning Procedures, undated, includes: . Food mixer- frequency of cleaning- daily and after each use. Cover mixer in clear plastic.On 6/1/26 at 10:50 AM, Surveyor observed three mixers to be stored under plastic and to be unclean with dried food particles on the undercarriages. DM H (Dietary Manager) indicated the mixers should have been cleaned before being covered in plastic and stored.Example 4On 6/3/26 at 4:38 PM, Surveyor observed [NAME] J use an alcohol wipe to sanitize his thermometer and then he used a dry paper towel to wipe the thermometer. [NAME] J indicated he was using the paper towel to dry the alcohol solution off the thermometer. [NAME] J probed a pan of rice to get a temperature reading on it. [NAME] J used the same dirty alcohol wipe to sanitize the thermometer and the same dirty paper towel to dry the thermometer and was just about to probe another food when Surveyor intervened. [NAME] J and DM H (Dietary Manager) indicated after using an alcohol wipe to sanitize a thermometer the alcohol wipe is dirty and should not be reused. DM H educated [NAME] J to allow the thermometer to air dry before using it to probe food. DM H indicated during interview that staff should not be using paper towels to dry the thermometer off after it has been wiped with alcohol. DM H also indicated staff should use a new alcohol wipe each time they sanitize the thermometer.Example 5Facility policy, titled Dishwashing Procedures, dated 2019, includes: all items are to be air-dried.On 6/3/26 at 8:56 AM, Surveyor observed DA I (Dietary Aide) to be placing wet coffee mugs, cups, and dessert bowls upside on plastic trays. DA I, DM H, and Surveyor observed white film on the upside-down dishware. DM H indicated the wet and upside-down dishware creates a seal that does not allow the dishware to air dry trapping the chemicals and creating a white chalky film inside. DM H indicated dishware should be allowed to air dry as that is the last step in the sanitation process.

Based on observation, interview, and record review the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living for 3 of 18 residents (R24, R40, R42) reviewed and 3 supplemental residents (R53, R62, R61). Surveyor observed 2 staff assisting 6 residents with their meal. 4 residents were made to wait until their turn to receive dining assistance while their plate of food sat on the table in front of them. CNA/Restorative Aide E kept getting up to assist at two different tables and reported that she is not able to converse with residents and sit alongside them while she assists them with dining, because of how many she is trying to assist. R42 was not assisted with her meal in a dignified and home-like manner. R53 was not assisted with his meal in a dignified and home-like manner. Evidenced by: Facility's admission Packet, undated, includes: . Every facility resident has the right to be treated as an individual with courtesy, respect, and dignity. The facility must maintain or enhance each resident's dignity and self-worth. The facility is pleased to offer Integrative Health services. Integrative Health is a philosophy of care that focuses on the well-being of the whole person; body, mind, and spirit. R62 admitted to the facility on [DATE] and her diagnoses include: Rhabdomyolysis (a serious and potentially life-threatening medical condition involving the rapid breakdown of damaged skeletal muscle), dementia without behavioral disturbances, moderate protein calorie malnutrition, adult failure to thrive, and cerebrovascular disease (condition that affects blood flow to your brain). R62's Comprehensive Care Plan, initiated 10/23/26, includes: Staff to provide verbal cues, set up tray, pour liquids, cut foods, and apply condiments with each meal, assist with eating as needed. R24 admitted to the facility on [DATE] and his diagnoses include: dementia. R24's Comprehensive Care Plan, initiated 10/16/23, includes: Staff to provide setup and supervision assist with feeding. Staff to provide verbal cues, set up tray, pour liquids, cut food, and apply condiments with each meal. R40 admitted to the facility on [DATE]. Her diagnoses includes: cerebrovascular disease, hospice, adult failure to thrive, vascular dementia, and disturbances of salivary secretion. R40's Comprehensive Care Plan, initiated 3/11/25, includes: Provide regular diet order with pureed textures and thin liquids as tolerated for comfort. Staff provide as needed assistance with all by mouth intake. Meals eaten in the restorative main dining room. Meals provided on a divided plate. R42 admitted to the facility on [DATE] and his diagnoses include: Congenital hydrocephalus ( an abnormal buildup of cerebrospinal fluid in the brain's ventricles). R42's Comprehensive Care Plan, initiated 9/22/25, includes: Staff to provide total assist with feeding. Feeding assistance at meals- alternate liquids and solids, slow rate of intake. R53 admitted to the facility on [DATE]. Her diagnoses include: Neurocognitive disorder with Lewy bodies, Parkinson's disease, feeding difficulties, and cognitive communication deficit. R53's Comprehensive Care Plan, initiated 2/15/21, includes: Staff provide feeding assistance/supervision as needed. R61 admitted to the facility on [DATE]. R61's MDS, with ARD of 3/27/26, indicates R61 requires setup and clean up assistance with eating. On 6/3/26 at 8:23 AM Surveyor observed CNA/Restorative Aide E (Certified Nursing Assistant) sitting between R42 and R53, assisting them with their meals. Surveyor also observed CNA/Restorative Aide E turn around to another table where she assisted R24 and R61. CNA/Restorative Aide E was going from one resident to the next assisting them by giving bites, placing forks or drinks in their hands, and providing verbal cues. Surveyor observed RN C seated between R40 and R62 assisting them with their meals. (It is important to note together the 2 staff were assisting 6 residents with dining.) On 6/3/26 at 9:53 AM Surveyor shared observation with NHA A (Nursing Home Administrator). NHA A indicated it would be hard for 2 staff to assist 6 residents with dining services. NHA A indicated staff should be seated next to a resident/s and assist them for the duration of the meal. On 6/3/26 at10:50 AM CNA/Restorative Aide E stated, I have been trying to tell them that we need more help in the dining room. There are usually more residents to assist too. CNA/Restorative Aide E indicated she does not think residents should get a bite and then have to wait for three others to take a bite before they get their next bite. CNA/Restorative Aide E indicated she would like to be able to sit next to one or two residents and be able to converse with them while assisting them with their meal, but she is unable to do that when she is trying to make sure four or more residents get a hot meal and they keep going. On 6/3/26 at 11:17 AM RN C (Registered Nurse) indicated there is usually one to two staff in dining room to assist 6 or more residents. RN C indicated more help is needed to assist residents in a dignified way. RN C indicated staff should not be getting up and going from resident to resident giving one bite to each like a circuit. RN C indicated she is not sure how the facility decides who will assist in the dining room, but she knew CNA/Restorative Aide E needed assistance so she came to help. On 6/3/26 at 12:16 PM DON B (Director of Nursing) indicated staff should sit next to one or two residents and assist them for the duration of their meal while conversing and interacting with that resident/s. DON B indicated CNA/Restorative Aide E going in between 4 residents does not allow CNA/Restorative Aide E to assist residents in a dignified way and leaves a lot of opportunity for missed hand hygiene. Example 2: R53 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement) and muscle weakness. R53's quarterly MDS (Minimum Data Set) assessment, with an assessment reference date of 3/8/26, indicates R53 requires substantial/maximal assistance for eating. On 6/1/26 at 12:22 PM, Surveyor observed CNA E (Certified Nursing Assistant) assisting R53 with her lunch meal. CNA E was standing up next to R53 while providing feeding assistance to R53. CNA E continued to provide feeding assistance while standing for the entirety of R53's meal. Surveyor observed CNA E use the clothing protector on R53's chest as a napkin. CNA E used the clothing protector to wipe R53's mouth. On 6/1/26 at 12:33 PM, Surveyor interviewed CNA E. CNA E indicated she usually feeds multiple residents at one time, and standing allows her to move faster between the residents. CNA E indicated R53's nose drips frequently and CNA E was assisting R53 to wipe her nose and that is why CNA E used the clothing protector. Example 3 R42 was admitted to the facility on [DATE] with a diagnosis of quadriplegia (the partial or total loss of motor and sensory function in all four limbs and the torso). R42's quarterly MDS (Minimum Data Set) assessment, with an assessment reference date of 3/4/26, indicates R42 is dependent on staff for eating. On 6/1/26 at 12:23 PM, Surveyor observed CNA D (Certified Nursing Assistant) assisting R42 with his lunch meal. CNA D was standing up next to R42 while providing feeding assistance to R42. CNA D continued to provide feeding assistance while standing for the entirety of R42's meal. Surveyor observed CNA D use the clothing protector on R42's chest as a napkin throughout the meal. CNA D continued to use R42's clothing protector to wipe his mouth during the meal. On 6/1/26 at 12:53 PM, Surveyor interviewed CNA D. CNA D indicated while assisting with feeding she watches and supervises all the residents in the dining room. CNA D indicated she stands while assisting R42 with his meal because R42's wheelchair is higher, and it is awkward to reach the utensil up to R42's mouth in a sitting position. CNA D indicated she uses the clothing protector in place of a napkin because the clothing protector is cleaner than the napkin. On 6/3/26 at 11:20 AM, Surveyor interviewed RN C (Registered Nurse). RN C indicated staff should be seated when proving feeding assistance to a resident. RN C indicated napkins should be use as it is not dignified to use clothing protectors as a napkin. On 6/3/26 at 12:16 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated staff should be seated when providing feeding assistance to a resident. DON B indicated staff should not be using clothing protectors as napkins.

Based on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 5 residents (R50) reviewed for unnecessary medications.R50 is receiving Melatonin for insomnia and did not have a sleep assessment/tracking completed. Findings Include:R50 admitted to the facility on [DATE] and has the following diagnoses: Insomnia, Chronic congestive heart failure, Type 2 Diabetes Mellitus, Anxiety disorder, Major Depressive Disorder, and mild cognitive impairment.R50's physician orders include, in part: Melatonin 3 mg at bedtime. Take one tablet by mouth at bedtime for sleep.On 6/3/2026 at 3:17 PM, DON B (Director of Nursing) indicated she was not able to find a completed sleep assessment for R50. DON B indicated the staff should be tracking R50's sleep patterns on the MAR (Medication Administration Record) and should have completed a sleep assessment. On 6/3/2026 at 3:28 PM RDCS L (Regional Director of Clinical Services) indicated R50 should have a completed sleep assessment and sleep monitoring in her MAR (medication administration record). RDCS L stated, There should be a box to enter how many hours of sleep she had for the shift. When she went to the hospital that was discontinued. We will start it again. She should have that because she is on Melatonin.(It is important to note, R50 did not have a sleep assessment completed related to Melatonin use and the facility did not track her sleep patterns.)

Based on interview and record review the facility did not ensure the Physician or Provider, reviewed the resident's total program of care, including medications and treatments or sign and date all orders for 1 of 1 Residents Physician orders reviewed (R5). R5 was missing a provider review of R5's total program of care, including medications and treatments due to not having signed monthly orders for January, February, April and May of 2026 Evidenced by: Facility policy entitled, Physician Services, indicates the following: Procedure: .11. The physician will: a. review the resident's total program of care, including medications and treatments, at each visit; b. Write, sign and date progress notes at each visit; and c. sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility standing house orders after an assessment for contraindications. On 6/18/26 Surveyor conducted record review and was not able to locate signed monthly physician orders. Surveyor asked for R5's signed monthly physician orders for the last 6 months. Surveyor received the following documents:Physician order report dated 2/6/26 - 3/6/26 which was signed by R5's provider.Physician Assistant encounter note dated 1/5/26, which did not include all of R5's orders/total program of care (no orders for dietary supplements, wound care treatments, bladder scanning, tubi grips etc.,) On 6/18/2026 at 1:33 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) regarding R5's physician orders. DON B indicated monthly MD orders get printed out for when providers are going to see them, they review them and sign them, and they get uploaded into the EMAR (electronic medication administration record) every month. Surveyor asked how often this is done, DON B indicated every month if on the list to be seen for rounds. DON B indicated on admission residents are seen every 30 days, 60 days, 90 days then 60 days thereafter with alternating provider between. Surveyor asked DON B to review R5's visit note. Surveyor asked DON B if visit note includes all orders being reviewed when signed DON B indicated it does not have those items. Surveyor asked if provider visits addressed treatment orders, supplements, blood sugar checks, tubi grips, bladder scan etc., DON B indicated no. Surveyor asked if all orders should be included in the order review? DON B and NHA A indicated yes. Surveyor asked if the orders signed on March 9th indicate how long they are good for, DON B indicated no.

Based on interview and medical record review, the facility did not ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 21 sampled residents (R50).R50 was noted to drop a pill while she was taking oral medications. The pill was never recovered, the other pills were swallowed, and it was unknown which medication was omitted. The facility failed to monitor R50 following the omission and failed to contact R50's Medical Doctor.Evidenced by:Facility policy, titled Medication Error/Occurrences, includes: 8/31/23, includes: When an error is made in the preparation or administration of a medication or a mediation error is discovered the licensed nurse is notified. The condition of the resident is assessed by a licensed nurse including obtaining vital signs. If a medication error requires nursing or medical intervention, observation, or treatment the provider is notified. The resident/resident representative is notified of the medication occurrence. Medication Error is the preparation or administration of drugs or biologicals which is not in accordance with the attending provider's orders, manufacturer's specification or accepted standards and principles of the professional providing the services. Examples of medication errors include:. omissions.R50 admitted to the facility on [DATE] and has the following diagnoses: Chronic congestive heart failure, Type 2 diabetes mellitus, anxiety disorder, major depressive disorder, and mild cognitive impairment.R50's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/22/26, indicates R50's cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 12 out of 15.R50's Nurse Notes, dated 5/28/26, includes: 4:33 PM Patient dropped a pill during her med pass. Writer alerted patient to wait a moment so he could see which pill fell. Patient then took the rest of her meds. Writer unable to locate pill that patient dropped and unable to determine due to patient taking the rest of her meds. Staff continue to search for loose pill.R50's Physician Orders, include:Mirtazapine tablet 15 mg once a day. 3:00 PM - 6:30 PM.Vitamins A, C, E, Zinc, Copper capsule 90 mg twice a day. 3:00 PM- 6:30 PM.Famotidine 20 mg twice a day. 3:00 PM- 6:30 PMXarelto tablet 10 mg once a day, take with food. 3:00 PM - 6:30 PM(It is important to note R50 takes the following high-risk medications at this time when one pill was omitted: Mirtazapine, an anti-depressant and Xarelto, a blood thinner that works by blocking a specific clotting protein in your blood.)On 6/3/26 at 11:26 AM, RN C (Registered Nurse) indicated an omission is a medication error. RN C indicated if a resident lost a pill during medication pass and she was unable to determine which pill it was, she would contact the resident's Medical Doctor, fill out a medication error sheet, and provide continued monitoring to be sure the resident does not have any side effects of the missed medications. On 6/3/26 at 11:54 AM, DON B (Director of Nursing), NHA A (Nursing Home Administrator), and Surveyor reviewed R50's Nurse Notes. DON B indicated she would expect follow-up after a pill was lost during medication pass and staff were unable to determine which pill was omitted. DON B indicated she would expect some continued monitoring. She would expect R50's Medical Doctor to be notified and she would expect staff to complete a safety event sheet in R50's medical record. NHA A agreed with DON B.

Based on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R40) reviewed for hospice. R40's hospice notes are not available to facility staff. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. As evidenced by: The facility policy entitled, Hospice, dated June 2021, states, in part: .Policy: The community will provide collaborative care with Hospice providers to ensure the resident's end of life preferences and choices are honored . Procedure 1. There is agreement for the provision of hospice services with one or more Medicare-certified hospices. 2. This signed agreement will include. i. A provision that the community associates are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. 4. There is a designate member of the community's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the community associates and hospice staff. 5. The interdisciplinary team member is responsible for. b. Communicating with hospice representatives. participating in the provision of care for the terminal illness, related conditions, other conditions. R40's most recent Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/24/26 indicates R40 has a Brief Interview for Mental Status score of 0 out of 15, indicating severe cognitive impairment. Section GG indicates R40 has lower extremity impairments on both sides and is dependent on staff for rolling left and right in bed. Section M indicates R40 is at risk for developing pressure injuries and has one stage two pressure injury and one unstageable pressure injury. R40's Physician Orders include:admitted to [Agency Name] Hospice. Start Date: 4/29/26. R40's Comprehensive Care Plan indicates:Problem: Resident receives hospice services related to cerebrovascular disease from [Agency Name] hospice, 24-hour contact number is [Phone Number].Approach:Facility will coordinate with Hospice providers and reference hospice care plan located in resident's chart. Start Date: 1/20/26.See hospice care plan for resident choices and preferences related to resident's comfort, cognition, pain, and functional status. R40's Physician Orders indicate:admission to [Hospice Agency Name]. Start Date: 1/7/26. On 6/2/26. Surveyor reviewed R40's hospice binder and electronic medical record. Surveyor was unable to locate any hospice nurse notes in either location. On 6/3/26, Surveyor notified DON B (Director of Nursing) and RDOCS L (Regional Director of Clinical Operations). of the investigation into R40's pressure injuries and requested all pertinent documentation. At that time, Surveyor was provided with some of R40's hospice notes that were written by registered nurses. The print date for all of the notes was indicated to be 6/3/26. On 6/3/26 at 3:59 PM, Surveyor interviewed WCN V (Wound Care Nurse). Surveyor asked WCN V who completes R40's wound dressing changes. WCN V indicates hospice completes wound dressing changes when they are in the facility, and facility staff complete the dressing changes when hospice is not in the facility. On 6/4/26 at 9:00 AM, Surveyor interviewed DON B and RDOCS L. Surveyor asks DON B what the process is when the facility receives notes or physician orders from hospice. DON B indicates the floor nurse gets a carbon copy, the HUC (Health Unit Coordinator) scans in the order and the nurse reviews the orders to make sure they are transcribed into the facility's electronic medical record. Surveyor asks DON B who is responsible for reviewing hospice notes for care updates. DON B indicates that there is no one individual staff member, but the floor nurses review the notes and will share the information with managers if something changes. Surveyor asks DON B who is responsible for updating care plans. DON B indicates the managers. R40's hospice visit notes were not available to the facility's direct care or licensed nursing staff.

Based on observation, interview, and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (R65 and R1) reviewed for infection control. R65 was not tested for COVID-19 after he was showing signs and symptoms of COVID-19. RN M (Registered Nurse) did not complete hand hygiene during R1's wound care. This is evidenced by: The facility's COVID-19 manual, dated 9/29/22, includes Symptom-and Contact-Based Testing: Test vaccinated and unvaccinated residents and associates (1) who develop COVID-19 symptoms. For symptom-based testing, anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. R65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that restricts airflow and makes breathing difficult) and heart failure. R65's nurse progress notes include the following:On 2/2/26 at 3:14 PM, .admitted to [Facility Name]. Lungs CTAB (Clear to Auscultation Bilaterally), on room air. On 2/4/26 at 6:15 PM, Noted resident noted to have pursed lip breathing. O2 sat (Oxygen Saturation) completed and at 85%. Resident reported I feel short of breath. Lungs auscultated with diminished breath sounds and wheezing. Breathing rapid and shallow, respirations at 22. See previous noted [sic] for further information contacting the on call provider. Discussed situation with resident and decision made to complete respiratory treatment and start Oxygen. Also resident refused to go to the ER (Emergency Room) to be evaluated if symptoms worsened. O2 (Oxygen) started at 1840 (6:40 PM). 1L (Liter) of O2 started per order and O2 sat was ranging from 88-91. Noted resident to have easier time with breathing and still intermittent SOB (Shortness of Breath). Resident refused to go to the ER. On 2/6/26 at 4:06 AM, .O2 remains at 2L and O2 sat was 91%. Denies SOB, respirations non-labored and lungs auscultated with diminished breath sounds and rales and rhonchi. On 2/6/25 at 6:24 PM, Resident reported dyspnea (difficulty breathing) when CNA (Certified Nursing Assistant) collected supper tray. As writer entered room resident was breathing with pursed lips, sitting upright in bed. Writer asked if resident was doing anything strenuous, resident denies. O2 read 87% on RA (Room Air) via pulse oximeter (device used to measure oxygen saturation). Occasional coughs noted. On 2/16/26 at 11:00 AM, .talked to the resident about having him sent in and agreed after the discussion. Was sent to [Hospital Name] via non emergent transport. R65's 2/16/26 Infection Tracker with McGeer's Criteria indicates R65 tested positive in the emergency room. On 6/3/26 at 11:31 AM, Surveyor interviewed RN C (Registered Nurse). RN C indicated she is the infection prevention nurse. RN C indicated residents and staff are tested for COVID-19 if they are symptomatic. RN C indicated some symptoms of COVID-19 would include a change in respiratory status, cough, abnormal lung sounds, and new onset of decreased oxygen saturation. RN C indicated if a resident exhibited any symptoms of COVID-19 a test should be done right away. On 6/3/26 at 12:11 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she would expect the facility staff to follow the facility's COVID-19 testing policies. DON B indicated the staff should have tested R65 for COVID-19 the day he started having symptoms but did not. Example 2 The facility policy, Hand Hygiene, reviewed 6/2026, indicates, in part, as follows: Purpose: Infection Prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization by germs acquired from the residents. Policy: It is the policy of the facility that all associates will be trained and competent in following proper hand hygiene practices. Procedure: Hand hygiene means cleaning hands using either handwashing (washing hands with soap and water), or antiseptic hand rub (i.e., alcohol-based hand sanitizer, including foam or gel). Times to Perform Hand Hygiene are but not limited to: Before and after direct resident contact, after removing gloves, and before and after changing a dressing. R1 was admitted to the facility 9/6/23. During R1's stay, R1 developed pressure injuries (localized damage to skin and underlying tissue) to her bilateral buttocks. On 6/4/26 at 10:15 AM, Surveyor observed RN M (Registered Nurse) and LPN N (Licensed Practical Nurse) complete dressing changes to R1's bilateral buttocks. Surveyor observed LPN N set treatment supplies in R1's wheelchair. Surveyor observed RN M put one glove on her right hand, pick up the garbage can with her right hand and move it next to her. RN M then removed the glove to her right hand and put on clean gloves. Surveyor observed RN M did not sanitize or perform hand hygiene in between glove changes. On 6/4/26 at 10:18 AM, Surveyor spoke with RN M. (Registered Nurse). Surveyor asked RN M, when should you wash or sanitize your hands. RN M stated, wash at the beginning (of a treatment), in between glove changes, dirty to clean, and at the end of the treatment. Surveyor asked RN M, should you have sanitized your hands after moving the garbage can with your gloved right hand and removing your right glove. RN M stated, yes. Surveyor asked RN M, should you set treatment supplies in a resident's wheelchair. RN M stated, no, she should have used a barrier. Surveyor asked RN M, is there a better place to set up treatment supplies. RN M stated, she should have cleaned the tray table, used a barrier, and set up supplies on the tray table. On 6/4/26 at 1:50 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, when should staff wash or sanitize their hands. DON B stated, before they enter the room, before putting on gloves, between any dirty and clean, when they exit the room, and in between working with residents. Surveyor asked DON B, when RN M put a glove on her right hand, move the trash can, removed the glove to her right hand and put on clean gloves should RN M have sanitized her hands after removing the glove to her right hand. DON B stated, yes. Surveyor asked DON B where staff should set up supplies when doing wound care. DON B stated staff should disinfect the tray table, put on a barrier, set supplies on the barrier, and disinfect the tray table when done. Survey asked DON B, is it acceptable for RN M to set treatment supplies in a resident's wheelchair. DON B stated, she does not think this is acceptable as we do not know what is on the wheelchair.

Based on interview and record review, the facility did not ensure staff provided adequate supervision to prevent an accident for 1 of 4 residents reviewed for falls (R1). R1 sustained a fall from bed on 1/6/26, resulting in a closed right clavicle (collarbone) fracture after a certified nursing assistant (CNA) failed to follow R1's care plan, which required the assistance of two staff members for cares. CNA C performed R1's morning cares on her own.This is evidenced by: Facility policy titled Integrated Fall Management, effective 8/24/17, states in part, .Policy: Residents are assessed for their risk of falls upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. R1 admitted to the facility on [DATE] and has diagnoses that include, in part: acquired absence of left foot, vascular dementia (moderate) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline without other emotional or behavioral symptoms present), end stage renal disease (failure of kidney function), dependence on renal dialysis, type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar affecting nerves throughout the body), depression, and gout (inflammatory arthritis). R1's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/1/25, indicates R1 is cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 1/21/26, Surveyor reviewed R1's Care Plan and CNA Care Guide in place before the fall on 1/6/26: R1's Care Plan stated, in part:-Category: Mobility - I am dependent on staff for my bed mobility, transfers and locomotion on and off unit. / Approach start date: 8/13/25 - Assist of 2 with full body hoyer lift for transfer.-Category: Bowel & Bladder: Resident is frequently incontinent of bladder and incontinent of bowel. Resident has impaired mobility and is dependent on staff for toileting. / Approach start date: 3/10/25 - Toileting plan: Staff assist per Mobility Care Plan for Resident to use bedpan/check and change every 3-4 hours as needed per resident preference.-Category: Falls I am at risk for falls d/t (due to) left sided weakness, generalized weakness. / Approach start date: 2/25/25 - Educate on prevention/reduction precautions per facility protocol. R1's CNA Care Guide stated, in part:ADLs (activities of daily living): Ax2 (assist of two)Transfer: Ax2 hoyerToileting: Ax2 R1's Progress Notes, dated 1/6/26, include in part: 8:30 AM - RN (Registered Nurse): Staff reported that the resident fell out of bed while being assisted with cares, being rolled onto his left side. Noted resident on the floor, face down. Neuros (neurological signs) are unremarkable. Denies pain. Logged [sic] rolled resident on his back. Noted cuts on residents [sic] left side forehead, under eye, and under nose. Applied cold compress on face. Called POA (power of attorney) and agreed to sending him in for evaluation. Reported to nurse manager. Facilitated transfer. Resident was assessed by first responders.left building around 0800 (8:00 AM). 11:00 AM - RN: Prior to returning to facility, writer received update from [Hospital] ED (emergency department) RN that resident did obtain a closed right clavicle fracture noting 'it was quite small.' Resident is to wear a sling for comfort to RUE (right upper extremity) which was provided by the ED. 11:45 AM - RN: Return [sic] returned to facility at this time via facility van and staff. R1's emergency department Discharge summary, dated [DATE], indicates in part:-History of present illness: Patient states that he was getting ready for the day and staff was assisting him getting dressed. Patient states that he rolled over and proceeded to fall out of the bed, hitting his head on the floor. No loss of consciousness. Patient reports facial pain and right shoulder pain.-Diagnostic x-ray - right shoulder: Impression: equivocal minimally offset fracture of the distal right clavicle, not visible on all views.-Impression and plan: .Discussed with patient finding of distal right clavicle fracture. Patient was placed in a shoulder sling for comfort. Recommend gentle range of motion of the right upper extremity and close outpatient follow up with primary care provider. He may also use acetaminophen for pain. Surveyor reviewed the facility's investigation summary of the incident. The incident summary indicates, in part: .At the time of the incident, it was identified that the resident's plan of care was not followed. Surveyor reviewed the facility's corrective action form, dated 1/8/26, for CNA C, the staff member taking care of R1 on the morning of his fall on 1/6/26. The form states, in part: Description of behavior/actions: During your shift on 1-6-26 you did not follow a resident's careplan [sic] for bed mobility. The resident required two staff for bed mobility and you did bed mobility on your own. This caused an injury to the resident. On 1/21/26 at 11:57 AM, Surveyor interviewed CNA C regarding R1's fall. CNA C indicated she typically works as a restorative aide but gets pulled into the halls sometimes when extra help is needed. On 1/6/26, CNA C was asked to help get residents up and went in to help R1. CNA C rolled R1 onto his left side and was performing toileting cares when he rolled off the bed and onto the floor, hitting the chair next to his bed on the way down. CNA C believed R1 was a one person assist, but he was actually a two person assist. CNA C indicated care guide sheets for each resident are inside of the linen closet door on each hallway. CNA knew this prior to helping R1 and indicated she should have looked at the sheet to verify if another staff member was needed to assist her with R1's cares. This information would have been found in the ADLs category. CNA C indicated DON B (Director of Nursing) followed up with her and pointed out this information on R1's care guide. CNA C indicated she was given education on care plans and DON B watched her perform cares before she was allowed to return to work. CNA C indicated she will look at the care plan for each resident before providing cares or performing transfers going forward. On 1/21/26 at 12:04 PM, Surveyor interviewed DON B. DON B indicated she was informed of R1's fall on 1/6/26 when she arrived at the facility that day. DON B said she found out R1's care plan had not been followed. R1's care guide had indicated he needed an assist of two staff members for ADLs. This is what staff members followed for bed mobility tasks. The care guides are posted in CNA linen closets on each hallway. CNAs can look at the guides and make copies for the day, if they choose to. They can either make a copy of the posting or have a nurse print a copy, which can be shredded at the end of the shift.CNA C was suspended pending an investigation into R1's fall. Bed mobility is now listed as a separate item on residents' care plans. Bed mobility is also listed separately on CNA care guides. A facility-wide air mattress sweep was done to ensure all air mattresses were functioning properly. DON B and maintenance checked R1's air mattress. An outside medical company and the facility's hospice vendor checked the rest of the air mattresses in the facility. No issues were found with the air mattresses or bolsters. Surveyor reviewed R1's Care Plan and CNA Care Guide in place after the fall: R1's Care Plan states, in part:-Category: Mobility - I am dependent on staff for my bed mobility, transfers and locomotion on and off unit. / Approach start date: 1/6/26 - Staff assist of 2 with bed mobility. R1's CNA Care Guide states, in part:ADLs: Ax2Bed Mobility: Ax2 with bed mobilityTransfer: Ax2 hoyerToileting: Ax2 On 1/6/26 the facility recognized the deficient practice and immediately implemented a corrective action plan as evidenced by the following: -Post-fall assessments were completed on R1 along with additional post-fall monitoring (skin and pain assessments).-All residents requiring a two-person assist and/or having air mattresses were reviewed for bed mobility. Care plans and care guides were updated to include this information.-The facility interviewed R1, CNA C, other staff members working at the time of R1's fall, and other residents regarding care plans being followed.-CNA C was suspended until the investigation into R1's fall was complete and received a written warning. CNA C was required to complete education and demonstrate cares before returning to work.-Air mattress inspections were conducted.-Education regarding following the plan of care was provided to licensed nurses and CNAs. Surveyor reviewed staff signatures. Most of this education was completed on 1/6/26. Surveyors interviewed several staff members on 1/21/26 regarding the education and they were able to verbalize the education.-Ongoing education provided upon hire, annually, and as-needed.-Bed mobility audits and following care plan audits being completed on a six-week tapered schedule. Date of last audits reviewed by surveyor: 1/19/26. Completed audits will be brought to the facility's Quality Council meeting to discuss.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent infection of PIs, or prevent new PIs from developing for 3 of 6 residents (R) reviewed for pressure injuries (R52, R49, R2). R52 was admitted to the facility with a stage II PI and determined to be at high risk for PI. Weekly assessments were not completed consistently, implementing interventions to prevent/improve PIs was not timely, turning and repositioning program was not monitored/reviewed, R52 was not educated on risk vs benefits of repositioning and offloading to prevent/improve PI, and physician was not notified when PI worsened. R52 developed a second stage II PI on 3/4/25. This example is being cited at actual harm. R49 was admitted to the facility with PIs. Weekly assessments were not completed consistently and the intervention of air mattress was added 8 days after admission. Staff did not follow standards of practice for hand hygiene during PI wound care for R2. Findings: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019: Staff should assess and document the physical characteristics of the wound bed and the surrounding skin and soft tissue at least weekly. Weekly wound assessment and documentation should include, in part: Anatomical location, category/stage, size and surface area, tissue type, color, peri wound condition, wound edges, exudate, and odor. NPIAP guidance also recommends repositioning all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. NPIAP guidance also recommends if progress toward healing is not seen within two weeks, the individual, the pressure injury, and the plan of care should be re-evaluated. The facility policy, titled Prevention and Treatment of Skin Breakdown copy right 2018, states: Purpose: Maintaining intact skin is integral to resident health and wellness. Care and serve are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur. Under Section 1 of the policy, states in part .3. Skin integrity is monitored, and abnormal findings are documented, weekly skin audits are performed by a licensed nurse .5. Education is provided to the resident/resident representative as indicated. Under Section 2 of the policy, states in part: If a resident is admitted with impaired skin integrity or a new PI, the following items are implemented: .5. Evaluate current pressure reduction interventions and revise resident centered care plan, Educate resident/resident representative on skin wound/pressure injury and care plan interventions .10. Weekly the licenses nurse will stage, measure and examine the wound bed and surrounding skin. If wound bed has deteriorated: notify provider 11. Notify the attending provider, resident/resident representative and supervisor if the PI has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluate plan as care as appropriate. The facility policy titled Handy Hygiene last revised 09/20/23, states, Purpose: Infection Prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the residents. The Hand Hygiene policy section labeled: Times to perform Hand Hygiene are, but not limited to, stated in part, .before and after changing a dressing, upon and after coming in contact with a resident's intact skin, after contact with a resident's body fluids or excretions. Example 1 R52 was admitted to the facility on [DATE] with a diagnosis of streptococcus bacteremia of right lower extremity cellulitis, pressure injury of left buttock and generalized weakness. R52's Minimum Data Set (MDS) assessment, dated 01/08/25, identified R52 scored 15 during a Brief Interview for Mental Status (BIMS), indicating R52 is cognitively intact. R52 requires substantial to maximal assistance for toilet transfer, toilet hygiene, personal hygiene and chair/bed-to-chair transfer. R52 is dependent on staff for sit to stand, and lower body dressing, and identified has a stage II PI and is at risk for PI. On 01/02/25, physician orders of: Bilateral buttocks/inner gluteal crease/L buttock pressure ulcer. Gently clean with warm soapy water. pat dry, apply a thin layer of z-guard as a moisture barrier. may hold in place with viva paper towel three times a day. On 01/02/25, Braden Scale indicated a score of 15 indicating at high risk for pressure ulcers and the facility identified need for interventions of pressure reducing device for chair, turning/repositioning program, pressure ulcer/injury care, and application of ointments/medication other than to feet. On 01/02/25, an admission nurse's notes indicated a stage 2 was identified to left buttock measuring approximately 0.5 cm with a wound bed red, no drainage. Surrounding tissue is excoriated, moist with blanchable erythema. On 01/03/25, an individualized care plan which states in part: I am at risk for alteration of skin status due to impaired mobility, incontinence and generalized weakness. Resident has pressure injury to buttock. Chooses to sleep in recliner, refuses to utilize bed. Resident has history of declining cares despite staff education. The facility entered care plan interventions of: On 01/03/25: turning and positioning program due to decreased mobility with assist of 1. I prefer to be repositioned every 2-3 hours and as needed. 01/27/25: Therapy recommendation: place ROHO cushion where resident is sitting in recliner or wheelchair 01/28/25: followed by wound nurse weekly. 01/28/25: treatment to buttock per MD order. Of note, the facility was unable to provide documentation to support when the ROHO cushion was implemented, or when it was first used in the recliner. On 01/03/25, Wound Rounds Completed: Left buttock: Length: 0.5 cm Width: 0.5 cm. Depth cannot be measured. No exudate. Stage 2. Tissue type: Epithelial tissue. Wound edges/margins: Well, defined wound edges. Skin surrounding wound: Erythema (redness) blanchable. On 01/07/2025, Physical Therapy entered notes stating: R52 was utilizing wheelchair ROHO cushion upside down and therapist placed ROHO in wheelchair the correct side up. On 01/10/25, Wound Rounds competed: Left buttock: Length: 0.4 cm Width: 0.4 cm. Depth cannot be measured. No exudate. Stage 2. Tissue type: Epithelial tissue. Skin surrounding wound: Pink/normal. Wound healing status: improving. On 01/17/25, Wound Rounds Completed: Left buttock Length: 0.4cm. Width: 0.4cm. Depth cannot be measured. No exudate. Stage 2. Tissue type: Epithelial Tissues. Wound edges/margins: well, defined wound edges. Skin surrounding wound: Pink/normal. Wound healing status: Stable. On 01/23/25, recorded as Late Entry on 01/27/2025, Wound Rounds Completed: Left buttock Length 1.5 cm. Width 0.5 cm. Depth cannot be measured. Exudate: none. Stage 2. Tissues Type: Epithelial Tissue. Wound edges/margins: irregular wound edges. Skin surround wound: pink/normal. Wound healing status: Declining. On 01/23/25, recorded as Late Entry on 01/27/2025, the facility progress notes state in part . Resident does utilize ROHO cushion. Resident observed to only have in wheelchair. Writer educated resident on importance of having ROHO in recliner chair also. Resident was in agreement to try ROHO in recliner.Resident is not always accepting of cares despite staff education and re-approach. Resident does choose to spend majority of time in wheelchair or recliner. Doesn't utilize bed. Of note, the facility was unable to provide supporting documentation of staff educating R52 of importance of accepting cares and repositioning and unable to provide supportive documentation that the physician was updated when PI was noted to be declining, no new interventions were considered, and no change in treatment was initiated. On 02/09/25, Wound Rounds Completed: Left buttock Length 0.6 cm. Width 0.6 cm. Depth cannot be measured. Exudate amount: light. Excaudate color and consistency: Bloody (bright red, thin). Stage 2. Tissue type: Epithelia Tissue. Skin surrounding wound: Pink/normal. Wound healing status: improving. Of note, no weekly wound assessment between 01/23/25 and 02/09/25 On 03/04/25, Wound Rounds Completed: Right Buttock (newly developed PI) Length: 1.0 cm. Width: 1.0 cm. Depth cannot be measured. Exudate amount: light. Exudate color and consistency: Bloody (bright red, thin). Stage 2. Tissue type: Epithelial tissue. Wound edges/margins: Irregular wound edges. Skin surrounding wound: Pink/normal. Wound healing status: stable. Of note, no weekly wound assessments completed between 02/09/25 and 03/04/25 of left buttock PI, wherein PI worsened and R52 developed a new stage II PI on right buttock. On 03/04/25 at 8:03 AM, Surveyor observed R52 sitting in wheelchair, where R52 remained until 11:45 AM and boarded transportation van for a 45-mile ride to dialysis appointment and not returning until approximately 4:30 P.M. On 03/04/25 at 1:16 PM, Surveyor interviewed Assistant Director of Nursing (ADON) J, who stated becoming aware of a new PI on 02/27/25 during a routine weekly skin assessment completed by nurses. ADON J stated the first wound round assessment was completed today. Of further note, ADON J, who is responsible for weekly wound rounds became aware of the new PI on 02/27/25. No new interventions were put into place upon finding new area, an assessment was not completed until 03/04/15, and the physician was not updated until 03/05/25 during routine rounds. On 03/04/25 at 2:29 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F, who stated R52 has a cushion that is placed on either recliner or wheelchair to sit and stated R52 often refuses on PM shift to get out of recliner and does not use the bed. On 03/04/25 at 2:29 PM, Surveyor interviewed CNA G, who stated R52 doesn't move much on AM shift, but will transfer to wheelchair for meals and then wants to go back into recliner, won't change before going to bed and rarely uses bathroom and is incontinent of urine. On 03/04/25 at 3:18 PM, Surveyor interviewed Regional Nurse H, who stated there was no risk vs benefits document presented to resident regarding offloading. if there would be anything it would be in progress or care plan notes. On 03/04/25 at 3:25 PM, Surveyor reviewed record which shows no documentation noted to support education of risk versus benefits of not repositioning and offloading was provided to R52. On 03/05/25 at 9:39 AM, Surveyor observed Registered Nurse (RN) C conduct wound care on R52. RN C pointed out stage II PI on left buttock and pointed out newly developed stage II PI on right buttock. RN C stated Physician Assistant was made aware of new area today. RN C conducted hand hygiene and placed on gloves, opened clean wound dressing packets and assisted R52 to stand. RN C moved incontinent product that was soiled with urine, away from area and removed old dressing. After cleansing of buttock area, RN C, without removing gloves and/or conducting hand hygiene, placed gloved palm hand on R52's buttocks and placed a clean dressing to PI. On 03/05/25 at 9:50 AM, Surveyor interviewed RN C regarding hand hygiene expectation during wound care. RN C realized RN C had not removed gloves or conducted hand hygiene during wound treatment. RN C stated the expectation would be to remove gloves and conduct hand hygiene after removing old dressings and after assisting with incontinence brief, prior to placing on clean wound treatment. On 3/05/25 at 9:55 AM, Surveyor interviewed Director of Nursing (DON) B regarding no weekly skin assessments completed between 01/27/25-02/09/24; and 02/09/25-03/04/25. DON B confirmed assessments were not completed during these time periods. On 03/05/25 at 10:10 AM, Surveyor interviewed DON B regarding R52's PI on Left buttock that had documentation to support worsening and new pressure injury noted on right buttock was unavoidable. DON B stated was not aware of new area and could not say if implementing the Roho cushion sooner would have made a difference. On 03/05/25 at 11:04 AM, Surveyor interviewed ADON J, asking for information on the start of the Roho cushion. Surveyor was provided an email sent on 01/02/25 (date of R52's admission) from facility staff requesting a Roho cushion. Surveyor was also provided Occupational Therapy (OT) notes dated 01/07/25 which indicates: R52 was utilizing wheelchair ROHO cushion upside down. ADON J was not able to provide documentation to support when ROHO cushion was put into place. On 03/05/25 at 11:10 AM, Surveyor asked ADON J if the worsening of left buttock pressure ulcer and new PI on right buttock were unavoidable. ADON J stated that due to R52's comorbidities, refusals of repositioning and declining to lay in bed does not believe PIs were unavoidable. On 03/05/25 at 12:45 PM, Surveyor interviewed ADON J, who stated the facility does not have any documentation to support repositioning program being completed, risk vs benefit of repositioning education provided to R52, or documentation to support the provider being notified of worsening left buttock PI or development of the new PI on 2/27/25. Example 2 R49 was admitted to facility on 02/12/25, with diagnoses that included pressure ulcer of unspecified site, Stage 2; diabetes, acute kidney failure with a BIMS of 15. R49's admission assessment indicates R49 was admitted with one stage 1 (coccyx) PI and one stage 2 PI (left buttock). On 02/12/25, Braden Scale completed with a score of 15 indicating At Risk with interventions of pressure reducing device for chair and bed, pressure ulcer/injury care, application of nonsurgical dressings, application of ointments/medication other than to feet. On 02/13/25 the facility conducted a weekly wound assessment of PI on left buttock: Length: 1.0 cm. Width: 1.0 cm. Depth: None. Exudate: None. Wound odor: No. Stage II. Undermining: No. Tissue type: Epithelial Tissue. On 02/26/25, the facility conducted a weekly wound assessment of PI on left buttock: Length 0.2 cm. Width: 0.2 cm. Depth. None. Exudate: None. Wound odor: No. Tissue type: closed/resurfaced. Of note there was no weekly wound assessment completed between 02/13/25 to 02/26/25 for the left buttock. On 02/13/25, Wound Rounds Completed of Stage 2 Coccyx: Length: 0.5 cm. Width: 0.5 cm. Depth: None. Exudate: None. Wound odor: No. Undermining: No. Tissue type: Epithelial Tissue On 02/27/25, weekly wound assessment of Stage 2 PI on coccyx: Length: 0.2cm. Width: 0.2cm. Exudate: None. Wound odor: No. Tissue Type: Closed/Resurfaced. Wound healing status: Improving. Of note there was no weekly wound assessment completed between 02/13/25 to 02/27/25 for the coccyx PI. On 03/05/25 at 10:16 AM, Surveyor interviewed DON B asking if there is documentation to support consistent weekly wound assessment being conducted of R49's PIs between 02/13/25 and 02/27/25. DON B stated there were no other wound assessments completed. On 03/05/25 at 10:16 AM, Surveyor interviewed DON B regarding expectation of hand hygiene during wound care. DON B stated expectation would be to remove gloves and conduct hand hygiene between going from dirty area to clean area. On 03/05/25 at 11:11 AM, Surveyor interviewed ADON J regarding interventions put into place for pressure injuries. ADON J stated an alternating air mattress was placed on R49's bed. Of note, R49's care plan was not updated until 02/20/25, when facility updated the care plan with a pressure relieving mattress to bed, eight days after R49 was admitted with two PIs. 39713 Example 3 R2's wound orders state, Aquacel AG (antimicrobial primary dressings for use for wounds) to area on buttocks, cover with foam dressing. On 3/04/25 at 2:15 PM, Surveyor observed wound care for R2's PI with RN E completing wound care on R2. RN E entered R2's room, washed hands and applied gloves. RN E cut two strips of Aquacel AG as part of R2's dressing orders. RN E then assisted R2 with standing and pulling down her pants. RN E then removed R2's soiled sacral dressing, placed the two strips of Aquacel AG onto the new sacral dressing and applied to R2's sacrum. RN E then removed her gloves and sanitized her hands, assisted R2 with pulling up her pants and sitting back in her chair. Of note: At no time during the dressing change did RN E remove her gloves or sanitize her hands. On 3/04/25 at 2:20 PM, Surveyor interviewed RN E. Surveyor asked RN E when should you wash your hands during wound care for a PI. RN E stated, before entering the room, after wound care and when leaving the room. Surveyor asked RN E if you should wash hands when going from dirty to clean. RN E stated, Dirty to clean? Surveyor explained dirty to clean and RN stated, Yes. On 3/04/25 at 3:01 PM, Surveyor interviewed DON B. Surveyor asked DON B when hand hygiene should be performed. DON B stated, before entering a room, with glove changes, when going from dirty to clean, and when leaving a room. Surveyor made DON B aware of observation made during wound care for R2's PI.

Based on observation, interview and record review, the facility did not ensure call lights were in reach for 2 of 15 sampled residents (R) (R18 and R2) and 2 of 2 supplemented residents (R9 and R29). R18, R2, and R9 were observed to not have their call lights within reach On 2/26/25, a grievance was filed regarding R29's call light not being within reach. Evidenced by: The facility's call lights - Call System Activation and Response Policy dated 2024, includes, in part, Purpose: The purpose of this procedure is to ensure timely responses to residents' requests and needs. Residents are provided with a means to call for staff assistance through a communication system that directly notifies a staff member or a centralized workstation. Procedure: 1. Each resident is provided with a means to call staff directly for assistance. The call system must be accessible to residents while in bed or other sleeping accommodations withing the resident's room. Example 1 R18 was admitted to the facility on [DATE]. R18's diagnoses include muscle weakness, abnormalities of gait and mobility and pain. R18's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 indicates R18 has moderate cognitive impairment, needs partial/moderate assistance for sit to stand and partial/moderate assistance for toilet transfer. R18's care plan problem: Resident needs assist with bed mobility, transfers, ambulation and locomotion due to weakness and poor endurance includes, in part, the following approach: Staff to ensure call light is in Resident's reach while in room and encourage to use it to make needs known. Start date: 9/6/24. On 3/3/25 at 9:53 AM, Surveyor observed R18 sitting in his recliner in his room. R18's call light was sitting on the bed. Surveyor asked R18 if he was able to reach the call light. R18 stated he could not reach his call light. R18 stated he needed to have the call light within reach so he could call for assistance. Example 2 R2 was admitted to the facility on [DATE]. R2's diagnoses include muscle weakness, osteoarthritis, and spinal stenosis. R2's most recent MDS with an ARD of 2/11/25 indicates R2 is cognitively intact and needs supervision with personal hygiene and taking off and putting on footwear. R2's care plan problem: Resident needs assist with dressing, personal hygiene, and bathing due to Left proximal femoral fracture, NWB (non-weight bearing) to LLE (left lower extremity), spinal stenosis, anxiety, osteoarthritis, morbid obesity, HTN (hypertension) and CHF (congestive heart failure). Resident chooses to sleep in recliner. Bed removed from room per resident request includes, in part, the following approach: Staff to ensure call light is in Resident's reach while in room and encourage her to use it to make her needs known. Start date: 10/17/23. On 3/5/25 at 8:34 AM, Surveyor observed R2's call light on the floor next to R2's recliner. R2 stated she needs the call light clipped to her recliner so she can call when she needs assistance. Example 3 R9 was admitted to the facility on [DATE]. R9's diagnoses include diabetes, chronic pain and weakness. R9's most recent MDS with an ARD of 2/20/25 indicates R9 has moderate cognitive impairment, needs partial/moderate assistance with personal hygiene and taking off and putting on footwear. R9's care plan problem: Resident needs assist with dressing, personal hygiene, and bathing due to weakness, sciatica, chronic pain syndrome, depression, ataxic gait and postherpetic nervous system includes, in part, the following approach: Staff to ensure call light is in Resident's reach while in room and encourage her to use it to make her needs known. Start date 3/30/24. On 3/5/25 at 11:07 AM, Surveyor observed R9 sitting in his recliner. R9's call light was on the bedside stand behind R9. On 3/5/25 at 11:09 AM, Surveyor and Licensed Practical Nurse (LPN) L entered R9's room. Surveyor asked LPN L if R9 should have his call light within reach. LPN L stated yes and moved R9's call light, clipping it onto R9's recliner. LPN L stated all resident call lights should be within reach. On 3/5/25 at 8:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G. Surveyor asked CNA G when a call light should be accessible to a resident. CNA G stated residents should always have a call light accessible. On 3/5/25 at 8:36 AM. Surveyor interviewed CNA K. Surveyor asked CNA K when a call light should be accessible to a resident. CNA K stated residents should always have a call light accessible. Example 4 The facility grievance log includes, in part, Date: 2/26/29, Resident: (R29), Concern: . R29's call light was out of reach one time . It is important to know there are no findings or actions related to this grievance on the grievance log. The facility customer concerns sheet includes, in part, the following: Concern Date: 2/26/25. Concern type: Call light issue. Describe concern: . R29's call light was out of reach one time . Staff person assigned to investigation: DON B (Director of Nursing). Findings: Resident/family not able to give date in which concern occurred. DON B attempted to interview resident on 3/5 at which time the resident had experienced a decline in condition and is not able to be interviewed . Actions: Call light response audits will be completed. Education regarding keeping resident's call light within reach at next nursing meeting scheduled for 3/12. On 3/5/25, Surveyor interviewed DON B. Surveyor asked DON B when a call light should be accessible to a resident. DON B stated residents should always have a call light accessible. Surveyor asked DON B if she had completed any audits or spot checks following R29's grievance that included R29's call light was not in reach. DON B stated no spot checks had been done and no staff had been educated.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 care observations (R209, R49 and R210). Staff did not perform hand hygiene before putting on gloves when passing medications for R210 and R49. R209's catheter bag was hanging from the garbage can and lying on the floor. Findings: Example 1 Facility policy titled, Hand Hygiene revised date of 9/2023, stated in part: Infection Prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the resident .Times to Perform Hand Hygiene are, but not limited to: * Before or after direct resident contact . * Before or after assisting a resident with personal cares . * Upon and after coming in contact with a resident's intact skin, such as when taking vitals or after assisting with lifting . * After removing gloves or aprons . On 03/04/25 at 7:39 AM, Surveyor observed Registered Nurse (RN) C administer medications to R210. R210 received a blood pressure medication that required vital signs to be taken first. Surveyor observed RN C take R210's vital signs and administer medications without performing hand hygiene after RN C took the portable vital sign monitor back to the medication cart and cleaned it with sanitization wipes. RN C did not perform hand hygiene after cleaning the monitor. RN C drew up insulin for R49, took the insulin to R49's room and put on single use gloves for the injection and no hand hygiene was performed. RN C completed administration of insulin, removed the gloves, and performed hand hygiene. Surveyor asked RN C if hand hygiene should have been performed after taking one resident's vital signs and before the administration of another resident's insulin and RN C replied, Yes. On 03/04/25 10:35 AM, Surveyor interviewed Director of Nursing (DON) B and informed DON B of the observation made during the medication administration. Surveyor asked DON B what the expectation is for hand hygiene with glove use. DON B replied the nurse should perform hand hygiene upon entering the room. Surveyor asked DON B what the expectation is with hand hygiene with resident cares such as passing medications. DON B stated hand hygiene is performed between each resident. Example 2 Facility policy titled, Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) last reviewed 8/30/2023, stated in part: Purpose: Though prevalence of indwelling urinary catheter use in the long-term care setting is lower than in the acute care setting, catheter-associated UTI (CAUTI) can lead to such complications as cystitis, pyelonephritis, bacteremia, and septic shock. These complications associated with CAUTI can result in a decline in resident function and mobility, acute care hospitalization s, and increased mortality. Prevention is key. On 03/04/25 7:21 AM, Surveyor observed R209's catheter bag hanging from garbage can and resting on the floor. On 03/04/25 7:35 AM, Surveyor pointed out to Certified Nursing Assistant (CNA) D the Foley bag resting on the floor and asked if this was acceptable and CNA D replied, No it is not, I will go fix that right away. On 03/04/25 10:35 AM, Surveyor interviewed DON B about the observation made of the catheter resting on the floor. Surveyor asked DON B what the expectation is for the Foley drainage bag placement. DON B stated the bag should not be on the floor.

Based on interview and record review, the facility failed to have a system in place to ensure the code status of residents (R), as indicated in the advance directives, is followed. This affected 1 of 1 resident reviewed (R1) whose Cardiopulmonary Resuscitation (CPR) wishes were not followed. R1's Physician Orders for Life Sustaining Treatment (POLST) indicated R1 wanted CPR. The facility failed to initiate CPR upon finding R1 with no respirations and pulseless. The facility's failure to follow the code status identified in the advance directives and failure to begin cardiopulmonary resuscitation created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on [DATE] at 1:55 p.m. The facility took steps on [DATE], immediately after the incident, to correct the deficient practice and to ensure compliance. The immediate jeopardy was removed on [DATE] and corrected on [DATE]. Based on this determination, the citation issued is past non-compliance. Findings include: The facility policy titled, Initiation of CPR/AED (Automatic Electric Defibrillator) and BLS (Basic Life Support) Associate Training Expectations, dated 2018, states in part: Procedure: Cardiopulmonary Resuscitation/Automatic Electronic Defibrillator (CPR/AED) will be initiated on a resident who is found unresponsive, except when: 1. A provider medical order states a code status of Do Not Resuscitate (DNR); 2. A resident Declination of CPR form is present: or there are signs of obvious, long-standing death of the resident present. In all cases, Emergency Response Service (EMS) will be activated, and CPR/AED will be initiated by a Basic Life Support (BLS) certified BHS associate when present at the scene. The facility's policy also states: Reasons to NOT Initiate CPR/AED upon finding someone pulseless, per CMS are: *A Provider medical order stating a code status of DNR. *A resident Declination of CPR Form is present. *Obvious signs of clinical death (e.g., rigor mortis, (chemical changes in the muscles after death, causing the limbs of the corpse to become stiff and difficult to move/manipulate), dependent lividity (purplish discoloration of the skin following death due to the settling of blood in the most dependent tissues), decapitation, transection, or decomposition are present. *Initiating CPR would cause injury or peril to the rescuer. R1 was admitted to the facility on [DATE] following hospitalization for pyogenic arthritis of the left knee joint and left knee arthrotomy. R1's additional diagnoses included end-stage renal disease, hypertension, and type 2 diabetes mellitus without complications. R1's medications included allopurinol 100mg by mouth daily, amlodipine 5mg by mouth daily, aspirin 81mg DR (delayed release) by mouth daily, bumetanide 5mg by mouth twice daily, metolazone 2.5mg by mouth as needed, reno caps 1mg by mouth daily, and sevelamer carbonate 1600mg by mouth three times a day. R1's Minimum Data Set (MDS) assessment, dated [DATE], indicated R1 required assistance of one staff with bathing, dressing, grooming, and hygiene. R1 required assist of one with a gait belt and a four-wheeled walker. R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating intact cognition. R1 had a Power of Attorney for Health Care (POA-HC), which was not activated. R1 was R1's own person. R1's advance directive, POLST, indicated R1 requested CPR and full treatment. A Physician Assistant (PA) note, dated [DATE], stated R1 was hospitalized from [DATE] through [DATE] with septic arthritis of the left knee. R1 had an Incision and Drainage (I and D) with insertion of an absorbable drug delivery device. During hospitalization , R1 had atrial fibrillation with rapid ventricular rate (RVR) and was back in sinus rhythm at discharge. R1 was on two weeks of apixaban for deep vein thrombosis (DVT) prophylaxis and discharged on a 7-day cardiac monitor. The monitor showed no atrial fibrillation or atrial flutter. R1 had physical therapy (PT) at the facility and was improving. R1 has been on hemodialysis since February of 2024 for end-stage renal disease with the amyloidosis light chain (AL) amyloidosis. The PA note stated vital signs were stable, with B/P ,d+[DATE], P 60, R20, T 96.8m, and O2 saturation at 96% room air. Labs from [DATE]: Sodium (Na) 133, Potassium (K+) 5.2, Creatinine 5.11 with a glomerular filtration rate (GFR) of 11, albumin 3.2, hemoglobin low but stable at 10.3, white count normal. PA did not make any changes to R1's care. R1's POLST form reads full code and full treatment. In March of 2024 during hospitalization , R1's POLST was completed. Upon further review, facility documentation was as follows regarding R1: On [DATE] at 4:45 a.m., R1 had transferred self to the bathroom. Certified Nursing Assistant (CNA) C made sure R1 was positioned on the toilet and gave R1 the call light. On [DATE] at 5:50 a.m., R1 was seen by the charge nurse, Registered Nurse (RN) E, kneeling on the floor, with R1's upper torso on the bed. R1's skin was grayish. R1 had no respirations or pulse. RN E last saw R1 at 2:30 a.m. RN E called for help. CNA C and RN D went into R1's room. RN E checked R1's POLST at 5:53 a.m. and confirmed R1 was a full code. RN E called 911. CNA C and RN D positioned R1's body on the floor and awaited instructions from RN E as to what to do. RN E told them to wait till RN E received direction from EMS. On [DATE] at 6:00 a.m., EMS/Police arrived at the facility. EMS started CPR. At 6:26 a.m., an update was given by EMS personnel to facility staff that resuscitation efforts were unsuccessful. On [DATE] at 6:30 a.m., the facility notified the on-call provider, and R1's death was pronounced. The facility notified the medical examiner, who came to the facility before releasing the body to the funeral home. The medical examiner verbalized no concerns, pending the final coroner report. R1's physician note dated [DATE] stated, overall, R1's clinical status had appeared to stabilize over the recent weeks, though R1 remained medically complex with amyloidosis light chain (AL) amyloidosis with renal involvement/end-stage renal disease (ESRD), smoldering myeloma, recent septic arthritis, hypertension, type 2 diabetes, mellitus, peripheral arterial disease, and history of atrial fibrillation. There did not appear to be any apparent modifiable factors or prodromal symptoms in the time leading up to R1's arrest. On [DATE] at 10:54 a.m., Surveyor interviewed CNA C via telephone and asked CNA C to walk through the event involving R1 on [DATE]. CNA C stated R1 self-transferred self to the bathroom at 4:45 a.m. CNA C stated that CNA C assisted R1 in making sure R1 sat on the toilet safely, gave R1 the call light, and told R1 to ring when finished in the bathroom. CNA C stated CNA C was busy with other residents and heard RN E yell for help. This was about 5:45 a.m. CNA C stated R1 was on both knees at the side of the bed, with R1's torso on the bed. At first, RN E and CNA C thought R1 fell but, upon assessment, R1's skin was gray. RN E went to call 911 and check R1's code status. CNA C stated that CNA C got RN D to help, and they placed R1 flat on the floor. CNA C stated that CNA C then left the room because call lights were going off, and RN D was in the room with R1. CNA C stated when CNA C left the room, it was a short time, sirens were heard, and EMS was arriving at the facility. CNA C stated it was probably a minute or two, and the ambulance was at the facility. According to EMS records, the ambulance service was dispatched [DATE] at 5:54 a.m. In route to facility at 5:57 a.m. At facility at 5:59 a.m. Initial CPR at 5:59:43 a.m. Resuscitation discontinued at 6:27 a.m. On [DATE] at 11:06 a.m., Surveyor interviewed RN D via telephone and asked RN D to walk through the events of [DATE] involving R1. RN D stated that RN D was working in the ,d+[DATE] hall and that R1 was not one of the residents in those halls. CNA C came to the nurse's station and told RN E that R1 was on the floor. RN D stated RN E went down to R1's room with CNA C. CNA C came back to the nurse's station and stated that RN E needed help. RN D stated RN D went down to R1's room, and R1 was kneeling next to the bed, arms next to R1's sides, and R1's torso was on the bed. RN D stated R1's arms and feet were purple/gray and was clearly deceased . R1 had no pulse and no respirations. RN E went to check R1's code status and call 911. RN E told RN D and CNA C to wait to see what EMS wanted them to do. RN D stated RN D and CNA C positioned R1 on the floor. No rigor mortis had set in, but R1's arms and feet were purplish. RN D stated R1 was obviously dead. RN D stated they did not undress him. EMS arrived then and initiated CPR but were unsuccessful. Surveyor asked why RN D did not initiate CPR. RN D stated, per policy, that if rigor or skin is purplish/gray, CPR should not be started. It should be noted that if a person knelt at the side of a bed, with their arms at their sides, and only the upper body from the waist up being on the bed---the arms, knees, and feet would be reddish, purplish from lack of proper circulation. According to RN D, RN D did not undress R1 and only saw his arms and feet. On [DATE] at 1:45 p.m., Surveyor interviewed NHA A and DON B and asked about the [DATE] incident involving R1 and R1's CPR status. NHA A stated the staff should have acted quicker for more efficiency and it was an issue of delegation of duties. Surveyor asked why the staff did not perform CPR when RN E verified R1 was a full code. DON B stated the length of time RN E was on the phone with EMS delayed action and duties weren't delegated quickly before EMS arrived at the facility. Facility staff delayed initiating CPR at least 7 minutes from determining R1 was full code at 5:53 PM until EMS arrived at 6 PM. Seconds and minutes count in an emergency situation. Brain death can occur within ,d+[DATE] minutes of the brain being deprived of oxygen. Further, the chance for a successful outcome decreases 7% with each minute that CPR is delayed. The website http://www.AED.com notes that there is a 5 minute survival window for a victim of sudden cardiac arrest with the survival depending upon early CPR and having access to an AED within that 5 minute timeframe .The Chain of Survival steps must all occur within 5 minutes: 1. Early Access to get help: Call 911 2. Early CPR to buy time: Begin CPR Compressions Immediately 3. Early Defibrillation to restart heart: Use AED as soon as possible on victim 4. Early ACLS to stabilize: Ambulance arrival time The facility's failure to follow the code status identified in the advance directives and begin cardiopulmonary resuscitation created serious harm, thus leading to a finding of immediate jeopardy that began on [DATE]. On [DATE], the facility identified the deficient practice that occurred when the facility staff did not perform CPR when R1 was found without respirations and a pulse. The facility took steps to correct the deficient practice and ensure compliance on [DATE]. The immediate jeopardy was removed on [DATE], and corrected on [DATE] when the facility completed the following: The facility completed crash cart audits, including nightly checks and weekly verification by DON B. The facility completed code status and POLST/POST audits for all facility residents. The facility reviewed/audited advance directives/care plans for all facility residents. The facility audited all in-house licensed staff on their CPR certifications. The facility provided all in-house licensed staff education, including RN D and RN E on the following: Facility CPR policy Nurse response and initiation of CPR for residents with a full-code status EMS activation POLST/POST and code status location/verification Crash cart location Delegation of duties CPR situational review The facility provided all staff (except licensed staff) with education on roles and responsibilities during a CODE. On [DATE], Surveyor reviewed the following: Audits for resident's code status Audit for staff's CPR certification Corrective action documents for RN D and RN E Quality Council agenda for discussion on self-report involving R1. Mock code competency audits were conducted on [DATE] through [DATE] on various shifts. Crash cart audits start on [DATE] through the date of the survey on [DATE] and will continue beyond. Documentation of the completion of education for RN D and RN E following R1's incident. Education for all staff. Based on this determination, the citation is issued as past non-compliance.

Based upon interview, policy review and record review, the facility did not ensure allegations of abuse and neglect were thoroughly investigated or prevent further potential abuse from occurring while the investigation was in progress for 1 of 1 (R270) resident reviewed. R270 alleged CNA N put her fingers up R270's rectum. R270 experienced recurring fear and anxiety, expressed by feeling tense, nervous and fearful of CNA N when CNA N came to her room after this incident. This is evidenced by: The facility's policy and procedure for Abuse Prevention, last reviewed 07/21/22, includes, in part: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This will be done by: * All allegations of abuse will be thoroughly investigated by the Director of Social Services, Director of Nursing. Measures will be taken to identify the source of the alleged abuse and prevent future incidents. * Identify and interview all who might know about the incident including the alleged victim, perpetrator, witnesses, or others who may have had related contact with the alleged perpetrator, related to the incident in question. * The focus of the investigation is to determine the extent, cause, and future prevention with thorough documentation of the investigative process completed and to protect the resident during the investigation. * Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property. * Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property, mistreatment, and making the necessary changes to prevent future occurrences . Such safety measures should include A. Responding immediately to protect the resident from further abuse. B. Examining the alleged victim for any signs of injury. E. Separating the suspected perpetrator and resident pending the outcome of the investigation, which may include placing an employee on administrative leave. F. Providing alternate caregiver to the resident as appropriate. R270 was admitted to the facility on [DATE] with the following diagnoses: central cord syndrome and posterior cervical fusion from C2-T2. The Minimum Data set (MDS) dated [DATE] indicates R270 has a Brief Interview for Mental Status (BIMS) of 13 which indicates cognitively intact. On 01/08/24 at 2:45 PM, Surveyor interviewed R270 regarding staffing and general care at the facility. R270 indicated that she had a concern about an incident that happened when admitted to the facility. R270 stated that she requested to use the bed pan to try and achieve a bowel movement. Certified Nursing Assistant (CNA) N and a nurse refused the bedpan to R270. CNA N rolled R270 over aggressively and said to R270, Here I will take care of it. R270 indicated that CNA N stuck CNA N's fingers inside R270's rectum and cleaned R270 out. R270 screamed, Stop it and get your fingers out of my butt! R270 indicated that CNA N pulled CNA N's fingers out of R270's butt and then did it again after R270 repeatedly said stop. R270 indicated R270 reported the incident to Physical Therapy (PT) I on 01/05/24. R270 stated R270 did not want CNA N to take care of R270 as R270 feared CNA N. R270 indicated that currently CNA N is still coming into R270's room and providing care. R270 indicated when R270 hears CNA N's voice in the hallway R270 gets nervous and tense. On 01/08/24 at 3:55 PM, Surveyor interviewed PT I and asked about the incident with R270. PT I indicated that R270 reported the incident to PT I and a Certified Occupational Therapist Assistant (COTA) P when they were working with R270 for physical therapy on 01/05/24. PT I indicated that PT I and COTA P immediately reported this to Director of Nursing (DON) B who stated DON B would investigate this. PT progress notes on 01/05/24 state in part: When PT I and COTA P were completing their exercise with R270, R270 stated, I'm seriously thinking of going to another nursing home because of falling out of bed twice and my experiences here, There's a Nigerian nurse or CNA that has been very rude to me and I don't want her helping me anymore. R270 states a female CNA who was white with glasses stuck her finger up my butt and swirled around telling me she was going to get the poop out. I felt violated. Progress note indicates PT I and COTA P went to Occupational Therapy Supervisor J. COTA P and OTS J went to Assistant Director of Nursing (ADON) V and management right away to report the allegation. Facility investigation notes on 01/05/24 at 11:00 AM, state in part: Concern: R270 was upset with the aide, from Nigeria, R270 reports she is rude to her. Findings: R270 states the aide, from Nigeria, is rude to her. CNA N is an aide from Nigeria working at the facility. Actions: Director of Nursing (DON) B and Assistant Director of Nursing (ADON) V interviewed R270. R270 denied abuse but stated that R270 doesn't care to work with CNA N anymore as a personal preference. R270 was satisfied with the outcome that CNA N will not work with R270 anymore. It was discussed that if R270's call light is on, CNA N may answer it to ensure R270 is safe and sound then will get another CNA or nurse to assist R270. CNA N was talked to about not assisting R270 with care but rather to answer her light if no one else is around to ensure safety and then get another staff member. CNA N was not removed from the schedule to protect R270 and other residents after the allegation of abuse. R270 experienced a fall on 1/5/24, at approximately 4:00 a.m. Fall investigation note on 01/05/24 at 1:00 PM, states in part: Concern: R270 reports that when R270 fell , R270 was incontinent, and it felt like they were digging it out when they were wiping me. Findings: R270 had a fall from bed early in the morning on 01/05/24, R270 reports R270 was dreaming, not quite awake and R270 tried to get out of bed. R270 had been incontinent of stool at the time of the fall. The CNA and nurse assisting the resident post-fall assisted the resident with incontinent care and then positioned R270 comfortably in bed. Staff report that bowel movement (BM) was caked on and within R270's crevices, needing additional wiping to fully cleanse R270's peri-area. Actions: Interview information was relayed to R270 who was satisfied with the response. R270 stated in the future R270 would like for staff to explain what they are doing at the time of the task. DON B talked with staff about the importance of discussing what you are doing with a resident before completing tasks. DON B discussed with R270 that if R270 has questions about what staff are doing that it is ok to ask them. And it is ok to ask for someone else to assist if she has concerns with that employee. The facility did not interview the staff involved in the fall incident to determine if neglect or abuse had occurred when R270 alleged staff had dug BM out of her. On 01/05/24 at 2:08 PM, a progress note with documentation by RN K stated in part R270 c/o staff from the previous shift Sticking fingers in my butt, I would consider that assault. I believe before I had a bowel movement. RN K explained to the resident that staff would never do anything to assault her in any way and she may have gotten something (suppository) for her bowels. DON B updated and discussed with R270. On 01/08/24, Bisacodyl suppository was ordered twice a day as needed for constipation. The first dose of a suppository was documented as given on 01/09/24 at 5:37 AM. The incident reported on 01/05/24 could not have been administering of a suppository. On 01/09/24 at 1:12 PM, Surveyors interviewed DON B, Nursing Home Administration (NHA) A, and ADON V and asked what had occurred with the incident and how the process went for the facility's investigation. DON B indicated that Friday 01/05/24, Registered Nurse (RN) K notified DON B of the incident. DON B indicated R270 was interviewed and only stated the Nigerian CNA was rude to R270. DON B indicated R270 denied any abuse from CNA N. This was not documented in the investigation. On 01/09/24 at 2:56 PM, Surveyor interviewed DON B about the Physical Therapy (PT) progress note. DON B indicated that the report from Occupational Therapy (OT) J on Friday 01/05/24 was vague, and OT J was very upset. DON B indicated OT J did say that R270 reported that CNA N's fingers were in R270's butt. DON B indicated that DON B went right down to R270's room to see if R270 was abused, but there was concern of the uncertain time frame when the incident could have occurred. DON B did not consider it an allegation of abuse. On 01/10/24 at 10:58 AM, Surveyor interviewed CNA M via phone regarding R270's fall on 01/05/24 around 4:00 AM. CNA M came into the room and found R270 on the floor wedged between the window wall/heater and bed. CNA M called for help with which RN O entered. CNA M stated that both placed sling under her and lifted her into bed safely. CNA M stated that R270 stated R270 had BM in her pants by accident. CNA M indicated that she was the one who cleaned R270 up. R270 had medium-large BM and doesn't remember if it was caked on or not but R270 kept having a BM while trying to clean R270 up. On 01/11/24 at 6:45 AM, Surveyor interviewed RN O and asked to describe events from the fall R270 had on 01/05/24 around 4:00 AM. RN O indicated that CNA M yelled for his assistance and to come into the room and found R270 on the floor wedged between the window wall/heater and bed. RN O helped CNA M get R270 off the floor with Hoyer sling and lifted in bed safely. RN O indicated that R270 was not in any distress and R270 did have a BM once R270 was in bed. The facility did not have a thorough investigation including all staff involved with R270's cares and fall event on 01/05/24. Interviews were not completed with CNA N who was the alleged perpetrator. The facility did not complete interviews with CNA M or RN O, who were witnesses to the fall and the incontinent episode during the fall. There were no interviews completed with other residents to determine if others were being abused.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 63 residents. The facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. The facility staff did not use appropriate Personal Protective Equipment (PPE) when entering COVID-positive isolation rooms on contact/droplet precautions residents (R) (R272, R49, and R41); and did not ensure shared medical equipment is properly sanitized. Staff did not keep clean linens stored in the linen rooms on all halls free from contamination of possible infections. Improper hand hygiene was observed during medication administration for R30 and R47. Findings include: The facility policy entitled, Water Management program for building water systems site management plan for [NAME] manor and villa prepared by Nalco water Ecolab company, dated 2018, indicates in 1.1- Facility team members not identified. 2.2 see process flow diagram in 2.2.1, 2.5.3.1 Water distribution: inspection and maintenance states eliminate dead-ends and flush stagnant areas as necessary. Perform system maintenance as necessary and address known issues. In section 4.1.1 systems requiring monitoring and verification plan. Ice machine checks- food services, nursing stations, and patient care areas, Recirculated bathing tubs used in select patient care areas . The facility policy entitled, COVID-19 overview and symptoms, dated [DATE], indicates, Healthcare providers caring for residents with suspected and confirmed COVID-19 should use full PPE (gowns, gloves, eye protection, and a NIOSH- approved N95 or equivalent or higher-level respirator) . Example 1 The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system in the policy and in a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread that pertained to the individual facility. - Identify where control measures should be applied. - Include a process to confirm the WMP was being implemented and was effective. - Document and communicate all the activities. - Include a water management team that reviews processes to the individual facility. Surveyor noted the flow diagram did not specify any distinguished locations or areas where Legionella could grow, spread, or any measures to control the possible spread. The WMP policy did not entail any monitoring risk measures, water sampling frequencies, or any documentation about measures to avoid Legionella infections. Surveyor noted the facility's WMP did not document specific names, contact information, or assignments of the individuals on the team, and the plan did not contain all the control points or measures taken to reduce Legionella. The WMP did not address dead legs throughout the facility. On [DATE] at 8:45 AM, Surveyor interviewed Director of Nursing (DON) B and asked process for preventing Legionella growth. DON B indicated that her part is to flush unoccupied rooms. DON B stated the flushing started on [DATE] and is kind of sporadic. DON B indicated that the system in place is when residents are expired or discharged DON B flushes rooms. DON B indicated the rest of preventing Legionella is the maintenance department's duty. On [DATE] at 8:55 AM, Surveyor interviewed Maintenance Manager S and asked process for preventing Legionella growth in the facility. Maintenance Manager S indicated that Eco lab comes in annually to check systems flush appropriately and check levels. Maintenance Manager S indicated that we have a flow diagram, but it is not individualized to specific locations where the water systems go. Maintenance Manager S indicated that the WMP is for facility Manor and Villa. Maintenance Manager S indicated that the flow diagram does not identify hot spots and stagnation areas. Example 2 On [DATE] at 12:10 PM, Surveyor observed Certified Nursing Assistant (CNA) T enter R272's room on COVID-19 isolation precautions with a surgical mask on her face. Surveyor did not observe CNA T wearing any other PPE of gown, gloves, N95, and eye protection. CNA T exited R272's room and left the surgical mask on. Surveyor did not observe CNA T perform any hand hygiene. On [DATE] at 7:44 AM Surveyor observed Licensed Practical Nurse (LPN) F don a surgical mask, then place an N95 mask over the surgical mask. LPN F applied gloves and gown. Surveyor observed LPN F wheel the vital machine and then walked into R272's room with it. LPN F came out with the vital machine and doffed all PPE except the surgical mask. LPN F left the same surgical mask on. LPN F wiped down the vital machine briefly. On [DATE] at 7:54 AM, Surveyor interviewed LPN F and asked about the process for masking in an isolation room. LPN F indicated that her process is to double mask for extra protection. LPN F indicated that the facility stated it is ok to double mask. On [DATE] at 7:57 AM, Surveyor interviewed ADON V and asked about the process for masking in isolation rooms. ADON V indicated the facility is not to be double masking, but only using N95s. ADON V indicated that after each use of an N95 the masks are to be thrown away. On [DATE] at 8:03 AM, Surveyor observed LPN F, after briefly wiping down the vital machine, take vital machine from R272's room on isolation for COVID-19 into R30's room to perform vitals. On [DATE] at 1:30 PM, Surveyor interviewed DON B and asked what the expectation is for PPE usage in COVID isolation rooms. DON B indicated that it is expected that all PPE, N95, goggles, gloves, and gowns, are to be worn into the isolation room and staff is to take all items off before exiting the resident's room. On [DATE] at 7:44 AM, Surveyor interviewed DON B and asked about expectations for vital machines in isolation rooms. DON B indicated that it is recommended and best practice that each isolated precaution resident have a designated vital machine. DON B indicated that manual blood pressure cuffs, stethoscopes, pulse oximeters, and thermometers are available for individual residents and located in the nurse's chart room or in the nursing management office. Example 3 On [DATE] at 11:50 AM, Surveyor observed LPN F come out of R49's room, which was a COVID positive room. LPN F had doffed their gown and gloves in the room. While in the hallway LPN F had 2 surgical masks on; LPN F took off one surgical mask and discarded it. Surveyor observed LPN F not wearing an N95 or eye protection while in R49's COVID positive room. On [DATE] at 7:08 AM, Surveyor observed CNA G go into R41's COVID positive room wearing goggles, surgical mask, gown and gloves. The sign on the door says isolation, STOP you MUST be in FULL PPE to enter this room. Outside of R41's door was a bin that contained the required PPE. Surveyor observed CNA G not wearing an N95 when in R41's COVID positive room. On [DATE] at 7:28 AM, Surveyor observed R49, who was COVID positive, come out of their room wearing a surgical mask on their chin and not covering their nose and mouth, R49 walked down the hall to another resident's room who was not COVID positive and visited with the other resident. Example 4 On [DATE] at 7:27 AM, Surveyor observed Laundry Assistant (LA) U deliver clean linens to the linen room in hall 300. Surveyor observed a black jacket hanging by a hook inside the linen room in hall 300 over Hoyer slings. Surveyor interviewed LA U and asked whose black jacket it belonged to. LA U indicated it is one of the aide's jackets and is not supposed to be stored in the clean linen room. LA U indicated there is an employee room down near 200 Hall where all employees are supposed to store their stuff. On [DATE] at 7:39 AM, Surveyor observed a clean linen closet on Hall 200 and a green jacket hanging over clean slings in the linen closet. On [DATE] at 7:40 AM, Surveyor observed a clean linen closet in Hall 100 with a camouflage jacket hanging over clean slings in the linen closet. On [DATE] at 7:43 AM, Surveyor interviewed CNA T in hall 300 and asked about the black coat located in the clean linen room. CNA T indicated that the employees are supposed to keep jackets in the break room, not in the clean linen room. On [DATE] at 3:40 PM, Surveyor interviewed DON B and Nursing Home Administrator (NHA) A and asked about clean linen closets in halls. DON B indicated the expectation is for employees to use the break room for personal items, not the clean linen closets. Example 5 On [DATE] at 11:41 AM, Surveyor observed Registered Nurse (RN) R enter R30's room. RN R wiped R30's abdomen with an alcohol pad, injected the insulin pen, and exited R30's room. RN R placed the pen back in the medication cart. Surveyor did not observe RN R perform any hand hygiene. On [DATE] at 11:47 AM, Surveyor observed RN R entering R47's room after prepping medications without hand hygiene. RN R administered medications to R47. RN R exited R47's room and went to the medication cart. Surveyor did not observe RN R perform hand hygiene. On [DATE] at 11:55 AM, Surveyor interviewed RN R and asked what the process is for hand hygiene in between medication administration from resident to resident. RN R indicated RN R should have performed hand hygiene and she did not. On [DATE] at 2:45 PM, Surveyor interviewed DON B and asked about hand hygiene expectations when administering medications. DON B indicated hand hygiene is performed between all resident cares. 43352

Based on observation, record review and interview, the facility did not ensure all drugs and biologicals were securely stored for 5 of 5 residents (R) (R56, R25, R41, R30, and R9) and did not ensure controlled drugs were stored in separately locked, permanently affixed compartments. The facility did not ensure drugs and biologicals were labeled with an expiration date in accordance with currently accepted professional principles for 1 of 1 resident (R) (R272). Findings include: Surveyor requested and reviewed the facility policy titled Hazardous waste pharmaceuticals/Disposal dated 2020. The policy in part reads: Products to be disposed of in the DEA receptacle include pills, tablets, capsules, ointment creams, lotions, powders, liquid medications, expired drugs, and all partial medications regardless of expiration status. It is suggested to keep all expired or no longer-in-use medications in a secure location, i.e., code-protected drop-down bin receptacle, until disposal. These receptacles are transported off-site by the vendor according to EPA guidelines . Example 1 On 01/10/24 at 9:00 AM, Surveyor observed discharged R56's medications in the medication room, on a 3 drawer bin. The medications were from 11/20/23: Bisoprolol Fumarate 10 milligrams (mg), Spironolactone 50 mg, Aspirin 81 mg, hydralazine 50 mg tablets and Duloxetine 30 mg packs lying on the counter in a bin. Surveyor observed discharged R25's medications from 11/16/23: Xarelto 20 mg tablets, and mirtazapine 7.5 mg tablets lying on the counter in a bin. Surveyor observed R41's medication Levothyroxine 75 mg tablets with an expiration date of 12/10/23 on the counter in a bin. Surveyor observed R30's medication sevelamer 80 mg tablets in a pack of four with an expiration date of 12/08/23 on the counter in a bin. Surveyor observed R9's medications Nortriptyline 10 mg capsules in a two pack with expiration dates of 12/05/23. Surveyor did not observe the bin locked or secured in the medication room. On 01/10/24 at 9:03 AM, Surveyor interviewed Director of Nursing (DON) B and asked about the destruction of medication and the process. DON B indicated that the facility uses a Med safe destroyer receptacle and is transported off-site by a vendor. DON B indicated DON B had notified the vendor that medications needed to be picked up. DON B indicated until the medications were removed the facility used an unlocked bin from the pharmacy to store unused or expired medications in the medication room. On 01/10/24 at 8:48 AM, Surveyor observed the medication room. Liquid Ativan was stored on the top shelf on the inside of the refrigerator door. Surveyor observed the Ativan medication to not be double locked. On 01/10/24 at 8:50 AM, Surveyor interviewed Registered Nurse (RN) Q and asked about the process for storing liquid Ativan in the medication room. RN Q indicated that RN Q is unsure how it is stored or handled. RN Q indicated RN Q would have to ask DON B. On 01/10/24 at 9:05 AM, Surveyor interviewed DON B about expectations for Ativan storage in the refrigerator in the medication room. DON B stated that the liquid Ativan in the fridge is supposed to be double-locked, but it is not. DON B indicated that she talked to the pharmacy about this, and it has not been fixed. Example 2 According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure the effectiveness of the medication. Surveyor reviewed policy Administering medications, last revised on 08/31/23, stated in part, .check expiration dates before administering medications . Surveyor reviewed the insulin expiration grid sheet located in the medication room titled, Insulin storage and dispensing info, last revised in 2021, stated in part, .Humalog (Lispro) U-200 pen expiration when opened, stored at room temp up to 86 F is 28 days . On 01/10/24 at 11:50 AM, Surveyor observed Registered Nurse (RN) R administer 18 units of insulin Lispro pen to R272. Surveyor observed the Lispro pen did not have an open date on the label. Surveyor interviewed RN R who indicated R272 uses the pen so fast that we don't worry with the expiration label on the Lispro pen. On 01/10/24 at 1:26 PM, Surveyor interviewed Director of Nursing (DON) B and asked about expectations of insulin pen administration and expiration dates. DON B indicated that once the insulin pen is opened the open date should be placed on the pen and discarded within 28 days of the open date. DON B indicated nurses follow the insulin expiration grid sheet located in the medication room and on medication carts.

Based on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs. Behavioral monitoring was not completed as outlined in the comprehensive care plan to determine effectiveness of the medication for 4 of 5 residents (R) reviewed. (R29, R46, R30, and R47) Findings include: Example 1 R29 was admitted on [DATE] and has diagnoses that include, dementia, adjustment disorder with mixed anxiety and depression, and type 2 diabetes. R29's Minimum Data Set (MDS), indicated that R29 has a Brief Interview for Mental Status (BIMS) of 07 which indicates that R29 is severely impaired. R29's care plan, with an approach start date of 07/21/23 reads in part monitor behavior every shift and document. On 01/10/24 at 2:25 PM, Surveyor interviewed Certified Nursing Assistant (CNA) E and asked where CNA's complete behavior monitoring would be located. CNA E indicated there was a binder at the nurse's station. Surveyor asked to see behavior monitoring for the month of January. Surveyor reviewed January behavior monitoring for R29 and nothing has been documented. CNA E indicated Director of Nursing (DON) B is working hard at trying to get people to do it. On 01/11/24, Surveyor interviewed Clinical Manager (CM) C asking for R29's behavior monitoring for January. CM C gave Surveyor a copy from the binder that was at the nurse's station and indicated that's all they have. Surveyor reviewed CNA flowsheet and there is nothing documented for the month of January for R29. Surveyor asked if this is where the CNAs would document behaviors. CM C indicated yes for each shift. Surveyor asked CM C since there is no documentation on the CNA flowsheet if that means it was not completed. CM C indicated yes. R29 had the following medications prescribed to them, quetiapine started on 07/10/23 and duloxetine started on 09/11/23. Both prescriptions are psychotropic drugs that affects brain activities associated with mental processes and behavior. Without behavior monitoring the facility is not able to determine if the medications are effective. 47807 Example 2 R46 was admitted on [DATE] and has diagnoses that include major depressive disorder, anxiety disorder, and post-traumatic stress disorder. R46's MDS indicated that R46 has a BIMS of 15, which suggests that R46 is cognitively intact. Record review identified R46 had the following psychotropic medication orders: Mirtazapine (antianxiety medication) 7.5mg at bedtime; start date was 01/08/24 Hydroxyzine HCL (antianxiety medication) 10mg every 8 hours PRN for the duration of 6 months; start date was 12/11/23 and end date is 04/09/2024. R46's Orders, with a start date of 10/05/23 reads in part TARGET BEHAVIOR MONITORING: Depressive disorder: negative statements. Flat affect. Isolates self in room. Fatigue. Hopelessness. Appetite changes. Excessive Sleeping. Three Times A Day Non-pharmacological interventions . Indicate Frequency of behavior. Indicate the number that corresponds with the non-pharmacological intervention. Indicate effectiveness (E=Effective, N = Non-Effective). On 01/11/24 at 8:30 AM, Surveyor reviewed R46's Treatment Administration Record (TAR), which indicated that between 01/01/24 and 01/10/24, R46's targeted behavior monitoring had only been completed 5 times out of 30 opportunities. R46's recorded behaviors had only been completed during the evening shift. The facility did not ensure behaviors were monitored to determine effectiveness of the psychotropic medications. 48793 Example 3 R30 was admitted on [DATE] and has diagnoses that include, anxiety disorder, major depressive disorder, and COPD. R30's MDS indicated that R30 has a BIMS of 15 which indicates that R30 is cognitively intact. Resident Mood Interview (PHQ-9) score of 3 indicates minimal depression. R30's care plan, with an approach start date of 11/27/23, reads in part monitor for target behaviors daily. Physician orders reviewed and indicated R30 had the following medications prescribed to them, duloxetine started on 11/27/23 and bupropion started on 11/28/23. Both prescriptions are psychotropic drugs that affect brain activities associated with mental processes and behavior. On 01/10/24 at 1:27 PM, Surveyor interviewed Registered Nurse (RN) R and asked where the RN's behavior monitoring for R30 would be charted or located. RN R indicated there was a binder at the nurse's station that CNAs and RNs review and update every shift. Surveyor asked to see behavior monitoring for the month of January. Surveyor reviewed January behavior monitoring for R30 and nothing has been documented. On 01/11/24 at 3:14 PM, Surveyor interviewed DON B asking for R30's behavior monitoring for January. DON B gave Surveyor a copy from the binder that was at the nurse's station and indicated that's all they have. Surveyor reviewed the flowsheet and there is nothing documented for the month of January for R30. DON B indicated behavior monitoring should be done for each shift. Without behavior monitoring the facility is not able to determine if the medications are effective for the diagnosis of major depressive disorder. Example 4 R47 was admitted on [DATE] and has diagnoses that include unspecified dementia, depression, and anxiety disorder. R47's MDS, indicated that R47 has a BIMS of 12 which indicates that R47 is cognitively intact, Resident Mood Interview (PHQ-9) score of 2 indicates minimal depression. R47's care plan, with an approach start date of 09/29/23, reads in part target behavior monitoring every shift. R47 had the following medications prescribed to them, memantine and fluoxetine. R47's prescriptions are a psychotropic drug that affects brain activities associated with mental processes and behavior. On 01/10/24 at 1:27 PM, Surveyor interviewed RN R and asked where the RN's behavior monitoring for R47 would be charted or located. RN R indicated there was a binder at the nurse's station that CNAs and RNs review and update every shift. Surveyor asked to see behavior monitoring for the month of January. Surveyor reviewed January behavior monitoring for R47 and nothing has been documented. On 01/11/24 at 3:14 PM, Surveyor interviewed DON B asking for R47's behavior monitoring for January. DON B gave Surveyor a copy from the binder that was at the nurse's station and indicated that's all they have. Surveyor reviewed the flowsheet and there is nothing documented for the month of January for R47. DON B indicated behavior monitoring should be done for each shift. Without behavior monitoring the facility is not able to determine if the medications are effective.

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials for 1 of 1 resident reviewed for abuse. (Resident (R) 270) Findings include: The facility's policy and procedure for Abuse Prevention, last reviewed 07/21/22, includes, in part: This will be done by: * Report within the timeliness of the guidance, if the event that caused the suspicion involves abuse or results in serious bodily injury, the individual is required to report the suspicion to the state immediately, but no later than 2 hours after forming the suspicion . R270 was admitted to the facility on [DATE] with the following diagnoses: central cord syndrome and posterior cervical fusion from C2-T2. The Minimum Data set (MDS) dated [DATE] indicates R270 has a Brief Interview for Mental Status (BIMS) of 13 which indicates cognitively intact. On 01/08/24 at 2:45 PM, Surveyor interviewed R270 regarding staffing and general care at the facility. R270 indicated that she had a concern about an incident that happened when admitted to the facility. R270 explained that when she was admitted about two weeks ago R270 became constipated, and the facility had given her oral stool softeners and laxatives. R270 indicated that this still could not produce a bowel movement. R270 stated that she requested to use the bed pan to try and achieve a bowel movement. R270 indicated that Certified Nursing Assistant (CNA) N rolled R270 over aggressively and said to R270, Here I will take care of it. R270 indicated that CNA N stuck CNA N's fingers inside R270's rectum and cleaned R270 out. R270 screamed, Stop it and get your fingers out of my butt! R270 indicated that CNA N pulled CNA N's fingers out of R270's butt and then did it again after R270 repeatedly said stop. R270 indicated R270 reported the incident to Physical Therapy (PT) I on 01/05/24. On 01/08/24 at 3:55 PM, Surveyor interviewed PT I and asked about the incident with R270. PT I indicated that R270 reported the incident to PT I and a Certified Occupational Therapist Assistant (COTA) P when they were working with R270 for physical therapy on 01/05/24. PT I indicated that PT I and COTA P immediately reported this to Director of Nursing (DON) B who stated DON B would investigate this. PT progress notes on 01/05/24 state in part: When PT I and COTA P were completing their exercise with R270, R270 stated, I'm seriously thinking of going to another nursing home because of falling out of bed twice and my experiences here, There's a Nigerian nurse or CNA that has been very rude to me and I don't want her helping me anymore. R270 states a female CNA who was white with glasses stuck her finger up my butt and swirled around telling me she was going to get the poop out. I felt violated. Progress note indicates PT I and COTA P went to Occupational Therapy Supervisor J. COTA P and OTS J went to Assistant Director of Nursing (ADON) V and management right away to report the allegation. On 01/09/24 at 1:12 PM, Surveyors interviewed Director of Nursing (DON) B, Nursing Home Administrator (NHA) A, and ADON V and asked what had occurred with the incident. DON B indicated that Friday 01/05/24 Registered Nurse (RN) K notified DON B of the incident. DON B indicated R270 was interviewed and only stated the Nigerian CNA was rude to R270. DON B indicated R270 denied any abuse from CNA N. This was not documented. DON B indicated that she is correlating the fall with the incident of incontinent bowel movement (BM) and the incident of fingers in the butt. R270 had a fall, early morning on 1/5/24; at this time R270 was incontinent of bowel. The CNA had to repeatedly wipe R270 to clean BM. DON B determined that there was no entry of fingers in the butt, but that there was some hard-to-clean BM and that could have been interpreted as rough. On 01/09/24 at 2:56 PM, Surveyor interviewed DON B about the PT progress note. DON B indicated that today was the first time anyone had seen the progress notes from COTA P on 01/05/24. DON B indicated that the report from OT J on Friday 01/05/24 was vague, and OT J was very upset. DON B indicated OT J did say that R270 reported that CNA N's fingers were in R270's butt on 1/5/24. DON B indicated that DON B went down to R270's room to see if R270 was abused. DON B had concern of the uncertain time frame when the incident could have occurred, so didn't consider it as abuse to report. DON B acknowledged when OT J reported on 01/05/24 that CNA N's fingers were in R270's butt, DON B did not report the allegation of abuse.

Based on interview and record review, the facility did not refer a resident with serious mental disorders for a Level II Preadmission Screen and Resident Review (PASRR), after the resident's stay was extended past 30 days; this occurred for 1 of 1 resident (R46). Findings Include: R46 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, anxiety disorder, and post-traumatic stress disorder. R46 has a Brief Interview for Mental Status (BIMS) score of 15, which means they are cognitively intact. On 01/09/24 at 7:23 AM, record review of R46's current PASRR one indicated that no level two was required due to the exemption of being in the facility for 30 days or less. R46 has been a resident since 4/25/23 and is currently a resident in the facility. On 01/11/24 at 8:09 AM, Surveyor interviewed Social Services (SS) H regarding the lack of a PASRR level two for R46. SS H said that when R46 entered the facility, they did not expect R46 to stay longer than 30 days, as indicated on the PASRR level one. SS H said they would look and see if the file was around but not uploaded to R46's profile in their electronic medical record. On 01/11/24 at 12:04 PM, Surveyor interviewed SS H. SS H said they did not complete a PASRR level two for R46; it was missed. SSH indicated if a resident was expected to stay longer than 30 days and their PASRR level one indicated they needed a PASRR level two, SS H would expect that it be completed.

Based on interview and record review, the facility did not ensure that residents are free of significant medication errors for 6 of 8 residents (R1, R9, R11, R12, R13, and R10) reviewed for medication errors. R1's medication error resulted in actual harm. R1's prophylactic antibiotic was discontinued when a nurse entered new orders for Spirolactone on 7/13/23. Per interview and record review it is unclear why the nurse discontinued the antibiotic. R1 was then hospitalized on [DATE] for spontaneous bacterial peritonitis (SBP; a serious infection of the fluid that fills the abdomen) due to not receiving her prescribed prophylactic antibiotic resulting in significant medication error. R9's dosing of Lorazepam was decreased from 0.5 mg to 0.25 mg. Pharmacy sent a card of the 0.5 mg Lorazepam and staff continued to give that dose without noting the dose difference. R11's Gabapentin was transcribed with an end date of 8/20/23 and should have been open ended with no stop date. The discrepancy was noted and fixed on 8/22/23. R12's Tramadol was transcribed incorrectly by facility staff to be given three times a day (TID) rather than what was prescribed as TID as needed (PRN). R13's international normalized ratio (INR; a blood test that indicates how well the blood is able to clot) was drawn with other labs. The facility did not receive the lab results for R13, and she missed a dose of her anticoagulant. R10 reported concerns with receiving her scheduled insulin an hour after eating her lunch meal. This is evidenced by: The facility policy titled, Medication Administration, dated 2020, states in part . Policy: To administer resident medications in a safe and accurate manner that will ensure the 6 rights of patient identification for administration. Procedures: 2. Medications are administered in accordance with the orders. 3. Medications are administered within their prescribed time. 4. The person preparing or administering the medication will contact the provider if there are questions or concerns regarding medication. 5. With any irregularities, appropriate notifications will be completed for clarification. 10. 6 Rights of medication administration. a. Right Resident. b. Right Medication. c. Right Dose. d. Right Time. e. Right Route. f. Right Documentation. 15. If medication error is noted refer to Medication Error policy. The facility policy titled, Medication Error/Occurrence, dated 2021, states in part . Policy: When an error is made in the preparation or administration of a drug or biological, the licensed nurse provides any necessary immediate care and notified the attending provider and resident or resident representative when nursing or medical intervention, observation or treatment is indicated. Medication errors are tracked and trended for quality improvement process. Procedure: 1. When an error is made the preparation or administration of a medication, or a medication error is discovered the licensed nurse is notified. 3. If a medication error requires nursing or medical intervention, observation, or treatment: a. The provider is notified. If new orders are given, implement as ordered. b. The resident/resident representative is notified of the medication occurrence, and any new order. 6. Documentation includes the date, time of the error or discovery of error, the resident's condition, including vital signs, notification of provider, medical orders, and notification of the resident/resident representative. 7. Action is taken to prevent the medication error from reoccurring. Definitions: Medication Error is the preparation or administration of drugs or biologicals which is not in accordance with the attending providers' orders, manufacturer's specifications or accepted standards and principles of the professional providing the service. Examples of medication errors include: Omissions Wrong Dose Wrong Time According to Humalog.com Inject Humalog or Insulin Lispro Injection, under your skin within 15 minutes before or right after you eat a meal. Example 1 R1 was admitted to the facility on [DATE] following a hospitalization . R1 has the following diagnoses, in part . hepatic encephalopathy, sepsis without septic shock, spontaneous bacterial peritonitis (SBP), alcoholic cirrhosis of the liver with ascites, opioid disorder, major depressive disorder, chronic obstructive pulmonary disease (COPD), and chronic pain with methadone use. Nurses Note dated, 7/21/23 at 9:22 AM state, Resident reports not feeling well. Upon writer's assessment, resident appears lethargic, tachy (tachycardic increased heart rate) at 137 and very warm to the touch. Remains orientated. Afebrile. BP (blood pressure) 109/76. Writer notified PA-C (Physician Assistant - Certified) ordered stat (immediate) lab panel and will further eval (evaluate) from there. Hospital Physician's Orders dated, 7/5/23 states in part . Start taking these medications: Sulfamethoxazole-trimethoprim 800-160 mg (milligram) tablet. Indications: SBP prophylaxis. Commonly known as: Bactrim DS. Take 1 tablet by mouth daily. For: SBP prophylaxis. Start Taking on: 7/06/23. R1's Medication Administration Record (MAR) states in part . Sulfamethoxazole-trimethoprim tablet; 800-160 mg; Amount to Administer: 1 table; oral. AM (morning) Med Pass 7:00-10:30. Of note: MAR shows Bactrim started on 7/6/23 with last dose given on 7/12/23. MAR also indicates that the medication was Not Administered: Refused on 7/11/23 and then discontinued on 7/13/23. Nurses Note dated, 7/21/23 at 12:40 PM state, Resident called writer back to room as she was experiencing increased BLE (bilateral lower extremity) edema. Writer unwrapped BLE dressing/ace wraps. BLE were minimally pink. Very large fluid filled blister to anterior RLE (right lower extremity). HR (heart rate) now 147s (high). Remains very warm to the touch. BP slightly decreasing to 90s/40s. Febrile 101.2 F (Fahrenheit). Writer paged PA-C again. Orders to send to ER (emergency room ) promptly for eval. Facility document titled, Investigative Summary, states in part . At 1447 PM (2:47 PM) - Facility was contacted by PA-C who was reviewing R1's MAR due to the hospitalization . It was noted that when she came back from the last hospitalization , she was started on Bactrim DS as a prophylaxis. MAR indicates that last dose was given on 7/13/23. Hospital Notes dated, 7/22/23 at 1310 (1:10 PM), states in part . History of Present Illness: Recently the patient was admitted here 6/28-7/5 for severe sepsis with acidosis and encephalopathy 2/2 (secondary to) SBP ppx (prophylaxis). Per review of SNF (skilled nursing facility) records, she has not taken the Bactrim since 7/12/23 although other notes in the EMR (electronic medical record) state 7/14/23 was the last day she received it. It is unclear why it was discontinued. Assessment and Plan: R1 has complex past medical history including cirrhosis 2/2 alcohol use disorder and NASH (nonalcoholic steatohepatitis) c/b (complicated by) HE (hepatic encephalopathy), prior SBP, cerebellar ataxia, various vitamin deficiencies as well as obesity s/p (status post) gastric bypass, hx (history) of tobacco use, chronic pain on methadone, GERD (gastroesophageal reflux disease), PTSD (post-traumatic stress disorder), anxiety, depression, OSA (obstructive sleep apnea) and COPD who presents from SNF with new fever, nausea and vomiting admitted ,d+[DATE] with severe sepsis with lactic acidosis 2/2 SBP. Blood Culture report from 7/21/23 shows Enterobacterales and Klebsiella were detected. Sensitivity indicates Klebsiella sensitive to TMP/Sulfa (sulfamethoxazole-trimethoprim). R1's hospital discharge summary dated 7/28/23, states in part . Principal Diagnosis: Severe sepsis secondary to SBP with lactic acidosis and hypotension, present on admission. Start taking these medications: Ciprofloxacin 500 mg tablet. Indications: SBP ppx. Commonly known as: Cipro. Take I tablet (500 mg) by mouth daily for: SBP ppx. R1's orders from 7/31/23 were to discontinue Ciprofloxacin and start Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg; 1 tablet daily in the morning for SBP prophylaxis. Of Note: R1 has been back on Bactrim DS since 7/31/23 and has had no further hospitalization s related to SBP. Assessment and Plan: R1 was admitted ,d+[DATE] for severe sepsis with lactic acidosis 2/2 SBP. R1 had episodes of hypotension initially and was treated with IV albumin x2 (times 2). Paracentesis with (interventional radiology) 7/21 which showed PMNs (Polymorphonuclear neutrophils) 1550, essentially diagnostic for SBP. Peritoneal fluid cultures no growth. Blood cultures positive for Klebsiella (gram negative bacteria). No other infectious sources including skin wounds, urinary, or respiratory origin. On 7/21/23 the facility completed education on order verification. All nursing staff completed the education but did not include the health unit coordinator (HUC) who also enters orders. Of note: The facility has had a total of 12 medication errors since 7/21/23. On 10/9/23 and 10/10/23 the facility started education on order entry/order verification/5 rights. Education was not completed with all nursing staff and the HUC prior to survey on 10/24/23 and 10/25/23. Medication error report completed by Director of Nursing (DON) who is no longer with the facility. The nurse that completed the error was terminated prior to the discovery of the error and the nurse that verified the discontinuation of R1's Bactrim was an agency nurse whose contract has ended. On 10/24/23, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator). Surveyor asked DON B and NHA A if they could tell Surveyor about R1's medication error. NHA A stated that at the time of discovery of the medication error the nurse was no longer working for the facility and would not return any calls placed to her. NHA A indicates that the facility contacted the pharmacy to inquire about the antibiotic. The pharmacy returned a call to the facility indicating that the medication had been found returned to the pharmacy by the facility. NHA A also indicated that the facility reached out to the nurse that verified the discontinuation of the antibiotic. This nurse was an agency nurse whose contract had ended but did return the facility's call indicating she did not remember discontinuing R1's antibiotic and could not provide any further information. On 10/25/23, Surveyor interviewed MD C (Medical Doctor). Surveyor asked MD C if the discontinuation of R1's antibiotic directly correlated with her hospitalization on [DATE]. MD C stated, I would say this discontinuation did correlate with R1's hospitalization for SBP. R1 has not been hospitalized for SBP since that hospitalization and she continues on the same antibiotic. The following examples are cited at a potential for harm/pattern. Example 2 R11 was admitted to the facility on [DATE]. R11 has the following diagnoses, in part . Type 2 diabetes mellitus, vascular dementia, pressure ulcer of unspecified site, anxiety disorder, and excoriation (skin-picking) disorder. The facility noted on 8/22/23 that R11's gabapentin was discontinued on 8/20/23. The facility did not have orders to discontinue to medication. The facility completed a medication error report but did not complete any education with the nurses that discontinued the medication. Example 3 R9 was admitted to the facility on [DATE]. R9 has the following diagnoses, in part . bipolar disorder, obsessive-compulsive disorder, anxiety disorder, tremor, syncope and collapse. On 8/6/23 order change was made for Lorazepam 0.5 mg to be decreased to 0.25 mg. Pharmacy sent the wrong card of medication and facility staff continued to give R9 the 0.5 mg dose of Lorazepam until 9/5/23. Medication error was identified but the facility did not complete any education to nursing staff or to the nurses that administered the incorrect dose, violating the 5 rights of medication administration. Example 4 R12 was admitted to the facility on [DATE]. R12's has the following diagnoses in part . fracture of the sacrum, subsequent encounter with routine healing, noninfective gastroenteritis and colitis, Type 2 diabetes mellitus with diabetic neuropathy, and chronic pain. The notes on 8/22/23 indicate a transcription error. Tramadol was scheduled for 3 times a day and the order were for Tramadol three times a day PRN. The facility completed a medication error report but did not complete any education with the staff that transcribed and verified the orders. Example 5 R13 was admitted to the facility on [DATE]. R13's diagnoses include, in part . Stable burst fracture of T11-T12 vertebra, subsequent encounter for fracture with routine healing, chronic kidney disease stage 3, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, congestive heart failure, venous insufficiency, long term use of anticoagulants, history of pulmonary embolism, and chronic atrial fibrillation. The facility noted on 10/17/23 that R13 had missed a dose of Coumadin on 10/16/23. Staff indicate they had not been sent the INR results and failed to check in with floor nurse regarding the INR. On call provider updated on missed dose and ordered for Coumadin 6 mg on Tuesday and Wednesday night and to recheck INR on 10/19. Re-education provided to staff. Audit completed on all INR's having orders and all correct and up to date. Teachable Moment completed with nurse who committed error. There is no evidence all nurses were educated. Example 6 R10 was admitted to the facility on [DATE]. R10 has the following diagnoses in part . congestive heart failure (CHF), chronic kidney disease (CKD) stage 3, and diabetes mellitus without complications. On 10/19/23, R10 reported concerns about receiving her scheduled insulin an hour after eating her lunch meal. The facility completed a medication error report and completed a Teachable Moment form with the identified nurse. The Teachable Moment resolution states, Resident likes insulin before she eats and making sure aware of when resident eats as Humalog should be given 15 minutes prior to eating or immediately after eating. Education provided to nurse on insulin administration. Nurse is aware. Working on prioritizing the hall with med pass. No ill effects noted. Notification to provider resulted in no new orders. On 10/25/23 at 12:25 PM, DON B (Director of Nursing) requested to speak with Surveyor. NHA A (Nursing Home Administrator) and DON B indicate that DON B found the medication error reports that had not been completed by the previous DON in the back of the filing cabinet. On 10/25/23 at 2:20 PM, Surveyor interviewed NHA A and DON B. Surveyor asked NHA A and DON B if education should be done with staff when errors are noted. DON B stated, yes. Surveyor asked if a pattern was noted in review of the medication errors. DON B stated, there was no patterns noted between shifts or nurses. Surveyor asked NHA A and DON B if they had noted the number of medication errors within the facility since 7/21/23. NHA A stated, yes there have been a lot. Surveyor asked NHA A and DON B if they had reviewed their process for transcribing medication error. NHA A stated, we noted some errors with the HUC (health unit coordinator) and have done some extra education with her. We do continue to review our process but as of this time the process has not changed. This week were going to complete more education but then you showed up. Surveyor asked NHA A and DON B if they were able to note the amount of medication errors if they had started re-education to all staff on transcribing orders or updated their process for order verification. NHA A stated, we are looking at having someone review orders that are changed or discontinued but have not as of this time. We will also be starting education to all staff on these areas. The facility failed to ensure that residents were free of significant medication errors. R1 had a significant medication error that required hospitalization . The facility completed staff education related to the error but continued to have several medication errors which did not result in education or correction of the errors. The facility was noted to have a total of 12 medication errors since 7/21/23.

Based on interview and record review, the facility did not ensure that residents are free of significant medication errors for 1 of 4 residents (R1) reviewed for medication errors. R1 was given R4's medications, including antihypertensive medications, which significantly dropped R1's blood pressure. R1 required evaluation in the emergency room (ER) and was transferred to intensive care unit (ICU) for care and monitoring. This is evidenced by: The facility policy titled, Medication Administration-General Guidelines, dated February, 2015, states in part . Policy: Mediations are administered as prescribed in accordance with good nursing principles and practices and only by persona legally authorized to do so. Personnel authorized to administer medication do so only after they have been properly orientated to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures: 4) FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check #1: Select the Medication - label, container and contents are check for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the AMR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. B. Administration. 7) Residents are identified before medication is administered using [two] methods of identification. Methods of identification include: a. Checking photograph attached to medical record. b. Calling resident by name (except in residents with cognitive impairment). c. Having the resident verify his/her last name. d. If necessary, verifying resident identification with other facility personnel. Per the National Heart, Lung, and Blood Institute, For most adults, a healthy blood pressure is usually less than 120/80 mm Hg. Low blood pressure is blood pressure that is lower than 90/60 mm Hg. If blood pressure drops too low, the body's vital organs do not get enough oxygen and nutrients. When this happens, low blood pressure can lead to shock, which requires immediate medical attention. R1 has the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 should have received the following morning medications on 12/1/21: Acetaminophen 1000 mg (milligrams) for pain, [MEDICATION(S)]-vitamin D3 600mg - 400 unit for vitamin D deficiency, [MEDICATION(S)] 1000 mcg (micrograms) for vitamin B deficiency, [MEDICATION(S)] propion-salmeterol blister with device; 250-50 mcg/dose 1 puff for [CONDITION(S)], [MEDICATION(S)] 18 mcg 1 puff for [CONDITION(S)], and omeprazole 20mg for GERD (gastro-[CONDITION(S)] reflux disease). R4 has the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had the following medications ordered, that R1 in turn received: Tylenol 650 mg for pain, [MEDICATION(S)] 10 mg for major depressive disorder, [MEDICATION(S)] 80mg for [CONDITION(S)], [MEDICATION(S)] 50 mcg (2000 unit) for nutritional [CONDITION(S)], [MEDICATION(S)] 1000 mcg, [MEDICATION(S)] 300 mg for polyneuropathy, [MEDICATION(S)] 20 mg for major depressive disorder, losartan 50 mg for hypertensive crisis, [MEDICATION(S)] 100 mg for hypertensive crisis, [MEDICATION(S)] 17 grams for constipation, omeprazole 20 mg for GERD, Senna-S 8.5-50 mg for constipation, [MEDICATION(S)] 4 mg for urge incontinence, and Vitron-C 65 mg iron - 125 mg for nutritional [CONDITION(S)]. Nurse's Note for R1, dated 12/01/21 at 14:24 PM (2:24 PM), documents the following; 9:26 AM this nurse entered resident's room and called a name that was not resident's name. Resident was exiting the bathroom with therapy and resident identified herself as that incorrect name and accepted the medications. Shortly thereafter this nurse noticed the error. PAC (Physician Assistant - Certified) was notified. A list of medication were identified and orders received to observe vitals q (every) 30 min (minutes). Facility ADON (Assistant Director of Nursing) and DON (Director of Nursing) notified. Resident notified and explained order for vital signs. Resident's BP (blood pressure) systolic running around 80 without (sic) symptoms. Resident stated she felt just like she always did except she is being bothered every 30 min. Afternoon CNA (Certified Nursing Assistant) notified this nurse of low BP, this nurse and PAC went in to check on resident's BP. Systolic was did not (sic) get above 60 rang (range). Per PAC and resident's consent, resident was sent to ER (emergency room ) around 1330 (1:30 PM). Nurse's Note for R1, dated 12/1/21 at 20:36 (8:36 PM), states the following: ED (Emergency Department) called facility with update. BP continues to be low, asymptomatic, will admit overnight for observation. R1's vital sign record has the following documentation: 12/01/21 at 10:44 AM, Blood Pressure 81/54 and Pulse 90 12/01/21 at 11:32 AM, Blood Pressure 80/38 and Pulse 81 12/01/21 at 12:04 PM, Blood Pressure 94/54 and Pulse 68 Note: PAC orders were to check BP every 30 minutes. There are three recorded blood pressure readings from the time of the error (9:26 AM) until R1 was transferred to the ED at approximately 1:30 PM. Note: For the two days prior to the medication error R1's blood pressure readings were . 11/29/21 at 4:55 PM, Blood Pressure 169/74 11/30/21 at 10:37 AM, Blood Pressure 115/77 PAC note from 12/1/21 documents the following: Updated on NH (Nursing Home) rounds that R1 received another patient's medications this morning in error. This included: [MEDICATION(S)] ([MEDICATION(S)]) 20 mg [MEDICATION(S)] 300 mg Losartan 50 mg [MEDICATION(S)] 100 mg [MEDICATION(S)] 10 mg [MEDICATION(S)] 80 mg [MEDICATION(S)] 4 mg Plan: Staff will monitor full vitals q 30 minutes x (times) 8 hrs. (hours) and encourage fluids, with biggest concern being potential [CONDITION(S)]. PAC note from 12/1/21 documents the following: Updated again by facility that patient's BP is now in the 50's/30's, with recheck of 66/42 (baseline BP upper 90s-low 100s systolic). Patient received incorrect medications this morning, including several that could cause [CONDITION(S)] (see my prior telephone note for exact meds (medications) given). Patient appears lethargic and states she doesn't feel well. POST indicates full code. Patient needs to be transported to the TEC (Trauma and Emergency Care) urgently for closer monitoring than can be provided in the nursing home. She is in agreement. R1's paperwork from emergency room documents in part .Encounter Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . History of Present Illness: R1 presents from her nursing home after inadvertent administration of another patient's medications. Per the nursing home report this patient typically has systolic blood pressures in the 80s to 90s. Following administration of these medications once they realized there are air (sic) they monitored her blood pressure at the nursing home. She has been persistently in the high 60s and low 70s all day. She remained asymptomatic with this and has been mentating normally. By this afternoon when her [CONDITION(S)] persisted they opted to send her to the emergency department. Vital Signs: BP: 73/49, Pulse: 62, Heart Rate (monitor): 60, Resp (respiratory rate): 16, O2 Sat: 85%, Device (Oxygen Therapy: room air, Flow (L/min): 2. R1's Critical Care admission paperwork documents in part . [CONDITION(S)] after in at were (sic) turned administration of multiple blood pressure medications that she is not on at the rehab facility. Persistent [CONDITION(S)] despite administration of 1 L (liter) of fluid. Because of her overall condition, some confusion, she requires close ICU (intensive care unit) care for monitoring. Discussed with poison control and no antidote is required for now. Continue monitoring blood glucose. Replace magnesium. Initiate the patient on DVT ([CONDITION(S)]) prophylaxis with [MEDICATION(S)] as she is subtherapeutic on [MEDICATION(S)]. Blood pressure rechecks ranged from 60s to 70s systolic over 40s diastolic. Magnesium was low at 1.5, and she was given magnesium sulfate in the ED. SpO2 was in the high 80s to low 90s so she was started on 2L O2. She was given a 500 cc bolus of NS (normal saline) which did not improve her blood pressure, but it was stable and she continued to by asymptomatic. Patient vital signed for the past 4 hours: 12/01/21 at 1810 (6:10 PM), BP 67/44, Heart Rate (monitor) 65, Respirations 18, SpO2 100% 12/01/21 at 1820 (6:20 PM), BP 66/44, Heart Rate (monitor) 64, Respirations 22, SpO2 99% 12/01/21 at 1830 (6:30 PM), BP 64/43, Heart Rate (monitor) 65, Respirations 21, SpO2 100% 12/01/21 at 1840 (6:40 PM), BP 63/46, Heart Rate (monitor) 66, Respirations 30, SpO2 96% 12/01/21 at 1850 (6:50 PM), BP 63/42, Heart Rate (monitor) 67, Respirations 17, SpO2 97% 12/01/21 at 1900 (7:00 PM), BP 63/42, Heart Rate (monitor) 66, Respirations -, SpO2 97% 12/01/21 at 1915 (7:15 PM), BP 66/45, Heart Rate (monitor) 66, Respirations -, SpO2 94% 12/01/21 at 1930 (7:30 PM), BP 73/47, Heart Rate (monitor) 65, Respirations 23, SpO2 93% 12/01/21 at 1950 (7:50 PM), BP 71/45, Heart Rate (monitor) 67, Respirations -, SpO2 95% 12/01/21 at 2000 (8:00 PM), BP 69/49, Heart Rate (monitor) 69, Respirations -, SpO2 94% 12/01/21 at 2030 (8:30 PM), BP 74/50, Heart Rate (monitor) 69, Respirations 20, SpO2 97% On 12/28/21 at 9:25 AM, Surveyor reviewed COTA D's (Certified Occupational Therapy Assistant) witness statement dated 12/3/21 at 11:00 AM. Statement states, I was working with R1 for therapy in her room. RN C (Registered Nurse) entered the room for her medication administration. The RN made a statement and called R1 by the name R4. I said, You mean R1? RN C looked confused, but maybe she didn't hear me or understand. R1 and RN C spoke about the medications a bit - I specifically remember them talking about [MEDICATION(S)] and her bowels. Note: The Nurse was corrected by COTA D about R1's name and questioned about medications being given to R1. The Nurse did not stop and verify she had the correct medications and the right patient before continuing to administer medications. On 12/28/21 at 10:17 AM, Surveyor interviewed RN C. Surveyor asked RN C if she could describe what happened on 12/1/21 with R1. RN C stated, Basically we do a check at the cart. I went down the medication list. I then did my first and second checks before leaving the medication cart. I went into R1's room and called her by another name. Therapist and husband were in the room and never corrected me. R1 and I talked about pain and the other medications. I left the room and went to go on to the next person and noted the picture in the eMAR (electronic medication administration record) was for the person that I just gave medications too. The person that got the wrong medications had a picture in the eMAR but not the person whose medications she received. I think at one point the therapist walked out, but husband was there and never corrected me. I immediately notified the ADON and PAC, who was in house. The PAC and I reviewed the eMAR and talked with the resident. The first couple of hours were okay and when we noted the change R1 was sent out right away. Surveyor asked RN C if she had recently received any education. RN C stated, We reviewed the 5 Rights of medication administration and the photos in the eMAR were updated. On 12/28/21 at 10:32 AM, Surveyor interviewed COTA D. Surveyor asked COTA D if she could describe what happened on 12/1/21 with R1. COTA D stated, The nurse came in and she called the resident by R4's name R1 looked at me and I said to RN C you mean R1's Name RN C set the pills on the tray table with liquid with a spoon in it. R1 asked RN C about the liquid and RN C explained it was to help go to the bathroom and left. R1 got the cup of pills and stated, this looks like a lot of pills put them in her mouth and took them. We were just finishing our session so I was not there long after that. Surveyor asked COTA D if RN C worked this hall prior to this event. COTA D stated, prior to that happening she had worked the hall on different occasions. The husband was also in the room but he never spoke much prior to this. On 12/1/21 at 10:56 AM, Surveyor interviewed PAC E. Surveyor asked PAC E about incident with R1 on 12/1/21. PAC E stated, I was in the building all day on 12/1/21. I was concerned from the start due to R1 having a history of low blood pressure readings even off antihypertensives. Her baseline was 90s to 100s systolic. She was drinking but oral fluids were not sufficient. R1 was asymptomatic with low readings. It wasn't until resident became lethargic and symptomatic that she was sent out around 1:30 PM. These were unfortunate circumstances but I feel they did the best that they could. On 12/1/21 at 11:04 AM, Surveyor interviewed DON B and ADON F. Surveyor asked DON B and ADON F about incident with R1's medications on 12/1/21. DON B stated, I wasn't here but they reported it to ADON F. PAC E was here and gave orders to monitor blood pressure every 30 minutes. ADON F went over the medication error right away with RN C. ADON F called me back later about R1 still having low blood pressures so the decision was made to send her out. Education facility provided is entitled Medication Administration Policy, Medication Error/Occurrences, and 5 Rights, which does not discuss verifying residents by looking at resident pictures or double checking information especially in light if someone corrects a resident name or comments on the medications being administered. The facility also completed a photo audit for the eMAR, updating pictures and adding those not populated. On 12/1/21 at 11:10 AM, Surveyor reviewed education provided to RN's (Registered Nurse), LPN's (Licensed Practical Nurse), GN's (Graduate Nurse), and Med Techs (Medication Technicians). The facility has 27 RN's, LPN's and Med Tech's but only 17 of those received the education. The following staff worked multiple shifts without having received the education on Medication Administration and 5 Rights. LPN G worked on: 12/14, 12/15, 12/16, 12/17, 12/18, 12/19, 12/21, 12/22, 12/23, 12/24 and 12/28. RN H worked on: 12/21 and 12/23 Med Tech I worked on: 12/27 LPN J worked on: 12/15, 12/16, 12/20, 12/21, 12/22, 12/24, 12/25, 12/26 and 12/27. LPN K worked on: 12/14, 12/16, 12/20, 12/23, 12/25, 12/26, 12/27 and 12/28. GN L worked on: 12/23, 12/24, 12/25, 12/26 and 12/28. R1 received R4's medications, which included multiple medications to lower the blood pressure. R1 did not have hypertension thus this medication drastically lowered R1's blood pressure which could be a life threatening situation. R1 was transferred to the hospital and received 500 cc bolus of normal saline, magnesium, [MEDICATION(S)], and O2. R1 also required extensive monitoring in the ICU and was not discharged until 12/3/21.

Based on record review and interviews, the facility did not ensure the necessary care and services to attain or maintain the highest practicable physical and mental well-being of the resident by not performing a timely physical assessment including a pain assessment for 1 of 1 residents. This resulted in a delay of identifying a tibia/fibula fracture to the left leg of the resident which caused increased pain experienced by the resident throughout the night and during cares when the leg was moved. This is evidenced by: The facility's policy titled Pain Assessment and Management, dated March 2015, states under General Guidelines #5, Conduct a comprehensive pain assessment .and when there is onset of new pain or worsening of existing pain. Under Steps in the Procedure Recognizing Pain 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain a. Verbal expression such as groaning, crying and screaming; d. Behavior such as resisting care,. f. Guarding, rubbing or favoring a particular part of the body; Possible Physiological Signs of Pain a. Increased blood pressure; b. [MEDICAL CONDITION] c. Increased respirations; d. diaphoresis. Assessing Pain d. Factors that precipitate or exacerbate pain. On 05/19/16, Surveyor reviewed Resident #1's medical record and identified Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) indicates that Resident #1 is not able to complete the Brief Interview of Mental Status (BIMS). Staff was interviewed and indicated Resident #1 has short and long term memory deficits. Resident #1 has targeted behaviors for [MEDICAL CONDITION], dated 10/28/15, which include crying, weeping and delusional disorder, dated 11/09/15. The targeted behavior for calling out in pain is not included in the Certified Nursing Assistant Flow sheet as a targeted behavior. A quarterly Pain Management Assessment, dated 03/09/16, by Registered Nurse (RN) K included the following observation details; Pain: received scheduled pain med regimen, Yes, APAP (Tylenol) BID. Pain Management: Received scheduled pain meds or offered and declined, No. Pain Management: Received non-medication intervention, No. Should Pain Assessment Interview be Conducted?, Yes. Have you had pain or hurting at any time in the last 5 days? No. Over the past 5 days, has pain made it hard for you to sleep at night? No. Over the past 5 days, have you limited your day-to-day activities because of pain? No. Under interventions: Indicate measures taken to alleviate pain, None of the above. Outcome of pharmacological measures used, No [MEDICATION NAME] necessary. Outcome of non-pharmacological measures noted, No interventions necessary. Indicate what referrals are appropriate, No referrals necessary. Indicate plan of care action taken, Continue current plan of care. Plan summary: Resident denies any c/o pain. Scheduled APAP BID is effective for pain relief. PRN APAP available with no use during the last 5 days. Surveyor reviewed Certified Nursing Assistant (CNA) A's facility interview, dated 04/29/16 at 1:46 p.m. The statement identified that on 04/28/16 at approximately 7:00 p.m., Resident #1 was toileted, cares were provided and then was assisted back into the Broda chair by CNA A. CNA A was asked if Resident #1 was in pain at any time and CNA A stated, No. Resident #1's Medication Administration Record [REDACTED]. Licensed Practical Nurse (LPN) F administered Resident #1's medications, which included Tylenol ES 1000mg. Surveyor reviewed the facility's interview of CNA B, dated 04/29/16 at 2:35 p.m. The statement indicated that on 04/28/16 at approximately 9:30 p.m., CNA B transferred Resident #1 to bed while CNA C was getting a warm blanket for Resident #1. CNA B continued to transfer Resident #1 from the broda chair to the bed using a bear hug transfer. CNA B admitted to not using a gait belt and documented that, When Resident #1 was seated on the edge of the bed she touched her leg and said ouch. She was saying that it was twisted, but she was lying down in bed, nothing was twisted. CNA C returned with the warm blanket and helped put Resident #1's legs in bed and stated that the leg had no apparent bruising. Both CNAs stated they did not inform the nurse at that time of Resident #1's leg pain. The facility's investigation suggests that this is the time the injury occurred. At this time, the CNAs did not report pain to the nurse and no assessment was completed. On 05/19/16 at 3:06 p.m., Surveyor interviewed CNA B, who confirmed this was the first time she transferred Resident #1 alone. Surveyor asked CNA B if prior to this transfer Resident #1 had ever stated ouch during transfers and CNA B said no. Surveyor reviewed CNA D's facility interview, dated 04/29/16 at 9:23 a.m., and LPN F's facility interview, dated 04/29/16 at 8:20 p.m. On 04/28/16 at approximately 10:45 p.m., CNA D approached RN E and LPN F while the nurses were doing shift change report and inquired if Resident #1 could have a pain pill. LPN F responded that Resident #1 would not take oral medication if lying down and to apply a warm blanket. There was no assessment of the pain to identify where the pain was, how intense the pain was and if a warm blanket was an appropriate intervention. Surveyor reviewed RN E's facility interview, dated 04/29/16 at 12:11 p.m. On 04/29/16 at approximately 12:00 a.m., CNA D approached RN E and reported that Resident #1 was in pain. RN E looked in on Resident #1 and stated that the resident was sleeping and did not want to disturb Resident #1 and a warm blanket was provided. RN E did not ask where the pain was or when it was occurring and no pain assessment was completed. Resident #1 reported pain 2 ½ hours later. Surveyor reviewed RN G's facility interview, dated 04/29/16 at 2:58 p.m., and the MAR, dated 04/29/16 at 3:14 a.m. On 04/29/16 at approximately 3:00 a.m., CNA D approached RN E and reported that Resident #1 was in pain. RN E was going on break and asked RN G to administer Tylenol. There was no physical assessment of location or level of pain documented by either nurse. On 04/29/16 at 3:14 a.m., the MAR indicated [REDACTED] Surveyor reviewed Resident #1's nursing notes, dated 04/29/16 at 7:06 a.m. This is the first progress note charted on Resident #1 since prior to 04/28/16. The progress note indicated that on 04/29/16 at approximately 4:15 a.m., RN E and RN G performed a physical exam of Resident #1's leg and noted [MEDICAL CONDITION] and could not feel a pedal pulse. RN E and RN G suspected a blood clot. This is the first physical assessment of the leg. A nursing note, dated 04/29/16 at 7:06 a.m., documents that on 04/29/16 at approximately 4:25 a.m., RN E contacted the on-call provider and was advised that Resident #1 can be seen on rounds the next morning as Resident #1 is comfort measures only. Per the MAR, dated 04/29/16 at 4:42 a.m., RN E charted that pain medication was not effective, has pain in left calf when moving leg or touching calf. There was no further assessment of the leg or notification to the doctor related to continued/increased pain in her leg. On 05/20/16 at 8:15 a.m., Surveyor interviewed RN E via telephone. RN E stated the physical assessment of Resident #1's leg was at approximately 4:15 a.m. RN E stated her foot was warm to touch and of normal color, but Resident #1 was unable to move her foot and RN E could not find a pedal pulse. RN E stated that she suspected a blood clot. RN E then contacted the on-call physician and was told by on-call physician that she was comfort cares and to put her on rounds. Surveyor asked if RN E asked for anything for Resident #1's pain and RN E stated, I told RN G that the on-call physician didn't order anything for pain. Surveyor asked if RN E called the on-call physician back after she felt the pain medication was ineffective and RN E stated, No. Surveyor reviewed nursing notes for Resident #1, dated 04/29/16 at 03:49 p.m., written by RN H. On 04/29/16 at 06:35 a.m., RN H assessed left leg of Resident #1 and noted no firmness or increased warmth. The assessment does not indicate if the leg was moved at this time or what Resident #1's reaction was. Per nursing notes, dated 04/29/16 at 3:49 p.m., on 04/29/16 at approximately 7:15 a.m., a day shift CNA requested RN H to assess Resident #1's left leg and that Resident #1 had minimal amount of movement and attempts at morning cares caused Resident #1 to scream out in pain. RN H completed a physical assessment of the left lower leg. RN H noted increased [MEDICAL CONDITION], the anterior shin had a bruise and two horizontal indentations. RN H attempted to call the physician and while attempting to place the call, Physician I entered the building and RN H advised Physician I of Resident #1's symptoms. On 05/19/16 at 1:50 p.m., Surveyor interviewed RN H. RN H stated she assessed the leg and noted indentations and felt that the leg was broken. RN H consulted with another RN and felt that Resident #1 was in so much pain that RN H then attempted to contact the physician. As RN H was trying to place the call, Physician I walked in the door. Per the MAR, dated 04/29/16 at 8:18 a.m., on 04/29/16 at 8:18 a.m., RN H administered 650 mg Tylenol for pain lower left extremity (LLE) pain and 0.25 mg of [MEDICATION NAME] for pain aid in comfort/relaxing. On 04/29/16 at 9:02 a.m., Physician I completed dictation which stated, Sometime in the last 12 hours, she has demonstrated severe pain in her left leg. It is bruised, painful. She is sitting with it in extreme flexion when I entered the room .When she does not move her leg, she is unaware of any pain or distress, .There is a large ecchymoses from mid-shin to ankle in the anterior portion of the left calf without eruption in the skin, blisters, or other deformity. There is no [MEDICAL CONDITION]. Pulse to her ankles is palpable. Any movement causes distress and anxiety. She is able to hold it rather rigid. We gently coaxed it into a more extended position. it is clear the ankle is unstable in a rotational fashion. She is pillowed, comfortable when I leave the room, while we wait for x-rays. On 04/29/16 at 10:38 a.m., an x-ray was obtained. On 04/29/16 at 11:10 a.m., Resident #1 was transported via ambulance to the emergency room . Surveyor reviewed CNA D's interview conducted by the facility for this incident, dated 04/29/16 at 9:23 p.m. CNA D was asked, Was (Resident #1's name) in any pain at that time? CNA D responded, Oh my god, Yes. Absolutely. She was laying on her side in bed in the fetal position and I went to try and reposition her and just the littlest touch to the sheet would make her yell out. When I went in for second rounds she was grabbing her leg a lot. You could not even touch her leg at all. Surveyor reviewed CNA J's interview conducted by the facility for this incident, dated 04/29/16 at 12:05 a.m. CNA J was asked, Was (Resident #1's name) in any pain at that time? CNA J responded, Yep, (Resident #1 name) was in pain. CNA J was asked, What did you notice about (Resident #1's name) leg? CNA J said, (Resident #1's) leg was hurting so asked me to help change (Resident #1). (Resident #1) was holding her leg a lot. We looked at it closer and it was bruised and a little pus or something was on it. Surveyor reviewed a radiology report from the hospital for Resident #1, dated 04/29/16 at 10:38 a.m. The report identified the following: -History: pain, deformity. -Impression: Comminuted tibial diaphyseal fracture, oblique fibular fracture with angulation and displacement as above. On 05/19/16 at 03:55 p.m. Surveyor interviewed the Director of Nursing (DON) and discussed that the staff had been re-educated on gait belt transfers and following the care plan, but the staff had not been re-educated on pain reporting and assessments.

Based on observation, record review and interview, the facility did not ensure that each resident received the necessary care and services needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the resident's plan of care for 4 of 21 residents reviewed for pain (Resident #9, #7, #10 and #3) and 1 of 21 residents (Resident #13) reviewed for skin integrity. 1. Resident #9 experienced recurring, severe pain related to a heel ulcer. The facility did not assess or monitor the pain, did not document the effectiveness of pain medications and did not premedicate the resident prior to performing wound care. 2. Resident #7 experienced recurring, episodic pain related to previous [MEDICAL CONDITION] and facility did not ensure pain assessments were completed and pain was treated appropriately during personal cares, transfers and wound care. Resident #7 had experienced weight loss, a decline in Activities of Daily Living (ADLs) and a decline in continence which could have been as a result of untreated pain. The failure to have a system in place in which staff were able to identify pain, assess pain and effectively treat pain and to keep residents as free as possible from recurring, episodic excruciating pain created an Immediate Jeopardy situation. The Immediate Jeopardy began on 02/24/15. The facility was notified of the Immediate Jeopardy on 03/04/15. The Immediate Jeopardy was removed on 03/05/15. The deficient practice continues at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan for 4 of 21 residents reviewed for pain. 3. Resident #10 experienced pain during treatment to an excoriated area. The facility did not assess the pain or explore other treatment options. 4. Resident #3 received pain medication due to an increase in pain and the facility did not do a pain assessment and did not chart medication within the medical record on the pain the resident experienced. Resident #3 also had received PRN (as needed) pain medication and facility nursing staff did not document the effect of the medication. 5. Resident #13 was not repositioned, in the wheelchair, according to the plan or care. The facility did not implement new interventions prior to, or after the reoccurring moisture-associated skin breakdown. The facility continued to use the same Sensicare cream on the resident's open areas, even after it was identified the cream is ineffective in healing, and preventing further skin breakdown. As evidenced by: The facility policy titled, Pain Assessment and Management, 2001 MED-Pass, inc. (Revised October 2010), includes in part: General Guidelines: 5. Conduct a comprehensive pain assessment upon admission to the facility, ..whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain... Monitoring and Modifying approaches: 1. Reassess the resident's pain and consequences of pain at least each shift for acute pain... 2. Monitor the following factors to determine if the resident's pain is being adequately controlled: a. The resident's response to interventions and level of comfort over time. 4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Documentation 1. Document the resident's reported level of pain with adequate detail (enough information to gauge the status of pain and the effectiveness of interventions for pain)" Examples: 1. Resident #9 was admitted [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) documents a brief interview for mental status (BIMS) score of 8, meaning the resident has moderate cognitive impairment. The MDS documents that Resident #9 has no pain and no pressure ulcers. The quarterly MDS, with assessment reference date of 02/17/15 documents a BIMS score of 7, meaning severe cognitive impairment. The pain level is moderate, occurring frequently, and has limited day to day activities. The pain assessment completed on 11/17/14 (on admission), documents no pain. The comprehensive care plan does not identify pain as a problem but does address the problem, titled, "Pressure Ulcer, resident has an unstageable pressure ulcer to his left heel r/t dementia, independence. Approaches in part: Maintain the head of the bed at the lowest degree of elevation possible...Observe and report signs of osteo[DIAGNOSES REDACTED] (pain, redness, swelling in affected joint..." Dated 02/10/15. There is no identified problem or care plan for anxiety. The nurses' notes include in part: 02/05/15 "...resident offers no complaints of pain..." -02/08/15 "Resident has two black spots on the bottom of his left heel. Nursing order to apply [MEDICATION NAME] to left heel..." -02/10/15 "...wound margin intact and defined. ..area remains tender to touch..." A telephone order written on 02/16/15 includes in part: "[MEDICATION NAME] 50 mg tablet one po (by mouth) every 4 hours prn pain ..." -02/17/15, 12:24 a.m., "...resident received 50 milligrams of [MEDICATION NAME], which had to be taken from back-up, and one 325 mg [MEDICATION NAME], forty-five minutes later. He was experiencing severe pain and could be heard moaning, 'I hope this stuff works soon'." -2/17/15 12:21 p.m. "Resident received new order for [MEDICATION NAME] 5/325 mg po 1- 2 tabs every 4 hours prn pain, [MEDICATION NAME] order discontinued..." The telephone order dated 02/17/15 "D/C [MEDICATION NAME]. [MEDICATION NAME] 5/325 mg 1 - 2 tablets po every 4 hours prn pain (1 tab pain 1 -5, 2 tabs pain 6-10)." -02/18/15, 11:33 p.m., "No request made for prn [MEDICATION NAME] this evening. denies pain when this writer questioned but aides said that he did have pain as he was saying 'ow, ow'." -02/19/15 12:36 p.m., "Resident continues to have a lot of pain in his left heel, especially when the area is touched or foot is moved. Crying out with cares this a.m. prn [MEDICATION NAME] was administered prior to tx (treatment) was done, which was effective. Resident was anxious about having pain in his heel but did not actually c/o pain during the tx..." -02/19/15 12:50 p.m. "...resident states that his heel is very painful, prn [MEDICATION NAME] administered prior tx with good effects..." -02/20/15 12:36 p.m., "Anxiety vs Pain: "Resident does exhibit anxiety each time he is given his pills...he tore the bandage apart on his left heel because he was looking for directions on how to do it...He did display some anxiety associated with his sore heel, 'be careful not to touch that corner'." -02/20/15, 1:11 p.m., "...Resident does experience a lot of pain in his heel. PRN [MEDICATION NAME] administered prior to tx which is effective...resident does anticipate pain in his heel during his tx which does make him anxious..." -02/21/15, 12:37 a.m., "...resident was medicated an hour and a half before wound care and he was still anxious and yelling out when his left foot/leg was touched. 'be careful because it hurts pretty bad'. He was calm throughout the dressing change except when it was cleaned and when the [MEDICATION NAME] was applied..." -02/21/15, 12:51 a.m., "Anxiety vs pain: Resident had less anxiety on p.m. shift on 02/20/15 because he stayed in bed, and rested his foot, and did not place any pressure on it..." -02/21/15 12:40 p.m., "Resident crying out in pain this AM, was given 2 [MEDICATION NAME] at 0830 which was ineffective. When approached and questioned about his pain he no longer yells out, but upon leaving the room he continues to do so. On Call M.D. ...notified, new order for [MEDICATION NAME] 0.5 mg BID (twice a day) prn every 6 hours not to be given at bedtime. Physician advised that if crying out continues after [MEDICATION NAME] administered he should be evaluated by the ED (emergency department)..resident received [MEDICATION NAME] at 1230 which has been effective..." -02/21/15, 9:53 p.m., "Resident was restless before dinner. After dinner he did quiet down. [MEDICATION NAME] was given to pre medicate before dressing change. Heel is sensitive to the touch and dressing change was painful for him. .." -02/22/15, 10:32 p.m., "Resident was yelling out in pain frequently throughout shift. When asked about his pain level he stated that his heel did not hurt. He was given [MEDICATION NAME] a 3:30 p.m. and that was effective. He was pre-medicated with [MEDICATION NAME] before treatment. He screams out in pain even when not touching affected heel..." A new telephone order is dated 02/22/15 and reads in part: "[MEDICATION NAME] 5/325 mg tab i tab po (by mouth) tid (three times a day). Please offer bid (twice a day) 1 hour before treatment re: pain." Nurses' notes continue: -02/23/15 7:49 a.m."...began yelling loudly and incoherently after 0500 a.m.. When asked why he was yelling, responded 'because I can not talk.' did not respond immediately when asked if he had pain, then yelled 'My foot hurts'! Was given [MEDICATION NAME] at 0530; continued to yell for about 10 minutes..." -02/23/15, 1:19 p.m., "...resident continues to anticipate pain during tx, but is easily calmed with verbal reassurance. Resident tolerated tx without difficulty...New orders received for [MEDICATION NAME] TID as well as prn [MEDICATION NAME] BID an hour before tx and [MEDICATION NAME] BID an hour before tx, and prn [MEDICATION NAME] every 6 hours..." -02/23/15, 11:09 p.m., "...resident had two episodes of yelling out 'ouch that hurts, don't touch that foot'...no further complaints of pain were noted at this time, only during the dressing change." -02/24/15, 10:55 a.m., "Resident calling out and moaning this a.m. prior to receiving pain and antianxiety medications...resident continues to become anxious and anticipates pain during wound care. He will cry out and yell before his heel is touched or when his leg is lifted but does not exhibit any signs of pain when ulcers are cleansed..." -02/25/15, 1:05 p.m., "Resident moaning early this morning, c/o pain in his left heel and foot. Administered scheduled [MEDICATION NAME] and he quieted soon after..." -02/26/15, 12:12 a.m., "Pain/anxiety: ...he received pain medication more than an hour before dressing change was done, and still reported severe pain, 'you people just do not know'. He was anxious during the dressing process, and while the staff removed his pants over the sore heel..." -02/26/15, 1:04 a.m., "Restless at 2330 (11:30) a.m., moving around in bed enough to trigger bed alarm, calling out. admitted to throat pain (relieved with a drink of water) and Left foot pain. Was offered pain pill and declined. 'I do not want to take any medicine that I do not need.' ... repositioned for comfort..." -02/26/15, 1:25 p.m., "Resident had severe pain during dressing change of his heel wound and during a.m. cares. Resident shouts and jerks his body at the slightest touch of his left leg or foot. Also called out several times while he was lying in bed having no cares or treatment done. Administered scheduled [MEDICATION NAME] and also one prn [MEDICATION NAME] this shift. Effective at keeping resident comfortable while in bed, but continued to shout and c/o pain during ADLs (activities of daily living)..." -02/26/15, 11:56 p.m. "Resident tolerated txs this evening, little resistance and jerking noted. Scheduled [MEDICATION NAME] was administered before tx. Resident started yelling out and had his legs bent at the knee while in bed, yelling out 'ouch, ouch'. Prn [MEDICATION NAME] and Prn [MEDICATION NAME] administer at 2230 (1030) p.m..." -02/28/15, 1:14 a.m., "Resident had increased pain and anxiety during treatment to left heel. Calling out ;'Please stop, why do you have to do this?' Reassurance was provided t-o resident, after treatment resident laid calmly in bed..." 02/28/15 10:43 a.m., "Resident continues to have episodes of yelling and calling out during wound care. Experiences anxiety in anticipation of pain. Will yell before the dressing is removed from his left foot or when blankets agree adjusted around his foot but does not c/o pain or exhibit any pain when ulcers are being cleaned and new dressing is being applied...." -03/01/15 10:38 a.m. "Resident anxious and agitated during wound care this a.m. Yelled and cried out each time writer touched residents LLE (left lower extremity) and while boot and old dressing were being removed. And continued to yell even after tx was completed..." -03/02/15 6:29 a.m. "Resident has been awake off and on all night. The last 2 hours he has been calling out. Tried to medicate him at one point and he refused. Very confused. Yelling at staff. Took a prn [MEDICATION NAME] at 0130 a.m.. Later did take an [MEDICATION NAME] at 0515 a.m..." Surveyor requested and reviewed any pain assessments that had been completed for Resident #9. One pain assessment was completed since the onset of the heel pain, it includes in part: Observation date: 02/03/15 Date Recorded: 02/03/15 Completed Dated: 02/14/15. At any time in the last 5 days has the resident received scheduled pain medication regimen? No At any time in the last 5 days has the resident received prn pain medications or was offered and declined? Yes At any time in the last 5 days has the resident received non-medication intervention for pain? Yes Should pain assessment interview be conducted? Yes Ask resident: Have you had any pain or hurting at any time in the last 5 days? Yes How much of the time have you experienced pain or hurting over the last 5 days? Frequently Over the last 5 days, has pain made it hard for you to sleep at night? No Intensity rating scale: 6 Verbal descriptor scale- Ask resident "please rate the intensity of your worst pain over the last 5 days. Severe Pain assessment summary: "Resident has had a recent increase in c/o pain d/t (due to) a wound to his LLE (left lower extremity). PRN Tylenol and elevation have been effective in relieving pain." On 03/03/15 at 1:00 p.m., Surveyor requested and reviewed the Medication Administration Records (MAR) beginnning 02/01/15. The February MAR indicated [REDACTED]. There are no pain scale ratings documented for any of the prn pain medications. The signs/symptoms for non-verbal residents such as moaning, is used three times. For the month of February, the effectiveness of the pain medication is not documented 13 times. The MAR for March 1st, 2nd and 3rd, documents Resident #9 received [MEDICATION NAME] four times. The [MEDICATION NAME] was ineffective two of the four times, when used for pain in the left foot and heel. The physician progress notes [REDACTED]. -02/16/16 "...he does have 2 pressure ulcers on his let heel. Both of them are dime sized...The lateral one has a slit in the middle of it...This one is quite painful to touch...Impression/report/plan: Unstageable pressure ulcer, left heel, very painful. I will go ahead and order some [MEDICATION NAME] for this. He was complaining throughout the exam of discomfort..." -02/23/15 "...Over the weekend he did have quite a bit of anxiety noted by the staff. They felt this was related to pain. He did have some as needed medication available; however nothing scheduled. When I see him today, he is calm. However, with any attempt to do the wound care, he does get very anxious, very painful. The on-call doctor was contacted over the weekend and did order some anxiety medication which was effective. Impression/report/plan: Pressure area to the heel resulting in pain with treatment. Plan: I will schedule his pain medication..." Observations On 03/03/15 at 6:40 a.m., Surveyor observed Resident #9 lying in bed on his back with the head of the bed elevated 45 degrees. The heel boot for the left foot was partially off and the heel was in direct contact with the mattress. Surveyor asked Certified Nursing Assistant (CNA) BB to come into the room and reapply the heel boot. As CNA BB lifted the left leg, Resident #9 yelled, "Oh! Oh!" as the boot was adjusted. On 03/03/15 at 7:50 a.m., Surveyor went into Resident #9's room. Resident #9 stated, "Something is wrong, this bed is as stiff as a board. I can't stand it." CNA BB came into the room, and Surveyor asked when she would assist Resident #9 with cares. CNA BB stated she would let the surveyor know and left the room without attempting to provide Resident #9 any comfort. Surveyor had continuous observation of Resident #9 with the head of his bed elevated from 6:40 a.m. until 9:47 a.m. On 03/03/15 at 9:47 a.m., the Assistant Director of Nursing (ADON) A came in to do wound care. As ADON A cleansed the left heel. Resident #9 stated, "Oh! It hurts." ADON A stated she uses only a Q-tip to apply the [MEDICATION NAME] because the heel is so painful. Resident #9 moaned in pain as the Kerlix was applied to his left foot. On 03/03/15 at 9:55 a.m., CNA BB came into assist Resident #9 with personal cares. As CNA BB was getting the clothes together she stated, "We don't put socks on him because he screams if we even try." When CNA BB removed the left heel boot, Resident #9 yelled, "EEEH, go easy on that foot." When CNA BB put Resident #9's pants on over the left foot again he yelled, "Go easy, Oooh! " Resident #9 was put back into bed at 10:10 a.m. with the head of the bed elevated greater than 45 degrees. On 03/03/15 at 12:05 p.m., Surveyor was walking down the 100 wing and could hear a resident yelling. Surveyor went into Resident #9's room, observing Resident #9 yelling, "Oooh, It hurts, It hurts!" Surveyor asked what was hurting. Resident #9 stated, "My foot, Oh! Oh!" Surveyor observed Resident #9 wincing in pain, utilizing pursed lip breathing. Resident #9's face was flushed, the cheeks red in color. Resident #9 then screamed, "Get it over with!" At this time no one is near Resident #9 and nothing is touching Resident #9. Surveyor went out into the hallway, where Registered Nurse (RN) P had been standing with her medication cart. Surveyor could easily hear Resident #9 continuing to yell and scream in the hallway. Surveyor asked RN P if Resident #9 could have something for pain. RN P stated, "I will check and see if he can have something. He has already had his scheduled pain med this morning." Surveyor went back into the room at 12:10 p.m., and continued to listen and observe Resident #9. Resident #9 continued to scream "Get it over with, ow! ow! It is murdering me!" Resident #9's body was jerking as he yelled, "Oooh, it hurts, Oh! Oh!, the longer they wait the worse it gets." RN P was in the hallway and was answering the questions of a family member while this was occurring. At 12:15 p.m., RN P came in and gave Resident #9 his pain medication, [MEDICATION NAME] one tablet 5/235 mg. Resident #9 continued to yell and moan in pain. RN P reapplied the right heel boot, and Resident #9 yelled out, "Just get it done!" Surveyor asked RN P if Resident #9 usually experiences this kind of pain. RN P stated, "Yes, it is up and down with him, if he feels good he can scoot himself in his wheelchair." Surveyor asked if his position in the bed could be causing discomfort in his heel. At 12:20 p.m., CNA BB came in and assisted RN P in lifting Resident #9 up into bed. Resident #9 screamed, "Oh! Oh! Oh!" as he was lifted up. Resident #9 was grabbing the hand rail of his bed so tightly after this, his nailbeds and knuckes of his right hand were white. Resident #9's head of his bed was put back in a greater than 45 degree position. At 12:25 p.m., Surveyor went to locate another surveyor to continue the observation. On 03/03/15 at 12:34 p.m., Surveyor observed Resident #9, who was lying on his back, in bed. The resident's privacy curtain was pulled around to the foot of the bed. The head of the bed appeared to be elevated to 45 degrees. Surveyor was able to hear the resident yelling, in the hallway, prior to the observation. At this time, Resident #9 was heard to be constantly moaning, and making crying sounds. During the observation, Surveyor heard the following remarks from Resident #9, who was alone in the room: "Ohh, ohh, ohh the worse it gets! Oh please! (crying sounds) Oww, just get it done! Ohhh! (crying and sobbing sounds) Get it over with! Ohh, please! (crying and moaning) You just make it worse! (crying sounds)." At 12:40 p.m., Surveyors and entered the resident's room, along with the Nursing Home Administrator (NHA). The NHA asked Resident #9 where it was hurting. Resident #9 stated, "My heel, the more you diddle around the worse it hurts." The NHA went to RN P and asked about the pain medication. RN P stated, "He just had his first prn pain medication a few minutes ago, he has it scheduled three times a day. He is already on the books to be looked at for pain, it varies with him, sometimes it can be bad, and sometimes it is better. It is hard to tell how much is anxiety and how much is pain." At 1:20 p.m., Surveyor observed Resident #9 in his bed. His eyes were closed, but he was wincing in his sleep. His knees were bent, his foot was in his boot, and the heel of the boot was pressed onto the mattress. There were blankets pressing on his bare toes. Resident #9's head was not on his pillow. Surveyor observed Resident #9 at 2:55 p.m., and the head of his bed was still rolled up, and his knees were still bent up, with pressure on his heel. He was asleep at this time. Resident #9 did not have an air mattress on his bed. On 03/03/15 at 1:45 p.m., Surveyor interviewed ADON A, Surveyor asked what they had done for Resident #9 since the observation that was shared with the NHA. ADON A stated, "The resident was given an [MEDICATION NAME] at 1:00 p.m." Surveyor asked if ADON A considered the pain that was observed to be severe or excruciating for Resident #9. ADON A stated, "Yes, that is severe pain and we should be doing more for him. He has been having more pain the past few days." Surveyor asked why there had been no pain assessments with the increased pain, and the medication changes for pain, to determine the effectiveness. ADON A stated, "I can't answer that." Surveyor clarified that the last pain medication change was on 02/22/15, which the resident first received on 02/23/15. ADON A acknowledged that was correct. ADON A stated she would contact the physician today. At 3:15 p.m., Surveyor observed that Resident #9 was still in bed, on his back, with his knees bent up. Surveyor asked ADON A to come and observe Resident #9. Surveyor told ADON A that Resident #9 had been in that same position since after his noon meal; that his heel was pressing onto the bed, blankets were pressing on his toes, and with the head of the bed elevated, there was a greater chance for shearing. ADON A agreed that Resident #9 would probably be more comfortable if he was turned onto his side, and stated he should probably have a bed cradle on his bed to keep the blankets off his toes. ADON A then walked down the hall with Surveyor , and stated that Resident #9 would soon have an air mattress put onto his bed, and the facility had changed the treatment order for his heel to Sensicare. Surveyor asked ADON A if she was going to see that Resident #9 gets repositioned when he wakes up, and she stated yes. On 03/04/15 at 6:50 a.m., Surveyor heard Resident #9 yelling, in the hallway. At this time, the resident was lying on his back, in bed. The head of the bed appeared to be elevated at 45 degrees. At approximately 6:51 a.m., CNA I entered Resident #9's room, and asked if the resident was in pain. The resident replied he was experiencing pain in his foot. CNA I stated she would inform the charge nurse, and left the resident's room. At 6:55 a.m., CNA I returned to the resident's room, and informed Surveyor RN P was told Resident #9 was in pain. At 8:04 a.m., Surveyor observed Resident #9 lying on his back, in bed. A tray of breakfast food was on the bedside table, in front of the resident. The food appeared to be untouched. The resident's head of the bed appeared to be elevated 45 degrees. Resident #9 was repeatedly moaning and calling out, "Oww, oww!" At this time, CNA H entered the resident's room and physically assisted the resident with the meal. As the resident was eating a banana, he was calling out, "Ohh, ohh! Don't hurt my foot anymore!" As the observation continued, CNA H stated she was not touching Resident #9's foot. The resident replied, "Oh, I don't know what to do with this stuff! My left foot! Ohhh!" At 8:15 a.m., CNA H raised the resident's blankets, at the end of the bed. Resident #9 flinched and yelled, "Don't touch me!" Surveyor observed the resident's left knee was bent, placing pressure on the resident's heel. CNA H asked the resident if the CNA should straighten Resident #9's left leg, and the resident did not respond. As CNA H slowly straightened the resident's left leg, the resident was yelling, "Don't! Don't! Don't!" CNA H then covered the resident's legs with a blanket, and continued to assist the resident with eating breakfast. The resident continued to make moaning and whimpering sounds. On 03/05/15 at 7:15 a.m., Surveyor interviewed the day shift Licensed Practical Nurse (LPN) Q. LPN Q said she works the floor routinely and is familiar with Resident #9's cares. Surveyor asked how long pain had been an issue for Resident #9. LPN Q stated, "I would say about three weeks or so. I medicate with the [MEDICATION NAME] when doing his treatment, because that is when the pain is the worst. He will yell and tense up when wrapping his foot. This past week he has been in a lot of pain. He has been yelling even after the medication has been given." On 03/05/15 at 7:30 a.m., Surveyor interviewed CNA R about Resident #9's pain. CNA R stated, "He has a lot of pain in his left heel, it is very painful for him. He anticipates the pain before you even touch him." Surveyor asked how Resident #9 shows he is in pain. CNA R stated, "He moans, has facial expressions of pain, and yells 'Ow! Ow!,' even when we wash him up he does this, it is best to just not touch him." Surveyor asked if Resident #9 has any behaviors of acting out that occur. CNA R stated, "No, only when he is having pain he gets agitated and upset." 2. On 03/02/15 at 2:30 p.m., Surveyor reviewed the medical record for Resident #7 and noted the following: - Resident #7 has a [DIAGNOSES REDACTED]. - MDS, dated [DATE], indicated Resident #7 was severely cognitively impaired, at risk for pain, had had a recent fall with a major injury, had occasional episodes of incontinence and required the assistance of one staff for all transfers. MDS indicated: ~ Resident #7 did not have a pressure ulcer but was at risk for pressure ulcers. ~ Resident #7 had moisture associated skin damage which was not a pressure ulcer. ~ no decline in upper or lower range of motion ability. ~ significant weight loss. ~ receiving a diuretic medication. ~ only behavior noted was wandering. - MDS, dated [DATE], indicated Resident #7 was now at risk for falls, required extensive assistance for all transfers and extensive assist for eating, had a decline in the bilateral lower extremities for range of motion, was incontinent of both bowel and bladder, was at risk for pain, had a stage III pressure ulcer to the coccyx, required extensive assist for all ambulation, and had a significant weight loss. MDS indicated Resident #7 had been receiving a diuretic medication. MDS indicated Resident #7 had no behaviors. - Current physician orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 20 mg 02/(milligrams) daily dated 01/23/15 and PRN [MEDICATION NAME] (Tylenol) liquid 500 mg/5 ml (milliliters) oral, dated 09/26/14, can be given every 4 hours as needed for pain. - Comprehensive nursing care plan, received 02/03/15, titled, "Communication," indicated Resident #7 has disordered thinking and awareness and was not able to effectively communicate to facility staff. - Comprehensive nursing care plan, received 02/03/15, titled, "ADL Function/Rehabilitation Potential," stated Resident #7's ADL function had declined due to dementia and pain. Care plan stated for staff to use assist of two for toileting, bed mobility and transfers. - Comprehensive nursing care plan, received 02/03/15, titled, "Behavioral symptoms," indicated Resident #7 refuses medications at times and yells out when foot care is being done. - Comprehensive nursing care plan, received 02/03/15, titled, "Urinary incontinence," indicated Resident #7 experiences frequent bladder incontinence due to dementia and decreased mobility and requires assistance from one staff for toileting. Nursing Notes On 03/02/15 at approximately 2:30 p.m., Surveyor reviewed the nursing notes for Resident #7 and noted the following: - 09/26/14: Resident #7 had fallen within the facility, sent to the ER where she was diagnosed with [REDACTED]. Resident #7 was readmitted to the facility with the following physician orders: PT/OT to evaluate and treat, [MEDICATION NAME] suspension and [MEDICATION NAME] nebulizer treatments, activity as tolerated - OK to sit in a wheelchair or walk with a walker - pain to be controlled by PRN [MEDICATION NAME]. - 09/26/14: "Resident restless, moaning and crying in pain, PRN 20 mg [MEDICATION NAME] administered at this time. Noted to be effective as resident became less restless and decreased moaning. Resident yells out in pain with little movement. Very difficult for staff to provide cares. Resident is very non-complaint with care and increasing pain has made matters worse. Will continue to monitor resident." - 09/27/14: "Gave resident [MEDICATION NAME] moaning and crying out in pain." - 09/28/14: "Resident notably wheezing with dyspnea...(POAHC) asked if he would like resident to be sent in for evaluation and he declined stating that they (hospital) wouldn't be able to do any more for her at the hospital than we were doing here...(POAHC) relayed to this nurse that he does not want resident to receive the PRN MS04 ([MEDICATION NAME]) as he feels like that is why she is having the respiratory difficulties." -09/29/14: "Resident has been moaning and restless this shift. Repositioned for comfort, ice put on Rt (right) hip and gave APAP (Tylenol) 500 mg as ordered for pain. Resident is now resting quietly." - 09/29/14: "MD (medical doctor) came to facility this AM (morning) to assess resident and meet with (POAHC). MD did a medication and care review of resident. [MEDICATION NAME] was d/c (discontinued) as resident was having respiratory depression. MD states that we are to utilize PRN Tylenol for pain. If this does not seem adequate at controlling her pain, he will consider either restarting the [MEDICATION NAME] at a lower dose, or will consider adding a low dose [MEDICATION NAME]. POA was in agreement with this plan." - 10/09/14: "Received call from (physician) with N.O's (nursing orders) for [MEDICATION NAME] 12 mcg/hr., change every 72 hours, and [MEDICATION NAME] 7.5 mg PO (oral) every HS (evening) for appetite." - 10/10/14: "Resident per baseline, no verbal complaints of pain. Resident does yell out during transfers and cares." - 10/10/14: "(Physician) here on rounds and assessed resident for special visit per son. Resident appears to be stable and doing well on [MEDICATION NAME]. No further concerns present." - 10/11/14: "(Resident #7) is unable to answer if she is having pain or is comfortable. When she is moved in bed or transferred has vocalizations of discomfort but once settled appears comfortable. She seems to tolerate being up in her wc (wheelchair), moving herself about the room and hallway." - 10/12/14: "Does vocalize discomfort with repositioning, cares and transfer." "Resident slept well during the night. Only when being repositioned did she vocalize some discomfort. Once reposition, she was quiet and went right back to sle

Based on medical record reviews, policy review, observation, and interview, the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers, and receives the necessary treatment to promote healing, prevent infection, and prevent new pressure ulcers from developing for 7 of 10 residents reviewed who either have pressure ulcers or are identified at risk to develop pressure ulcers (Resident #9, #7, #3, #6, #1, #8, #5). The first two examples are assessed to be at actual harm and the remaining examples are at a severity level 2. 1. Resident #9 developed an unstageable left heel ulcer in the facility on 02/08/15, which has caused him severe pain. The facility did not ensure new prevention measures were put in place when Resident #9 was not keeping his heels floated to prevent pressure. The ulcer has increased in size since 02/08/15. An air mattress was not put in place until 03/03/15. 2. Resident #7 had a stage III pressure ulcer to the buttock area and was not positioned according to plan of care while in bed and in wheelchair. Resident #7 had stage I pressure ulcers to both the left hip and left ankle and facility did not assess and document areas within the medical record. 3. Resident #3 was at high risk for pressure ulcers and was not repositioned according to plan of care. 4. Resident #6 has an unstageable deep tissue injury to heel and her heels were not floated off the bed per plan of care. 5. Resident #1 is at risk for skin breakdown, and has two current pressure ulcers. Resident #1's heels were not floated during observations, as the care plan directs. 6. Resident #8, who is at risk for pressure ulcers, has a care plan which instructs staff to reposition him every two hours in bed and every one hour in his wheelchair. Resident #8 was left sitting up in his wheelchair for approximately 4 1/2 hours. He also has very high risk for pressure ulcers on his feet, and his care plan instructs staff to put heel protecting boots on his feet. He was observed in bed without the boots on, and without his heels floated. 7. Resident #5 has a history of a boggy heel and is to have her heels floated when in bed. She was observed to not have her heels floated. This is evidenced by: 1. Resident #9 was admitted [DATE], with [DIAGNOSES REDACTED]. His admission Minimum Data Set (MDS) documents a brief interview for mental status (BIMS) score of 8, meaning he has moderate cognitive impairment. The MDS documents that Resident #9 has no pain, and no pressure ulcers. The quarterly MDS, with assessment reference date of 02/17/15, documents a BIMS score of 7, meaning severe cognitive impairment. The quarterly MDS documents Resident #9 has one unstageable heel ulcer. The comprehensive care plan has the problem, titled, "Pressure Ulcer, resident has an unstageable pressure ulcer to his left heel r/t dementia, independence. Approaches in part: assess and record the condition of the skin surrounding the pressure ulcer weekly. Assess the pressure ulcer for location, stage, size...Conduct a systematic skin inspection weekly on bath day...Keep clean and dry as possible. Keep linens clean, dry, and wrinkle free. Maintain the head of the bed at the lowest degree of elevation possible...Observe and report signs of osteo[DIAGNOSES REDACTED] (pain, redness, swelling in affected joint..., observe and report signs [MEDICAL CONDITION], Place bilateral heel float boots for pressure reduction when resident in bed. Resident requires to be repositioned every 2 hours in bed and is independent in w/c (wheelchair), use pressure redistribution cushion for pressure reduction when resident is in chair. Use pressure redistribution mattress when resident in bed for pressure reduction." Dated 02/10/15 (Note, per interview with the ADON A on 03/03/15, an air mattress was not added until after 03/03/15). The nurses' notes include in part: 02/08/15 "Resident has two black spots on the bottom of his left heel. Nursing order to apply [MEDICATION NAME] to left heel..." Nursing notes continue: (early nurses notes identify two pressure ulcers (upper and lower heel), as the dates continue the two ulcers are incorrectly identified (both as lower)). 02/10/15 8:21 a.m. "Unstageable pressure ulcer to left outer heel (upper). length 0.5 cm x 1.3 cm. Wound presents as dark purple in color. Dry cracked in appearance. Wound margin intact and defined...Elevate heels when in bed on pillow. Treatment ordered. Request family bring in different footwear as currently resident wears dress shoes that may be rubbing on heels and contributing to pressure areas..." 02/10/15 8:26 a.m. "Unstageable pressure ulcer to left outer heel (lower). length 1 cm x 1 cm. wound presents as dark purple in color. Dry cracked in appearance. Wound margin intact and defined...Elevate heels when in bed on pillow. Treatment ordered. Request family bring in different footwear as currently resident wears dress shoes that may be rubbing on heels and contributing to pressure areas..." A telephone order written on 02/10/15 includes in part: D/C [MEDICATION NAME] to left heel. Cleanse left heel daily with warm soap and water apply 3M barrier wipe and foam dressing for protection. change daily and prn (as needed). Nursing notes continue: 02/16/15 12:08 p.m. "Unstageable pressure ulcer to left outer heel (lower) 1 cm x 1 cm...elevate left heel with heel float boot at all times when in bed. Family did bring in more supportive slipper type footwear to hopefully decrease any pressure to area." 02/16/15 12:15 p.m. "Unstageable pressure ulcer to left outer heel (upper) 1.5 cm x 1.5 cm. ...elevate left heel with heel float boot at all times when in bed. Family did bring in more supportive slipper type footwear to hopefully decrease any pressure to area." (This ulcer is larger in size from the measurement on 02/10/15.) The physician progress notes [REDACTED]. Both of them are dime sized...The lateral one has a slit in the middle of it. It is draining some serosanguineous fluid very very scantly...there is some [DIAGNOSES REDACTED] around the periwound....This one is quite painful to touch...Impression/report/plan: Unstageable pressure ulcer, left heel, very painful. I will go ahead and order some [MEDICATION NAME] for this. He was complaining throughout the exam of discomfort...we will change the treatment to his heel to include [MEDICATION NAME] 2 times daily. I will also add 3 days of [MEDICATION NAME], as the periwound is erythemic. I think there may be a component of infection there that we need to clear up..." A telephone order was written 02/16/15: [MEDICATION NAME] to left heel bid, cover with gauze. No shoes, foam or air boot if [MEDICATION NAME] 500 mg one po (by mouth) for 5 days. Nursing notes continue. 02/17/15 0:24 (12:24 a.m.), "Heel Ulcer: resident was in bed all of p.m. shift with a foam boot on his left foot, due to a newly diagnosed heel ulcer....resident received 50 milligrams of [MEDICATION NAME], and one 325 mg [MEDICATION NAME], forty-five minutes later. He was experiencing severe pain and could be heard moaning. 'I hope this stuff works soon'." 02/17/15 12:21 p.m. "Resident received new order for [MEDICATION NAME] 5/325 mg po 1- 2 tabs every 4 hours prn pain, [MEDICATION NAME] order discontinued..." 02/19/15 12:50 p.m. "...resident states that his heel is very painful, prn [MEDICATION NAME] administered prior tx with good effects..." 02/20/15 1:45 p.m., "Anxiety vs Pain: "Resident does exhibit anxiety each time he is given his pills...he tore the bandage apart on his left heel because he was looking for directions on how to do it...He did display some anxiety associated with his sore heel, 'be careful not to touch that corner'." 02/20/15 13:11 (1:11) p.m., "...Resident does experience a lot of pain in his heel. PRN [MEDICATION NAME] administered prior to tx which is effective...resident does anticipate pain in his heel during his tx which does make him anxious..." 02/20/15 2:07 p.m. "Left heel wound: the peri wound skin on the left heel ulcers is whiteish in color and the surrounding skin is a dark pink color. very very tender to touch. Thee was no drainage noted on the old dressing. ...an hour or so later the resident had removed both of the foam booties that were applied to protect his feet, and ripped the dressing apart,...he was quiet throughout most of the dressing change except once or twice he warned staff not to touch his heel and be very careful around it. Resident is receiving an antibiotic for the heel infection and is tolerating that medication..." 02/21/15 0:37 (12:37) a.m., "...resident was medicated an hour and a half before wound care and he was still anxious and yelling out when his left foot/leg was touched. 'be careful because it hurts pretty bad'. He was calm throughout the dressing change except when it was cleaned and when the [MEDICATION NAME] was applied..." 02/21/15 12:40 p.m., "Resident crying out in pain this AM, was given 2 [MEDICATION NAME] at 0830 which was ineffective. When approached and questioned about his pain he no longer yells out, but upon leaving the room he continues to do so. On Call M.D. ...notified, new order for [MEDICATION NAME] 0.5 mg BID (twice a day) prn every 6 hours not to be given at bedtime. Physician advised that if crying out continues after [MEDICATION NAME] administered he should be evaluated by the ED (emergency department)..resident received [MEDICATION NAME] at 1230 which has been effective..." 02/22/15 22:32 (10:32) p.m., "Resident was yelling out in pain frequently throughout shift. When asked about his pain level he stated that his heel did not hurt. He was given [MEDICATION NAME] at 1530 (3:30) p.m. and that was effective..." The telephone order is dated 02/22/15 and reads in part: "[MEDICATION NAME] 5/325 mg tab i tab po (by mouth) tid (three times a day). Please offer bid (twice a day) 1 hour before treatment re: pain." Nurses' notes continue: 02/23/15 12:16 p.m. "Unstageable pressure ulcer to left outer heel (lower) 1 cm x 1.6 cm. wound presents as dark purple in color. More moist in appearance upon assessment today...wound margin intact and defined. Scant bloody drainage present on removed dressing. Periwound skin intact." (This wound is identified as lower heel in this note, but charted on the upper heel event report) 02/23/15 12:17 p.m. "Unstageable pressure ulcer to left outer heel (lower) .6 cm x 0.5 cm. wound presents as dark purple in color. ...wound margin intact and defined. Scant bloody drainage present on removed dressing. Periwound skin intact." physician progress notes [REDACTED]. They felt this was related to pain. He did have some as needed medication available; however nothing scheduled. When I see him today, he is calm. However, with any attempt to do the wound care, he does get very anxious, very painful. The on-call doctor was contacted over the weekend and did order some anxiety medication which was effective. Impression/report/plan: Pressure area to the heel resulting in pain with treatment. Plan: I will schedule his pain medication..." Nurses' notes continue: 02/23/15 23:09 (11:09) p.m., "...resident had two episodes of yelling out 'ouch that hurts, don't touch that foot'...no further complaints of pain were noted at this time, only during the dressing change." 02/26/15 0:12 (12:12) a.m., "Pain/anxiety: ...he received pain medication more than an hour before dressing change was done, and still reported severe pain, 'you people just do not know'. He was anxious during the dressing process, and while the staff removed his pants over the sore heel..." 02/26/15 1:04 a.m., "Restless at 2330 (11:30) p.m., moving around in bed enough to trigger bed alarm, calling out. admitted to throat pain (relieved with a drink of water) and Left foot pain. Was offered pain pill and declined. 'I do not want to take any medicine that I do not need.' ... repositioned for comfort..." 02/26/15 13:25 (1:25) p.m., "Resident had severe pain during dressing change of his heel wound and during a.m. cares. Resident shouts and jerks his body at the slightest touch of his left leg or foot. Also called out several times while he was lying in bed having no cares or treatment done. Administered scheduled [MEDICATION NAME] and also one prn [MEDICATION NAME] this shift. Effective at keeping resident comfortable while in bed, but continued to shout and c/o pain during ADLs (activities of daily living)..." 02/26/15 23:56 (11:56) p.m. "Resident tolerated txs this evening, little resistance and jerking noted." 02/28/15 1:14 (1:14) a.m., "Resident had increased pain and anxiety during treatment to left heel. Calling out ;'Please stop, why do you have to do this?' Reassurance was provided to resident, after treatment resident laid calmly in bed..." 02/28/15 10:43 a.m., "Resident continues to have episodes of yelling and calling out during wound care. Experiences anxiety in anticipation of pain. Will yell before the dressing is removed from his left foot or when blankets are adjusted around his foot but does not c/o pain or exhibit any pain when ulcers are being cleaned and new dressing is being applied...." 03/01/15 10:38 a.m. "Resident anxious and agitated during wound care this a.m. Yelled and cried out each time writer touched residents LLE (left lower extremity) and while boot and old dressing were being removed. And continued to yell even after tx was completed..." 03/02/15 8:40 a.m. "Unstageable pressure ulcer to left outer heel (lower) .6 cm x .6 cm. wound presents as dark purple in color. Eschar is dry in appearance. wound margin intact and defined. No drainage present on removed dressing. Periwound skin intact...Area remains tender to touch. elevate bilateral heels with heel float boot at all times when in bed." 03/02/15 8:44 a.m. "Unstageable pressure ulcer to left outer heel (lower) 1.5 cm x 2.0 cm. wound presents as dark purple in color. Eschar is dry in appearance. wound margin intact and defined. No drainage present on removed dressing. Periwound skin intact...Area remains tender to touch. Elevate bilateral heels with heel float boot at all times when in bed." (This measurement is larger that the measurement last week, and is charted on the upper heel event report) Observations On 03/03/15 at 6:40 a.m., Surveyor observed Resident #9 lying in bed on his back, with the head of the bed elevated 45 degrees. The heel boot on the left foot was partially off and the heel was in direct contact with the mattress. Surveyor went to get Certified Nursing Assistant (CNA) BB, who came into the room and lifted up Resident #9's left leg to reapply the heel boot. Resident #9 yelled, "Oh! Oh!" during the process. On 03/03/15 at 7:50 a.m., Surveyor went in to check on Resident #9. Resident #9 stated, "Something is wrong, this bed is as stiff as a board. I can not stand it." CNA BB came into the room. CNA BB went on to say that Resident #9 likes to spend most of his time in bed and likes to lie on his back. Resident #9 continued to say to Surveyor , "Feel this thing there is something wrong with it, it is as hard as a board," as he kept feeling the mattress with his hands. Surveyor had continuous observation of Resident #9 with the head of his bed elevated from 6:40 a.m. until 9:47 a.m., lying on his back. On 03/03/15 at 9:47 a.m., the Assistant Director of Nursing (ADON) A came in to do wound care. As ADON A cleansed the left heel. Resident #9 stated, "Oh! It hurts." ADON A stated she uses only a Q-tip to apply the [MEDICATION NAME] because the heel is so painful. Resident #9 moaned in pain as the Kerlix was applied to his left foot. On 03/03/15 at 9:55 a.m., CNA BB came in to assist Resident #9 with personal cares. As CNA BB was getting the clothes together she stated, "We don't put socks on him because he screams if we even try." When CNA BB removed the left heel boot, Resident #9 yelled, "EEEH, go easy on that foot." When CNA BB put Resident #9's pants on over the left foot again he yelled, "Go easy, Oooh!" Resident #9 was put back into bed at 10:10 a.m. with the head of the bead elevated greater than 45 degrees. When Resident #9 stood up Surveyor could observe an open area, in the coccyx area, just above the gluteal cleft. Surveyor asked CNA BB if that area was open before. CNA BB stated, "No, that is the first time I have seen it." On 03/03/15 at 12:05 p.m., Surveyor was walking down the 100 wing, and could hear a resident yelling. (Reference F309 for details on the pain observation.) At this time Resident #9 had the head of his bead elevated since 10:10 a.m. at greater than 45 degrees. Surveyor did ask Registered Nurse (RN) P, if the position of the bed could be causing pressure on the heels. RN P adjusted the heel boots, and then left Resident #9 in the same position with the head of the bed elevated greater than 45 degrees, after moving the resident up in bed. On 03/03/15 at 1:45 p.m., Surveyor interviewed ADON A, Surveyor asked how Resident #9 developed the heel ulcer. ADON A stated, "He never liked to keep the pillows under his heels, he would always kick them out." Surveyor asked what they did differently when they were aware of it. ADON A said, "I guess we could have checked on the pillows more often. We started heel boots on 01/02/15 but he did not like them and always kicked them off." Surveyor clarified that they were aware he was not keeping the boots on. ADON A stated, "Yes, we should have checked him more often or tried a different kind of boot." Surveyor shared the observation of how uncomfortable Resident #9 was in his bed, and asked if an air mattress had been considered to prevent pressure on the heels. ADON A stated, "Yes, we could have done that too. I will look for an available air mattress today." Surveyor shared the observations of pain, ADON A stated, "It is severe pain and we should be doing more for him, he has been having more pain the past few days." Surveyor then asked if ADON A was aware of the open area on the bottom. ADON A stated she was not, but would assess it as soon as she could. The observation of the head of the bed being elevated greater than 45 degrees for more than three hours, with Resident #9 being on his bottom were shared. On 03/04/15, a skin assessment was completed, documenting a new stage II pressure ulcer, on the top of the gluteal cleft, measuring 0.3 cm x 0.3 cm. 2. On 03/02/15 at 2:30 p.m., Surveyor reviewed the medical record for Resident #7 and noted the following: - Resident #7 has a [DIAGNOSES REDACTED]. - MDS, dated [DATE] indicated Resident #7 was severely cognitively impaired, at high risk for pressure ulcers and had moisture associated skin damage which was not a pressure ulcer. - MDS, dated [DATE], indicated Resident #7 was significantly cognitively impaired and had a stage III pressure ulcer to the coccyx. - Comprehensive nursing care plan, received 03/02/15, titled, "Pressure Ulcers," indicated Resident #7 currently had a pressure ulcer, is to be turn and reposition every two hours in bed and every one hour when in wheelchair and use a roho cushion while in the wheelchair. Care plan did not indicate stage I pressure ulcers to left hip and left ankle. - CNA care plan, received 02/03/15, indicated Resident #7 had an air mattress, required to be repositioned by two staff members every two hours while in bed and every one hour while in wheelchair, had dementia, was both continent and incontinent of both bowel and bladder and required the assist of one staff member for toileting needs, toileting is to be offered every two hours and resident is to wear a brief in between, requires assist of one for repositioning, bed mobility and wheelchair mobility and assist of two for repositioning, bed mobility and wheelchair mobility as needed. Current Physician Orders - Current physician orders [REDACTED]. - Cleanse and apply Sensicare to coccyx and periarea BID (twice a day). - Santyl ointment; 250 unit/gram; amt: 250 unit/gram; topical: Special instructions: Pack wound with mesalt and santyl, cover with foam dressing and change daily for [DIAGNOSES REDACTED]. Twice a day; 07:00 - 15:00 (3:00 p.m.), 15:00 - 23:00 (9:00 p.m.). - [MEDICATION NAME] Patch 12 mcg (micrograms)/hour [MEDICATION NAME], dated 02/28/15, to be replaced every 72 hours for generalized pain. - PRN [MEDICATION NAME] (Tylenol) liquid 500 mg/5 ml (milliliters) oral, dated 09/26/14, can be given every 4 hours as needed for pain. Nursing Notes On 03/02/15 at 2:30 p.m., Surveyor reviewed the nursing notes from 09/01/14 - 03/02/15 for Resident #7 and noted the following: - 09/26/14: Resident #7 had fallen within the facility, sent to the ER where she was diagnosed with [REDACTED]. - 10/19/14: "Resident up in w/c for meals and after supper. Remained in room. Alarms on bed and w/c. Noted during cares after lunch that coccyx has superficial open area. Area appears to have scar tissue present that has opened up. Cleaned and SensiCare barrier cream applied." - 10/21/14: "Resident was crying out, yelling in pain at HS. Staff attempted to give PRN APAP crushed in juice but resident threw it at staff. Resident was repositioned for comfort. Continues with [MEDICATION NAME] for pain control. No s/s of infection to open area on coccyx. Continue to apply SensiCare as ordered. Will continue to monitor." - 10/21/14: "Continues to have poor appetite. Did let this RN (Registered Nurse) feed her ice cream for HS snack. Gave PRN Tylenol at 2100 (9:00 p.m.) for elevated temp of 99.2. SensiCare to open area on coccyx." - 10/23/14: "Very restless, calling out at about 0520 (5:20 a.m.). Yelled with any repositioning in bed. Was given APAP 500 mg...has been quiet since then." - 10/29/14: "Scoop mattress has been discontinued from resident's care plan. She now requires use of an air mattress for protection due to a break in skin integrity." - 10/29/14: "Stage 3 pressure ulcer right gluteal fold. Length: 3 cm (centimeters) Width: 3 cm. Wound bed presents with 90% [MEDICATION NAME] tissue and 10% yellow, dry, adherent slough. Wound margin defined, attached and regular. No drainage noted upon assessment today. Periwound skin intact and WNL (within normal limits). No s/sx of infection noted. Updated MD/POA and new treatment started. Air mattress in place as well as resident to be turned and repositioned Q (every) 2 hours in bed, Q1 hour in w/c." - 11/2/14: "Resident has no pain issues at this time; has received no schedule or PRN [MEDICATION NAME] within the past seven days. Resident receives SensiCare to coccyx and right upper thigh." - 11/09/14: "Nursing asst. (assistant) informed nursing that pt (patient) has an open area on the right buttock/fold area. Applied SensiCare and left message with DON (Director of Nursing) via phone 22:00 (10:00 p.m.) to follow up." - 11/12/14: "Length: 0.2 cm Width: 0.2 cm. Wound bed presents with 80% yellow, dry, adherent slough and 20% [MEDICATION NAME] tissue. Wound margins defined, attached, and regular. No epibole noted. No drainage present upon assessment. Periwound skin pink, intact and blanchable." -11/25/14: "Stage 3 Pressure Ulcer right gluteal fold: length: 2.5 cm; width: 2 cm; depth: 0.6 cm. Wound bed presents with 90% yellow, moist, adherent slough, and 10% [MEDICATION NAME] tissue. Wound margin defined, attached and regular. Scant amount of serosanguinous drainage noted on removed dressing. Periwound skin intact and WNL (within normal limits). No s/sx (signs and symptoms) of infection noted." - 12/02/14: "Stage 3 pressure ulcer right gluteal fold: Length: 2.5 cm, Width: 2.2 cm, Depth: 2 cm: Wound bed presents with 90% yellow, moist, adherent slough, and 10% [MEDICATION NAME] tissue. Wound margin defined, attached and regular. Scant amount of serosanguinous drainage noted on removed dressing. Periwound skin intact and WNL. No s/sx of infection noted. Noted increase in size. Updated (nurse practitioner) today and new treatment orders received and noted." - 12/09/14: "Stage 3 pressure ulcer right gluteal fold: Length 1 cm; width 2 cm; Depth 2.5 cm; Wound bed presents with 60% yellow, moist, adherent slough, and 40% [MEDICATION NAME] tissue. Wound margin defined, attached and regular. Moderate amount of serosanguinous drainage noted on removed dressing. Periwound skin intact and WNL. No s/sx of infection noted. Continue treatment with santyl and mesalt." - 12/16/14: "Stage 3 pressure ulcer right gluteal fold; Length: 1 cm; width 1.5 cm; depth 2.6 cm; Wound bed presents with 20% yellow, moist, adherent slough and 80% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Continue treatment with santyl and mesalt." - 12/23/14: "Stage 3 pressure ulcer right gluteal fold; Length: 1.3 cm; width: 2 cm; Depth: 2.8 cm; Wound bed present with 20% yellow, moist, adherent slough and 80% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. Periwound skin intact and WNL. No s/sx of infection noted. New order received yesterday to increase treatment with santyl and mesalt to BID r/t (related to) drainage." - 12/30/14: "Stage 3 pressure ulcer right gluteal fold: Length: 1.3 cm; Width: 2 cm; Depth 2.8 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN (as needed)." - 01/06/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1.4 cm; Width: 2 cm; Depth 2.7 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN (as needed)." - 01/13/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1.3 cm; Width: 1.8 cm; Depth 2.1 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN (as needed)." - 01/20/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1.5 cm; Width: 1.5 cm; Depth 1.5 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN (as needed)." - 01/27/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1 cm; Width: 1.5 cm; Depth 1.3 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN (as needed)." - 02/03/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1.3 cm; Width: 1 cm; Depth 1 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN (as needed)." - 02/10/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1.3 cm; Width: 1.3 cm; Depth 1 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN (as needed)." - 02/16/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1 cm; Width: 1 cm; Depth 1 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Sinus tract/tunneling present to wound at 1100 upon assessment today. Depth noted at 3.5 cm. (Nurse practitioner) updated and will assess on rounds. Continue packing wound as ordered previously. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. Periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN." - 02/23/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1 cm; Width: 1 cm; Depth 1 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Sinus tract/tunneling present to wound at 1100 upon assessment today. Depth noted at 2.8 cm. (Nurse practitioner) updated and will assess on rounds. Continue packing wound as ordered previously. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. Periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN." - 03/02/15: "Stage 3 pressure ulcer right gluteal fold: Length: 1.5 cm; Width: 1 cm; Depth 1 cm; Wound bed presents with 100% [MEDICATION NAME] tissue. Sinus tract/tunneling present to wound at 1100 upon assessment today. Depth noted at 2.9 cm. (Nurse practitioner) updated and will assess on rounds. Continue packing wound as ordered previously. Wound margin defined, unattached and irregular. Moderate amount of serosanguinous drainage noted on removed dressing. Periwound skin intact and WNL. No s/sx of infection noted. Will continue to measure weekly and PRN." - 03/02/15: "Did call out during wound treatment. Calling out "stop", don't do that", "that hurts". No other complaints of pain this shift." Wound Care Observations On 03/03/15 at 8:00 a.m., Surveyor observed CNA V and CNA W perform routine personal cares for Resident #7. ADON A entered the resident's room to perform daily wound care treatment to the Stage III pressure ulcer to Resident #7's coccyx area. It was noted that Resident #7 was lying on her left side. CNA W removed Resident #7's incontinent pad exposing a dressing to Resident #7's right buttock area. ADON A removed the dressing and cleansed the wound area. ADON A applied packing to the tip of the Q-tip and placed it into the center of the wound to pack the wound area. Resident #7 immediately yelled out, "Oh no...oh no...no...no...no...no....ouch....ouch...stop." Resident #7 appeared to be yelling out in pain during the wound care treatment by ADON A and squirming around in the bed. ADON A stated, "We are almost done...you're doing really well." Surveyor discussed concerns with ADON A in regard to Resident #7 appearing to be in a lot of pain during wound care. ADON A stated that wound care is done daily and that Resident #7 does experience a lot of pain during wound care. Surveyor asked ADON A if Resident #7 had been premedicated with pain medication prior to wound care being done and ADON A stated, "Oh yes...absolutely." CNA V and CNA W then continued with personal cares. CNA W and CNA V attempted to roll Resident #7 onto her back. While rolling onto her back Resident #7 started yelling out. CNA W looked at Surveyor and stated, "She's in a lot of pain when ever we roll her or reposition her." Once on her back, CNA W then removed her incontinent pad and Surveyor noted a large deep red area to Resident #'7's left hip area which measured approximately 4 x 4 cm. A small red area to Resident #7's left ankle which measured approximately 2 x 2 cm's was noted. Surveyor asked ADON A if she was aware of Resident #7 having these two red areas and ADON A stated, "Yes...we apply SensiCare lotion to these

Based on observation, interview and record review, the facility did not provide the necessary treatment and services to promote healing, prevent infection and prevent new open areas from developing for 3 of 3 residents (Residents #5, #7 and #4) reviewed with pressure ulcers. 1. Resident #5 currently has two stage 2 pressure ulcers. The facility did not complete a skin assessment such as a tissue tolerance test to determine a specific repositioning schedule and did not complete Braden scale assessments per policy. The resident's interdisciplinary care plan and the Certified Nursing Assistant (CNA) care plan directed Resident #5 to be repositioned every two hours. Resident #5 was not repositioned for four hours. 2. Resident #7 did not have appropriate interventions on care plan to prevent an unstageable pressure ulcer to the right heel. Resident #7 was also noted to have a red area to the coccyx and staff did not notify the floor nurse with the change in condition. 3. The facility did not ensure that Resident #4's wound cares were performed in a sanitary manner. This is evidenced by: 1. Resident #5's quarterly Minimum Data Set (MDS), dated [DATE], states the resident is bedfast, requires extensive assistance with Activities of Daily Living (repositioning, incontinence cares, dressing and personal hygiene), has a Foley catheter, receives nutrition via tube feeding and is at risk for developing a pressure ulcer. The current interdisciplinary care plan and CNA care plan states, "Pressure Ulcer - Turn and reposition every 2 hours." History of Pressure Ulcers - Per "Weekly Wound Documentation Progress Sheet" dated 06/21/13, Resident #5 had an in-house acquired stage 2 pressure ulcer measuring 2.8 cm x 1.7 cm. on the right mid buttocks. This pressure ulcer healed on 08/21/13. Per "Other Skin Condition Forms": 07/02/13 The resident had a reddened slit not open on the gluteal cleft measuring 2.5 cm long. 07/09/13 The resident had a 2 cm open slit on the gluteal cleft. 07/29/13 The skin was intact. 08/06/13 An open slit 1 cm x 1 cm was present. 08/14/13 - 11/27/13 No open areas present. 12/05/13 New superficial area open to gluteal cleft and right buttocks 2 cm x 2 cm. 01/07/14 No open areas present. 02/18/14 Slit on coccyx with no depth or width. Braden Scales- On 02/20/14 at 7:05 a.m., Surveyor reviewed the Braden Skin assessments completed in the last year with Registered Nurse (RN) I (who completes the weekly wound assessments). RN I stated Braden scale assessments are done quarterly and when a new pressure ulcer develops. The Braden scale, dated 10/23/13, documented a score of "11" (score of 10-12 is high risk for developing pressure ulcers). Observation and Interviews- On 02/19/14 at 6:30 a.m., 8:00 a.m. and at 9:25 a.m., Surveyor observed Resident #5 in bed on her back with a body pillow placed under her right side. On 02/19/13 at 9:35 a.m., Surveyor observed CNA N provide am cares for Resident #5. Resident #5 was positioned on her back with a body pillow under her right side. The resident had a Foley catheter in place with a washcloth folded and placed in the peri area. CNA N removed the washcloth and told the surveyor it was wet with urine. CNA N and Q rolled the resident to her right side. The resident was incontinent of stool. Surveyor observed the resident's back and buttocks to be reddened but blanchable. The coccyx area and buttocks were covered with cream. CNA N told Surveyor the resident is to be turned every two hours and had not been repositioned since she started her shift at 5:30 a.m. by herself or any other staff. CNA Q also stated the resident had not been repositioned since she started her shift at 6:00 a.m. On 02/19/14 at 10:05 a.m., Surveyor observed RN O provide skin care to Resident #5's coccyx and buttocks. RN O cleansed the coccyx and buttocks areas with normal saline and wiped the buttocks with mineral oil per physican order to remove "old" cream. RN O and RN U noted an open area on the right buttocks and gluteal cleft. RN U staged the ulcers as stage 2 ulcers. RN O measured the ulcers on the right buttocks at 2 cm x 0.5 cm and the gluteal cleft at 3 cm x 0.5 cm. This is larger than previously measured on 02/18/14 as a slit with no depth or width. On 02/20/14 at 7:05 a.m., Surveyor interviewed RN I, the facility wound care nurse. RN I stated she measures wounds weekly. RN I stated Resident #5 had an open area to the gluteal cleft that occurred on 07/02/13. RN I stated this area is chronic with healing and reopening. RN I stated the resident currently has a stage 2 ulcer of the gluteal cleft. The resident has a history of ulcers of the right mid buttocks that opened 06/21/13 and healed and now reopened. RN I stated the resident had a history of [REDACTED]. RN I stated the buttocks ulcers were facility acquired. RN I stated the resident has always been on a alternating pressure mattress since admission and three months ago received the Airdyne Alternating Pressure mattress. RN I stated the resident has bladder spasms, leaks around the catheter and was started on [MEDICATION NAME] on 12/20/13. RN I stated the facility reviews the resident weekly in the nutritional at risk meetings. RN I stated the facility does not complete assessments such as a tissue tolerance test. Surveyor informed RN I of the resident not being repositioned for four hours. RN I stated the resident should have been repositioned every two hours per the care plan. RN I stated the resident needs to be turned and repositioned maybe more often as every hour. RN I stated Resident #5 was being seen today by the nurse practioner for assessment of the two new pressure ulcers. On 02/20/14 at 8:30 a.m., Surveyor discussed the observation of Resident #5 not repositioned for four hours with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). According to the standards of practice outlined by the NPUAP (National Pressure Ulcer Advisory Panel), a pressure ulcer is skin and tissue damage, as the result of friction and shearing (rubbing) and/or pressure (pressing in) over a bony prominence. The NPUAP states bed bound persons should be repositioned at least every two hours and chair bound residents should be repositioned every hour. The facility's policy, "Policy and Procedure for the Prevention and treatment of [REDACTED]." 2. On 02/18/14 at 4:05 a.m., Surveyor # reviewed the medical record and noted the following for Resident #7: - Resident #7 was originally admitted to the facility on [DATE]. - Resident #7 was discharged to hospital on [DATE] for a surgical procedure; Left total knee arthroplasty. - Resident #7 was readmitted on [DATE] to facility status [REDACTED]. - Resident has a [DIAGNOSES REDACTED]. On 02/19/14, Surveyor # reviewed the CNA care plan for Resident #7 and noted the following information: - CNA Care plan, dated 09/10/13 (before the knee surgery) for Resident #7 has the following two areas: "Skin Risk" and "Mobility." The skin risk section has the following areas with boxes, to be checked if needed: high risk -initiate CP - tissue tolerance, special mattress, heel protectors/elevate heels, barrier cream, wheelchair cushion and repositioning schedule. None of these boxes were checked on this care plan. The Mobility section was checked for assist for repositioning by one staff member and assist with bed mobility by one staff member. - CNA Care plan, dated 12/19/13 (after the knee surgery), for Resident #7 has the following two areas: "Skin Risk" and "Mobility." The skin risk section has the following areas with boxes, to be checked if needed: high risk -initiate CP - tissue tolerance, special mattress, heel protectors/elevate heels, barrier cream, wheelchair cushion and repositioning schedule. None of these boxes were checked on this care plan. The Mobility section was checked for assist for repositioning by one staff member only. No assist with bed mobility was indicated on this care plan. On 02/19/14, Surveyor # reviewed the comprehensive care plan for Resident #7 and noted the following information: - Care plan for Pressure Ulcers, dated 01/14/14, states, "Avoid friction and shearing forces during transfers or position changes...Keep bony prominence from direct contact with one another with pillows...Use multipodus boots to relieve pressure on the heels. On at all times when in bed..." None of these intervention are mentioned on either of the CNA Care plans mentioned above. On 02/19/14 Surveyor # reviewed the MDS for Resident #7 and noted the following: - MDS, dated [DATE], for section M (which refers to skin) was coded as Resident #7 being at risk for obtaining pressure ulcers. No current pressures ulcers indicated. - MDS, dated [DATE], for section M was coded as Resident #7 being at risk for obtaining pressure ulcers. No current pressure ulcers indicated. - MDS, dated [DATE], for section M was coded as Resident #7 being at risk for obtaining pressure ulcers. No pressure ulcers indicated. - MDS, dated [DATE], for section M was coded as Resident #7 being at risk for obtaining pressure ulcers. No pressure ulcers indicated. - MDS, dated [DATE], for section M was coded as Resident #7 being at risk for obtaining pressure ulcers. This MDS also stated Resident #7 has one unstageable pressure ulcer. - MDS, dated [DATE], for section M was coded as Resident #7 being at risk for obtaining pressure ulcers. This MDS also stated Resident #7 has one unstageable pressure ulcer. On 02/19/14, Surveyor # reviewed the nursing notes for Resident #7, for 01/13/14 and the following was noted: - "PHYSICIAN CONTACT: (NP (Nurse Practitioner) X) here on rounds this AM and assessed right heel. Resident c/o (complaint of) pain throughout the NOC (over night) and therapy noticed some bleeding from right heel. Upon assessment with NP unstageable open area present to right heel measuring 5 cm (centimeters) in length x 6.5 cm in width. Received new orders to cleanse daily and apply [MEDICATION NAME] silver followed by protective dressing. Multipodus boots to be worn at all times when in bed." On 02/19/14, Surveyor # reviewed the weekly skin assessments for Resident #7 from RN I who is currently the Wound Care nurse for the facility. RN I stated she is not wound care certified. The following information was noted from the wound sheets: - 01/13/14: The wound was first identified to the right heel on 01/13/14. The size of the wound is 5 cm in length x 6.5 cm in width with 90% granulation and 10 % eschar. Moderate amount of serosanguineous drainage noted to the wound. Wound edges intact and pink. Pressure ulcer is unstageable. - 01/22/14: Wound is 2 cm in length x 4 cm in width with 10% granulation and 90% eschar. Wound has scant serosanguineous drainage. Wound edges are intact, pink and dry. Pressure ulcer is unstageable. - 01/28/14: Wound is 2 cm in length x 4 cm in width with 10% granulation and 90% slough. Wound has scant amount of serosanguineous drainage. Wound edges intact, pink and dry. Pressure ulcer is unstageable. - 02/04/14: Wound is 2 cm in length x 2.5 cm in width with 90% granulation and 10% slough. Wound has scant amount of serosanguineous drainage. No odor. Wound edges are intact, pink and dry. Pressure ulcer is unstageable. - 02/11/14: Wound is 1.5 cm in length x 2.5 cm in width with 100% granulation. Wound has moderate amount of serosanguineous drainage. No odor. Wound edges intact and pink. Pressure ulcer is unstageable. - 02/18/14: Wound is 1.7 cm in length x 2.5 cm in width and 0.2 cm in depth. Wound has scant amount of serosanguineous drainage. No odor. Wound edges intact and pink. Pressure ulcer is unstageable. On 02/19/14 at 7:43 a.m., Surveyor # observed CNA N perform morning cares to Resident #7. While assisting the resident into a standing position to pull up incontinence product, this surveyor observed a red area to the left side of the buttocks, near the tailbone area, on Resident #7. The red area was approximately 3.0 cm in length by 5.0 cm in width. This surveyor asked CNA N if the red area was new and CNA N stated, "No...it happens because he (Resident #7) sits too long in one position." This surveyor asked CNA N if the new red area was something she would report to the floor nurse and CNA N stated, "No...would only tell the nurse if the skin was broken down...this area just looks like it is caused from sitting too long...red area will probably go away." This surveyor asked CNA N if resident is on a repositioning schedule and CNA N stated, "No...can reposition himself while in bed and in the wheelchair." On 02/19/14 at 9:45 a.m., Surveyor # interviewed RN O who was the floor nurse in charge of taking care of Resident #7. This surveyor asked RN O if a red area to the coccyx region had been reported to her. RN O stated, "No." RN O stated it is the expectation of all staff to report any changes in skin condition on any resident to the floor nurse immediately. This surveyor asked RN O if she would assess Resident #7's skin. RN O agreed. This surveyor observed RN O assess the coccyx region of Resident #7 and the red area to the left of the buttocks, near the tailbone, was still visible. Red area was blanchable per nursing assessment. This surveyor asked RN O if the red area was caused by pressure and RN O stated, "Most likely." RN O stated Resident #7 is not currently on a repositioning schedule. This surveyor discussed concerns with RN O in regard to no repositioning schedule being done for Resident #7 when he has already triggered for being at risk for pressure ulcers and currently has an unstageable pressure ulcer to the right heel. RN O stated she would discuss the situation with the DON. On 02/19/14 at 4:20 p.m., Surveyor # interviewed RN I. This surveyor discussed care plans and interventions needed to prevent pressure ulcers from occurring for Resident #7. RN I reviewed the CNA Care plans, dated 09/10/13 and 12/19/13. RN I stated each resident, upon admission, is provided with this care plan and the nurses fill all sections out according to their assessment of the resident. RN I stated the original care plan stays in the resident's chart and is updated as needed. The CNAs then receive a copy of the care plan, upon admission and with any/all changes, so they will then know how to take care of the residents. RN I stated when Resident #7 was first coded as being at risk for pressure ulcers, according to the MDS dated [DATE], interventions should have been indicated on the care plan. RN I stated no interventions were put into place on the CNA care plan for the CNAs on how to properly maintain Resident #7's skin. RN I stated when Resident #7 returned from the hospital, status [REDACTED].#7. RN I stated when Resident #7 developed a pressure ulcer, in house, to his right heel on 01/13/14, interventions should have been indicated on the CNA care plan to help ensure the staff are providing appropriate cares to prevent further skin damage to Resident #7. RN I agreed with this surveyor, indicating both care plans should have been updated reflecting the appropriate cares needed for Resident #7 to maintain the highest quality of care to prevent pressure ulcers. RN I stated Resident #7 is his own person and the facility did not document education, if any, to the resident on risks of skin breakdown. RN I stated the pressure ulcer to the right heel is avoidable because the facility did not put appropriate interventions into place to ensure safety to the resident's skin. RN I stated Resident #7 is diabetic and is at risk for skin breakdown. On 02/19/14, Surveyor # interviewed the DON and RN I. This surveyor discussed the concerns of not having appropriate interventions into place and Resident #7 then acquired an unstageable pressure ulcer and now has a red area to the coccyx region. Both the DON and RN I agreed the pressure ulcer was avoidable and Resident #7 should be repositioned on a routine basis. Both the DON and RN I agreed if Resident #7 was on a repositioning schedule the reddened area to the coccyx region may have been avoidable as well. RN I stated staff education would immediately be completed and care plans would reflect appropriate interventions. 3. [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (Methacillian Resistant Staph. Aurous). On 02/19/14 at 1:30 p.m., Surveyor observed wound cares performed for Resident #4. Wound treatments were provided to the resident by RNs H and I. RNs H and I gained permission to perform wound cares. RN I and RN H donned gowns and entered the room. RN I and RN H then performed hand hygiene and donned vinyl gloves. RN I and RN H placed a barrier over the resident's tray table after cleaning it. Wound care supplies were gathered from a pink basin, which was stored in the resident's room. RN H and RN I performed hand hygiene and donned fresh gloves. RN H and RN I then positioned the resident for left trochanter wound cares. RN H removed the soiled wound dressing from the trochanter area, then without performing hand hygiene or glove change, irrigated the wound with a spray bottle of wound wash. After the wound wash irrigation, RN H obtained a dry 4x4 gauze from the general supply located on the bedside table, thus contaminating other clean supplies, and proceeded to dry the outer edges of the wound. After disposing of the 4x4 used to dry the outer wound edges, RN H obtained another clean 4x4 gauze and wrapped the gauze around a wooden handled q-tip. RN H then dried the inside of the wound and inner wound edges. After disposing of the gauze wrapped q-tip, RN H then removed gloves and performed hand hygiene. After donning a fresh pair of gloves, RN H packed the wound with calcium alginate (a wound medication) and covered the wound with a bordered wound dressing. RN H then performed hand hygiene and donned a fresh pair of gloves. Next, RN H removed a soiled dressing from the left ischeal area. RN H then placed the soiled wound dressing in a plastic bag. Then without changing gloves or performing hand hygiene, RN H irrigated the wound with wound wash. RN H then obtained a dry 4x4 gauze from the general supply that was placed on the bedside table, thus contaminating other clean supplies, and proceeded to dry the outer edges of the wound. After disposing of the 4x4 used to dry the outer wound edges, RN H obtained another clean 4x4 gauze and wrapped the gauze around a wooden handled q-tip from the general supply on the bedside table, and proceeded to dry the inner wound and wound edges. After disposing of the gauze wrapped q-tip, RN H then preformed hand hygiene and donned a fresh pair of vinyl gloves. RN H then packed the wound with calcium alginate (a wound packing) using a q-tip, and covered the wound with a bordered wound dressing. RN H then removed gloves and performed hand hygiene. After donning a fresh pair of gloves, RN H and RN I repositioned the resident in order to perform wound care to her right lower abdominal area. RN H again removed the soiled dressing and placed it in a plastic bag. Then, without changing gloves or performing hand hygiene, RN H irrigated the wound with wound wash. RN H then dried the outer wound edges with a 4x4 gauze that was removed from the general supply on the bedside table, thus again contaminating the clean supply. After disposing of the used 4x4, RN H obtained a fresh 4x4 gauze, wrapped it around a fresh q-tip and dried the inner wound bed. RN H then removed gloves and performed hand hygiene. After donning a fresh pair of gloves, RN H packed the wound with calcium alginate and covered the wound with an ABD (a type of dressing) and secured it with tape. RN H then removed her gloves and performed hand hygiene. RN H and RN I repositioned the resident. RN H removed a soiled wound dressing from the upper right posterior rib area. After removing the soiled dressing and without changing gloves or performing hand hygiene, RN H cleansed the wound with wound wash. Then RN H dried the area, which was closed, with a 4x4 gauze obtained from the general stack of clean 4x4s located on the resident's bedside table, thus contaminating the clean 4x4s. RH H then placed a foam dressing over the closed wound area and applied a border dressing. Next, RN H removed a soiled sternal wound dressing. RN H placed the soiled dressing in a plastic bag. Then, without performing hand hygiene or changing gloves, RN H cleansed the area with wound wash. After cleansing the area with the wound wash, RN H dried the area with a fresh 4x4 gauze removed from the general clean supply on the resident's bedside table, thus contaminating the clean supply. Then RN H removed gloves, performed hand hygiene and donned a fresh pair of gloves. After donning a fresh pair of gloves, RN H removed a wooden handled q-tip from a package and applied [MEDICATION NAME] (a wound treatment) to the sternal wound. RN H then covered the sternal wound with a bordered dressing. RN H and RN I then performed hand hygiene and donned fresh gloves. RN H and RN I assisted the resident with repositioning. After assisting the resident with repositioning, RN I performed hand hygiene and donned a fresh pair of gloves. RN I then wiped the outer container of wound wash with an antiseptic wipe. RN I gathered the clean supplies and placed them back in the resident's pink basin, and placed the basin into a drawer. RH H removed her gloves and performed hand hygiene. After donning a fresh pair of gloves, RN H gathered the plastic bag of soiled supplies and disposed of it in the soiled utility room. RN H then performed hand hygiene. On 02/20/14 Surveyor interviewed RN I, who functions as the Wound Nurse for the facility. RN I told Surveyor that she also noticed that RN H did not perform hand hygiene after removing the soiled wound dressings and prior to cleansing Resident #4's wounds. RN I stated, "That is why I wiped down the outside of the wound wash spray bottle." RN I told Surveyor that the facility's practice is to perform hand hygiene and don fresh gloves after the removal of soiled wound dressings. Surveyor reviewed a policy entitled "Policy and Procedure For The Prevention and treatment of [REDACTED]. Pull gloves over dressing and discard into appropriate plastic waste bag. Wash hand thoroughly. Put on disposable gloves. Irrigate/cleanse the wound as ordered..."

Based on observation, interview, medical record review and policy review, the facility did not ensure each resident received adequate assistance or supervision to prevent accidents for 1 of 6 sampled residents reviewed for falls, Resident #3. The facility did not ensure the resident environment remained free of accident hazards for 53 of the 75 residents with cognitive impairment. Resident #3 had nine falls during the time period of 04/08/11 through 08/16/11. While the facility implemented measures to prevent falls, the facility did not thoroughly investigate and analyze the root cause of each fall and implement further measures including increased supervision to prevent falls. Five out of the nine falls occurred during Resident #3's night time/bed time hours and involved Resident #3 needing to use the bathroom. The facility had not implemented a night time toileting schedule for Resident #3 as of the time of survey. Following the fall on 07/26/11 Resident #3 was diagnosed with [REDACTED]. The fireplace in the lounge by the front door had an opening where hot air was expelled, where residents could possibly be burned. There are 53 residents in the facility who have cognitive impairment. This is evidenced by: The facility policy and procedure for "Falls" dated 10/11 read in part: Policy: To ensure proper and consistent documentation and follow up of falls. Procedure: When a fall occurs, documentation of the "incident" is done as follows: ? Wing nurse documents what occurred in ECS (electronic charting system) under "Falls." 1. Review of Resident #3's medical record by Surveyor beginning on 10/25/11 identified Resident #3 had nine falls since being admitted to the facility on [DATE]. A document titled Safety Risk Data Collection Evaluation completed for Resident #3 on 04/08/11 read, "Based on Collected Data Resident Is @ (at) Risk for Falls @ This Time...No" was X'd. On this same form in the section Analysis or Summary of Safety Risks the following was written; "Resident is alert & oriented times 3, w/ (with) occasional confusion. Expresses needs w/o (without) difficulty. Uses call light appropriately. She is at risk for falls due to her history of falls. Resident is in agreement w/ plan. Tab alarm in place." During an interview with the Director of Nursing (DON) on 10/25/11 at approximately 1:30 p.m. Surveyor asked the DON if she had more information regarding Resident #3's falls, such as an investigation of the falls, incident report or statements from staff. The DON told Surveyor she had no further information other than what was documented in the nurses' notes as follows. ~04/08/11 (date of admission) at 10:00 p.m. Resident #3 was observed on the floor near her bedside. Tab alarm sounded and alerted staff. Resident stated she was going to the bathroom. The note identified resident was last observed at 9:30 p.m. and she was sleeping per staff. The nurses' note did not identify what time Resident #3 had last been toileted prior to the fall. After this fall, the facility implemented a floor mat next to her bed and a low bed along with the Tabs alarm already in place. The nurses' note read there was no injury from the fall. The "Fall Safety Risk Review" document after this fall read "Safety Interventions/Environmental modifications implemented: Low bed & floor mats & continue w/ tab alarm." ~04/11/11 at 1:35 a.m. Resident #3 was found on the floor next to her bed. The Tab alarm had been in place but the clip had come unfastened from her garment. Resident told staff she was on her way back to bed from using the bathroom. The nurses' note regarding this fall did not identify when Resident #3 had last been toileted prior to the fall. No injury identified from the fall. The facility action to prevent reoccurrence was documented in the nurses' notes to implement a pressure alarm for her bed and increase/encourage toileting. Resident #3's care plan or Certified Nursing Assistant (CNA) assignment card did not identify how they were going to increase/encourage toileting during the night. Resident #3's care plan did not contain a toileting routine for Resident #3's bedtime hours. Resident #3's care plan included the approach to toilet Resident #3 before and after meals and at bedtime but not specifically during the night. The "Fall Safety Risk Review" document following this fall read, "Safety Interventions/Environmental modifications implemented: Pressure sensor alarm, encourage and increase toileting." ~04/13/11 at 2:15 p.m. Resident #3 was observed on the floor in her room lying on the landing mat. Bed was in low position. The 04/13/11 nurses' note read, "Resident had been in therapy. Therapy staff (initials) assisted her to bed, bed was left in low position with landing mat in place side of the bed. CNAs were not aware resident returned from therapy. Therapy staff (initials) did not place alarm on staff (meant resident) when assisted to bed. Alarm was still on w/c (wheelchair)." No injury occurred with fall. The nurses' note for the 04/13/11 fall read, "Analysis as to cause of occurrence: Therapy staff did not apply alarm to resident, did not notify CNA resident had returned. Residents are to be toileted before laying down in bed...Action to prevent reoccurrence: Talked to therapy staff. CNAs are to be notified when resident is return to room so alarms can be checked and resident toileted if needed." The 04/13/11 nurses' note regarding that fall did not identify when Resident #3 had last been toileted prior to the fall. The "Fall Safety Risk Review" document read "Safety Interventions/Environmental modifications implemented: Therapy to notify CNA when resident returns to room (Need to check alarms & toilet)." A nurses' note dated 05/25/11 with a time of 1:16 p.m. read, "Temporary Problem: Resident takes her tab alarm off and goes to the bathroom independently. No amount of reminding does any good. Will take the alarm off for three day to assess her safety. If it is determined she is safe the alarm will be removed." A nurses' note written 05/25/11 time of 8:46 p.m. read "Temporary Problem: Resident did attempt to self-transfer x 2 this PM shift. Tab alarm was placed for safety. Resident did not make any attempt to remove alarm." According to nurses' notes on 06/03/11 at 5:10 a.m. Resident #3 was found on the floor at the foot of her bed. The nurses' note read: "resident found on her right side on the floor of her room, silent, moving arms and legs, bed alarm was not sounding, pressure pad in place but not working, replaced with a new one and is currently functioning." The note did not identify if the Tab alarm was in use and if it had sounded. The facility did not investigate why the pressure pad alarm was not functioning. The nurses' note also included, "When resident last observed? 0415 (4:15 a.m.) What were they doing? sleeping Time last rounded/toileted or changed 0415." The note did not specify if she had actually been toileted at that time. The 06/03/11 nurses' note with the time of 6:26:06 identified Devices/Equipment/Supplies and read, "Floor mat Low bed Alarm type pressure sensor in bed, tab when in w/c." A temporary problem nurses' note provided later to Surveyor on 10/26/11, dated 06/03/11 with the time of 1:33 p.m. read, "Tab alarm and pressure alarm intact while in w/c and in bed." There is conflicting information if the Tab alarm was being used in the wheelchair and in the bed at the time of the 06/03/11 5:10 a.m. fall as it was not addressed if the Tab alarm was on and sounding at the time of the 06/03/11 fall. A temporary problem nurses' note entry for 06/03/11 at 10:17 p.m. read, "...Tab/pressure alarm in place for safety at this time." The "Fall Safety Risk Review" document following this fall read, "Safety Interventions/Environmental modifications implemented: pressure pad changed, working." Review of Resident #3's medical record by Surveyor on 10/26/11 identified a nurses' note written by Registered Nurse (RN) E dated 06/08/11 with a time of 10:29 p.m. that read, "Nurse charting: Tab alarm and floor mat will be discontinued at this time. Resident noted to take tab alarm off self and attempt to transfer self several times. Resident's daughter (daughter's name), here and both her and resident agree to discontinue alarm and floor mat at this time." On 10/26/11 beginning at 2:27 p.m. an interview was conducted by Surveyor with RN E in the presence of the Director of Nursing (DON). Surveyor asked RN E how the decision came about to discontinue the Tab alarm and the floor mat for Resident #3. RN E stated she thought there had been a temporary problem at that time addressing the Tab alarm and the plan was to discontinue it. Surveyor asked if there was an assessment for the discontinuation of the Tab alarm and fall mat. The DON told Surveyor that the surveyor did not get the temporary problem documentation as they do not print out with nurses' notes as they are in a different folder in the computer. The DON provided Surveyor with the temporary problem documentation from 06/01/11-07/15/11. This information did not contain an assessment for discontinuing the Tab alarm other than she takes it off. A temporary problem note dated 06/09/11 read, "Resident is being trailed (spelling incorrect (sic)) without her alarm for the next three days to see if she is safe without it. She is using the furniture as an aide to steady herself as she navigates her room. Has had no falls since she has been taking her alarms off for some time." Surveyor was informed on 10/26/11 during the interview with RN E and the DON that the pressure alarm had continued in bed which is contrary to a temporary problem note of 06/12/11 which read, "Resident continues without alarms, doing well. Transferring self safely." The interview also contradicts the facility ' s Safety Risk Data Collection Evaluation quarterly review Analysis/summary section dated 07/08/11 which read, "No alarms at this time. No low bed/floor mats." Resident #3 fell again on 07/25/11 and the record did not identify any information about an alarm sounding or in use. Nurses' notes documented on 07/25/11 at 12:25 a.m. Resident #3 was found on the floor in her bathroom. The nurses' note read, "CNA heard a thud sound from room (number) and went to the room and found resident laying on her back on the floor in the bathroom. The toilet high riser was on the floor also. (CNA's initials) notified me by walkie talkie and I went down to the room right away. Resident was laying on her back on the Bathroom floor between the toilet and the bathroom sink. I asked resident if she hit her head and she said yes. I did not find any lumps or bruises on resident's head. ...I asked resident to straighten out her legs. Resident was able to straighten out her right leg. Resident could not straighten out her left leg. She held on to her left hip and grimaced and yelled out in pain." Resident #3 was taken by ambulance to St. Francis Medical Center emergency room (SFMC ER) in La Crosse. The incident nurses' note does not identify if the pressure pad alarm was sounding at the time of the fall. The Tab alarm had been discontinued on 06/08/11 as Resident #3 could take the Tab alarm off. The nurses' note for the 07/25/11 fall contained the following: Action to Prevent Reoccurrence: "Tell resident to use call light for assist to the bathroom at night. We will put a tab monitor on her tonight if she comes back to us from SFMC-ER." From review of Resident #3's medical record, both of these interventions had proven ineffective in the past, as resident does not use the call light consistently and the Tab alarm she would remove. Resident #3 returned to the facility at some point on 07/25/11. It was not documented that Resident #3 returned to the facility nor the time Resident #3 returned. The nurses' note on 07/25/11 with the time of 10:39 a.m. identified a call was placed to the physician on call and obtained that the x-rays were negative. Resident #3 was having increased pain in her left leg and needed the assistance of two staff with transfers. The nurse obtained a stronger pain medication order for Resident #3. Vital signs were charted at 12:14 p.m. and 9:38 p.m. on 07/25/11. The "Fall Safety Risk Review" document following the 07/25/11 fall read "Safety Interventions/Environmental modifications implemented: Left leg pain-Sent to ER for eval (evaluation). Bed low position tab alarm bed & chair, 2 assist c/ (with) gait belt & 4 w\ (wheeled) walker. Summary: Discussion held will reapply alarms Bed & chair, low bed." The facility did not complete an assessment of Resident #3's toileting needs so a toileting plan could be implemented to help reduce falls. On 07/26/11 at 2:20 a.m. nurses' notes documented Resident #3 was found on the floor. The nurses' note written at 5:13 a.m. read: Nature of Injury: "None. Resident found sitting on her buttocks next to her bed with her legs out in front of her. She did not hit her head. No internal or external rotations noted. She was able to place both feet flat on floor with knees bent and assist to boost herself up to standing. Two assist and gait belt used. Resident was able to stand and pivot transfer to the toilet. She did grimace related to left hip pain from fall 07/25/11." Activity Level At Time Of Occurrence: Up with help When resident last observed: 0200 (2:00 a.m.) What were they doing: sleeping" The nurses' note did not include when Resident #3 had last been toileted. Analysis as to cause of occurrence: "Other resident unable to self-transfer due to left hip pain from last fall 07/25/11. She needed to transfer to the bathroom to void." Action To Prevent Reoccurrence: "landing mat placed to prevent injury." The "Fall Safety Risk Review" document after this fall read "Safety Interventions/Environmental modifications implemented: landing mat on bathroom side of bed. Tab sensor alarm in bed and wheelchair. Summary: Wireless chair & bed alarm put in place." During an interview on 10/26/11 the DON explained to Surveyor a wireless alarm is one that does not beep (alarm) in the resident's room, it alarms at the nurses' station and over a pager. The next nurses' notes for 07/26/11, written at 6:23 a.m., documented Resident #3 had been given a pain pill for continued pain control. A note at 1:26 p.m. listed her vital signs. The next note on 07/26/11 at 7:49 p.m. read, "Contact made to physician related to her left hip pain." Orders were received for Resident #3 to be transferred to FSH (Franciscan Skemp Hospital) for evaluation of her lift hip. A nurses' note with the time of 8:03 p.m. on 07/26/11 read in part as follows: "Resident noted to facial grimace and moan upon movement of left leg the PM shift. No shortening of the leg or outward turning noted. Resident noted to have difficulty transferring, guards left hip. Able to point to area of pain, stating, 'It hurts.' Pain unrelieved by PRN percocet...Resident was admitted to FSH due to a break in her left trochanter." Resident #3 underwent an open reduction internal fixation (ORIF) surgical procedure on 07/27/11 for repair of the left hip fracture. Resident #3 returned to the facility on [DATE]. While at the hospital Resident #3 was also diagnosed with [REDACTED]. A nurses' note written 07/31/11 at 3:48 p.m. read, "...Resident has poor judgment and safety awareness secondary to dementia. Pressure alarm in place at all times. Low bed with floor mat in place when resident in bed." On 07/31/11 a nurses' note with the time of 8:39 p.m. identified Resident #3 was observed on the floor near her bedside at 7:45 p.m. The nurses' note identified: Devices/Equipment/Supplies "Low bed Floor mat Alarm type: pressure" The note did not identify if the alarm was sounding when Resident #3 was found on the floor. Action To Prevent Reoccurrence: "Will provide 30-minute checks times 3 days." During an interview conducted on 10/26/11 by Surveyor with the DON, Surveyor asked if there was an evaluation or assessment of the results of the 30-minute checks done for the three days. From review of Resident #3's medical record, it is determined Resident #3 did not fall during those three days when the 30-minute checks were being done. The DON provided Surveyor with copies of the 30-minute check sheets. The sheets identified where she was when checked on. Review of Resident #3's nurses' notes from 08/01/11-08/04/11 by Surveyor identified there was no evaluation of the 30-minute checks. The 30-minute checks were stopped after the three days. The "Fall Safety Risk Review" document after this fall read "Safety Interventions/Environmental modifications implemented: Will provide 30-minute checks times 3 days. Summary: Returned from hosp (hospital). S/P (status [REDACTED]. More confused than was prior to surgery. 30-minute checks appropriate." A nurses' note of 08/05/11 with the time of 5:57 a.m. identified Resident #3 set off her bed alarm at 2:15 a.m. and was assisted to the toilet. An 08/05/11 nurses' note with the time of 2:59 p.m. read in part, "Resident continues to attempt to transfer self. Will not use her call light or wait for assistance." According to nurses' notes, on 08/13/11 at 9:10 a.m. Resident #3 was observed on floor in her room. Her alarm was sounding and alerted staff. The 08/13/11 10:58 a.m. nurses' note read "When resident last observed: Propelled self back from dining room at 0845 (8:45 a.m.) Time last rounded/toileted or changed 0740 (7:40 a.m.)." The note does not clearly identify if she was toileted or changed at 7:40 a.m. Devices/Equipment/Supplies "Wheelchair, Floor mat, Low bed, Alarm type: pressure pad in w/c (wheelchair), TAB alarm in bed." Analysis As To Cause Of Occurrence: Behavioral. Resident will not use call light or wait for assistance from staff. Not completely aware of safety risk." Action To Prevent Reoccurrence: "Staff will assist resident back from dining room after meals and assist her back into her bed to prevent resident from attempting to transfer herself." Review of Resident #3's care plan and the CNA assignment card by Surveyor on 10/26/11 identified those interventions were not listed as approaches on her plan of care. The "Fall Safety Risk Review" document after this fall read, "Safety Interventions/Environmental modifications implemented: Assist to & from dining Rm (dining room) assist back to bed /p (after) meals." According to nurses' notes, on 08/16/11 at 8:00 p.m. Resident #3 was observed on the floor in her room. The nurses' note identified Resident #3 had been gotten up from bed and assisted to her wheelchair and toileted at 7:45 p.m. Using the communication board Resident #3 informed staff she was going to the bathroom when she fell . The nurses' note read, "Silent alarm in place at this time" and "Resident uses wireless alarm system while up in wheelchair/bed." The nurses' note did not identify if the alarm had alerted staff to Resident #3's fall. Action to prevent reoccurrence read, "A three day bowel and bladder diary in place to evaluate resident's toileting habits." The "Fall Safety Risk Review" document following this fall read, "Safety Interventions/Environmental modifications implemented: A three day bowel and bladder diary in place to evaluate toileting habits. Summary: Will have room change to have @ (arrow pointing up) (upper) hall higher traffic area & less alarm on hall." Surveyor reviewed the bowel and bladder voiding diary completed for Resident #3 08/16/11-08/19/11. The summary at the end of the voiding trial read, "Resident is occasional incontinent of bowel and bladder. She is alert & oriented. Resident is on alarms due to fall risk. She is monitored on intake & output. Voiding w/o (with out) difficulty. Bowel movements are regular." After the diary was completed, no toileting routine had been established for night time hours to help prevent falls from needing to use the bathroom at night. The diary showed that on the night of 08/16/11-08/17/11, Resident #3 was toileted at 1:45 a.m. and 4:30 a.m. and remained dry and did not fall. On the night of 08/17/11-08/18/11 Resident #3 was toileted at 1:30 a.m. and 5:30 a.m. and remained dry and did not fall. The night of 08/18/11-08/19/11 Resident #3 was toileted at 12:00 a.m. and was dry. A nurses' note on 08/16/11 with the time of 10:26 p.m. read, "...Resident trying to self-transfer all shift. Resident non compliant with putting the call light on and waiting for help. Alarms in place." The facility knew Resident #3 was trying to self-transfer, however they did not implement measures other than the three day bowel and bladder diary. They did not increase the supervision of Resident #3. Resident #3's Care Area Assessment (CAA) completed by the facility dated 08/08/11 identified Resident #3's had a history of [REDACTED]. The DON and Nursing Home Administrator were informed of the above concerns on 10/26/11 related to Resident #3's falls. 2. Surveyor performed an environmental tour on 10/25/11 at 1:30 p.m. There was an electric fireplace in the lounge by the front door. The fireplace was not lit, but there was a gap in front of the fireplace, approximately 18 inches wide by 1 inch high, approximately 2 feet above the floor, through which hot air was blowing. Surveyor took the temperature of the hot air, which was 175 degrees. This temperature was verified by Registered Nurse (RN) D. This gap was at a height where residents with dementia, and in wheelchairs, could place their fingers. Surveyor then discussed the above observation with the Nursing Home Administrator (NHA), who unplugged the fireplace. He stated he would have the maintenance department figure out a way to do away with the cord. The facility has 61 residents who are in chairs most of the time, according to the Resident Census and Condition Report, and 53 residents who are noted to have cognitive impairment, according to the Resident Roster Matrix.