Every finding on record at Bradley Estates Nursing and Rehab LLC

Based on observations, record reviews, and interviews, the facility failed to protect the resident's right to be free from physical abuse by a staff member for one of three residents (Resident (R) 2) reviewed for abuse in a total sample of 11. R2 was the subject of physical abuse when Certified Nurse Aide (CNA) 5 poured coffee on R2. This had the potential to cause physical as well as psychological harm to the residents CNA5 provided care for. Findings include: Review of R2's undated admission Record, located under the Profile tab of the electronic medical record (EMR) revealed that R2 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/27/26 revealed a Brief Interview for Mental Status (BIMS) of three out of 15 indicating a severe cognitive impairment. During an interview on 07/08/26 at 7:13 AM, CNA4 stated the accused CNA5 was playing around with R2 tapping the resident on the arm. CNA4 stated that R2 poured a glass of juice on CNA5. Then CNA5 then grabbed a coffee container and stated she was going to stoop down to the residents' level and proceeded to pour the old coffee on R2's shirt sleeve. CNA4 stated that CNA5 did not pour coffee on R2's head. During an interview on 07/08/26 at 7:18 AM, CNA5 stated that R2 and she were sitting in the common area playing around when R2 threw her drink in CNA5's face. CNA5 stated that she grabbed the coffee and poured it on R2's shirt sleeve. CNA5 stated there was another CNA who reported her. CNA5 stated that no one else was present in the room but CNA4 claimed she witnessed the event. CNA5 stated that she was made to leave the facility right then and does not understand why because her and R2 were just playing around. During an interview on 07/08/26 at 8:00 AM, the Director of Nursing (DON) stated that she contacted R2's family to inform them of the incident. The DON stated that she had CNA5 immediately removed from the building. The DON stated that she was told that R2 threw a glass of juice on CNA5 and then CNA5 poured some old coffee on R2's shoulder. The DON stated that the coffee was left from earlier in the day and was not hot. The DON stated that R2 could not remember the event. The DON stated that R2 could not be interviewed due to her cognitive impairment. The DON stated that the facility completed skin checks on R2 to ensure there were no injuries. Review of the facility-reported incident revealed that the facility was still completing the investigation and that the proper steps have been taken to protect the residents from further abuse from CNA5. There was not a police report available at the time of the investigation. During an interview on 07/08/26 at 9:25 AM, the Administrator stated that the incident did happen with CNA5 and R2. The Administrator stated that the facility was still in the process of the five-day investigation for the stated agency. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 02/2026, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.

Based on observation, interview, record review, and policy review, the facility failed to ensure a clean and homelike environment was maintained for eight of 31 sample residents (Resident (R) 20, R28, R14, R15, R18, R19, R16, and R17) reviewed for the environment. This had the potential to affect residents' well-being throughout the facility by not having a clean and homelike environment. Findings include:1. Review of R20's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident to the facility on [DATE].Review of R20's EMR titled quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 10/07/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was moderately cognitively impaired.2. Review of R28's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident to the facility on [DATE].Review of R28's EMR titled quarterly MDS located under the MDS tab with an ARD of 09/12/25 indicated the resident had a BIMS score of 12 out of 15 which revealed the resident was moderately cognitively impaired. 3. Review of R14's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident to the facility on [DATE].Review of R14's EMR titled admission MDS located under the MDS tab with an ARD of 10/29/25 indicated the resident had a BIMS score of 13 out of 15 which revealed the resident was cognitively intact.4. Review of R15's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident to the facility on [DATE]. Review of R15's EMR titled annual MDS located under the MDS tab with an ARD of 11/04/25 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. 5. Review of R18's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident to the facility on [DATE]. Review of R18's EMR titled admission MDS located under the MDS tab with an ARD of 10/29/25 indicated the resident had a BIMS score of nine out of 15 which revealed the resident was moderately cognitively impaired. 6. Review of R19's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 06/11/25.Review of R19's EMR titled quarterly MDS located under the MDS tab with an ARD of 12/03/25 indicated the resident had a BIMS score of seven out of 15 which revealed the resident was severely cognitively impaired. 7. Review of R16's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 08/06/24.Review of R16's EMR titled quarterly MDS located under the MDS tab with an ARD of 11/12/25 indicated the resident had a BIMS score of 10 out of 15 which revealed the resident was moderately cognitively impaired. 8. Review of R17's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 07/23/25. Review of R17's EMR titled quarterly MDS located under the MDS tab with an ARD of 11/10/25 revealed the staff could not determine the resident's BIMS score. During observations and interview conducted on 12/29/25 at 11:55 AM, R20 permitted the surveyor to open the [NAME] and [NAME] bathroom (a bathroom with entry from two different resident rooms with a shared bathroom space for use). There was a used urinal and a container of soiled clothing in a plastic hamper. The hamper was uncovered and there was a strong smell of urine. A general tour was conducted of the resident's room. There was a thick layer of dark dust on the top of her wall heater. The window shelf adjacent to the resident's bed was covered with dark dust as well. The sink in the room had a broken drain plug. The room next to R20 was observed. R28 stated that the staff never moved her bed to clean underneath it. The window shelf, adjacent to her bed had a thick layer of dust and a cobweb. There were candy wrappers on the side of the resident's bed. The wall heater had dust on the top of it. The floor around the resident's bed was sticky. The floorboard at the head of the resident's bed was coming off the wall. The room for R14 and R15 was observed. The ceiling above R14's bed had a large splatter on it. The window adjacent to R15 had a towel in front of the base of the window. There were visible splash marks on the wall in which the television of R15 was mounted. On the wall adjacent to R14's bed were large scrapes. There were no patching and no paint in this area. R15 confirmed that the staff did not repair the walls in the residents' room. There was a broken sink plug in R14 and R15s' room. The baseboard across from R14's bed had two thick brown stains that could not be wiped off. The room for R16 and R17 was observed. There were deep scratches on the wall adjacent to R17. The ceiling above R17 had brown stains. The bed extenders for R17 had brown and yellow dried material on them. The attached closet in the room had exposed pressed wood from under the closet. A tour was conducted on 12/29/25 at 12:20 PM with the Regional Manager for (name of contracted housekeeping service for the facility). The Regional Manager confirmed all observations. Regional Manager stated there was a new Director of Housekeeping. The Regional Manager stated there were call offs during the weekend and the person who was scheduled to clean this unit was late due to the weather. During this interview, the Regional Manager entered the room for R18 and R19. There was a missing tile under the residents' sink. A request was made for the cleaning schedules for the residents' rooms from 09/25 through 12/25. A review was conducted of the deep cleaning schedules provided by the Regional Manager. The facility failed to provide evidence that the residents' rooms were deep cleaned for the month of 12/25. During an interview on 12/30/25 at 10:14 AM, the Maintenance Assistant stated staff were to place any repair work into TELS (a building management system to log in repairs needed by staff). The tour commenced at 10:20 AM. The Maintenance Assistant entered the following resident rooms: R20, R28, R14, R18, R19, and R16, and R17. The Maintenance Assistant stated he was not aware of the areas of disrepair. Review of a facility's undated policy titled, Daily Cleaning Procedures, indicated .High Dust. Work your way clockwise around the room (starting at the door and finishing at the door) and dust all high surfaces. This includes, but is not limited to: pictures/prints, televisions, over-the-bed lights, blinds, vents, and all corners.Disinfect. Work your way clockwise around the room (starting at the door and finishing at the door) and disinfect flat surfaces and high-touch items. This includes, but is not limited to: doorknobs, light switches, call lights, TV removes, bed rails, bed frames, footboard and headboard, bedside tables, closet handles, windowsills, chair, heating unit, and any flat surfaces.Review of a facility's policy titled, Quality of Life-Homelike Environment, dated 04/14, indicated .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview, record review, and facility policy review, the facility failed to ensure resident council grievances were resolved in a timely manner for three out of six monthly meetings, by three council members/attendees of the resident council meetings (Resident (R) 29, R15, and R31) of 31 sample residents. Failure to address and resolve grievances raised during resident council meetings in a timely manner has the potential to negatively affect residents' quality of life and satisfaction with care.Findings include:1.Review of R29's electronic medical records (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 05/13/25.Review of R29's EMR titled annual Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 11/01/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact.2. Review of R15's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 11/25/24.Review of R15's EMR titled annual MDS located under the MDS tab with an ARD of 11/04/25 revealed the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. 3. Review of R31's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 12/01/17.Review of R31's EMR titled annual MDS located under the MDS tab with an ARD of 11/19/25 indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. A review was conducted of documents provided by the facility titled Resident Council Meeting Minutes, dated 10/21/25, indicated the resident council members voiced that they would like feedback on all the administrative changes, requests were made for more puzzles, shopping trips out in the community, more fresh fruit, and vegetables, and voiced that there were times there were not enough snacks for the residents. The members of the resident council meeting voiced that they wanted more butter and syrup with the pancakes that were served during breakfast. Finally, the council attendees voiced that they would like to meet with dietary to discuss concerns with meals served. A review was conducted of documents provided by the facility titled Resident Council Meeting Minutes, dated 11/19/25, revealed the former Activity Director informed the resident council attendees that there was a new Administrator but failed to ensure the attendees were informed of any resolution from the previous Resident Council Meeting. The meeting minutes failed to have a section in the document which addressed current Resident Council Members' concerns for the month. A review was conducted of documents provided by the facility titled Resident Council Meeting Minutes, dated 12/18/25, indicated the resident council attendees were not provided resolution from 10/21/25 issues. Specifically, the council attendees voiced the same concerns identified in 10/21/25 with no resolution.During an interview conducted on 12/29/25 at 4:37 PM, the facility's Concierge stated she was responsible for addressing resident grievances. The Concierge stated she had not been invited to any resident council meetings from 08/25 through 11/25. The Concierge stated she was recently invited to the resident council meeting for the month of 12/25, and she was invited by the President of Resident Council (R15). During an interview conducted on 12/30/25 at 8:35 AM, R15 confirmed she was the President of the Resident Council. R15 stated that there had been multiple complaints filed by the members and attendees of the resident council meeting and there had been no follow-up by the facility. R15 stated this was extremely frustrating to see the same issues unaddressed from month to month with no resolution. During an interview on 12/30/25 at 9:45 AM, R29 was only able to answer yes/no questions by shaking her head. R29 confirmed there were issues identified at each resident council meeting such as complaints about food and there had been no follow-up made by the facility. During an interview on 12/30/25 at 11:43 AM, R31 confirmed she attended the Resident Council Meetings and verified that there had been complaints formulated and no follow-up was made by the facility. During an interview on 12/29/25 at 3:14 PM, the Regional Nurse stated all grievances were to be resolved.Review of a facility's policy titled, Resident Council, dated 12/06, indicated .The facility supports residents' desire to be involved in and have input in the operation of the facility though the Resident Council.Minutes include names of the council members, and any guests present; issues discussed; recommendations from the council to the Administrator; and follow-up on prior issues.The Administrator reviews the minutes and any responses from departments within the facility. Responses are presented at the next meeting, or sooner, if indicated.

Based on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 6) reviewed for abuse/neglect was protected from physical abuse by R7 of 31 sample residents. (Cross Reference F610)On 11/22/25 R7 was found by Certified Nursing Assistant (CNA)9 to be hitting R6 in the chest. R7 and R6 were roommates at the time. A reasonable person would not expect to be hit by their roommate in their own room/living space.Findings include:1. Review of R6's electronic medical record (EMR) titled admission Record located under the Profile' tab indicated the facility admitted the resident on 08/05/22.Review of R6's EMR titled Care Plan located under the Care Plan tab, dated 08/05/22, indicated the resident had limited physical mobility related to general weakness, Parkinson's disease, traumatic brain injury, and hemiplegia (paralysis affecting one side of the body). Review of R6's EMR titled nursing Progress Notes located under the Prog (Progress) Notes tab, dated 11/22/25, indicated Certified Nurse Aide (CNA) 9 observed R7 hitting the chest of R6. CNA9 reported she immediately removed R7 from the resident-to-resident incident. 2. Review of R7's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/08/23. Review of R7's EMR titled Care Plan located under the Care Plan tab, dated 01/26/25, indicated that the resident had altered activities of daily living related to mobility impairment, hemiplegia, and cognitive impairment. Review of a document provided by the facility titled Misconduct Incident Report, dated 11/22/25, indicated that CNA9 heard R6 yelling out and went to his room. CNA9 found R7 hitting R6 in the chest. R7 stated I can't take it anymore. The residents' responsible parties were notified of the resident-to-resident incident, and the police were called. There was evidence that the facility reported the resident-to-resident incident to the State Survey Agency (SSA) timely. Review of a document provided by the facility titled .Summary., dated 12/01/25, revealed R6 had a recent Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was severely cognitively impaired. The document indicated that R7 had a recent BIMS score of 10 which revealed that the resident was moderately cognitively impaired. Both residents were unable to state what precipitated the resident-to-resident incident. In addition, R6 did not sustain any injuries and was moved to a private room. There was evidence that the facility reported the five-day summary to the SSA timely. During an interview on 12/29/25 at 9:17 AM, R6 stated he felt safe living at the facility and did not remember hitting another resident. During an interview on 12/29/25 at 9:53 AM, R7 stated he felt safe living at the facility and the resident did not remember being hit by another resident. During an interview on 12/30/25 at 8:22 AM, CNA9 confirmed she was the staff member who observed R7 hitting R6 in the chest. CNA9 confirmed she immediately removed R6 from R7 and reported the resident-to-resident incident. During an interview on 12/30/25 at 9:03 AM, the Administrator stated that whenever there was a resident-to-resident incident they wanted to make sure if the situation was isolated or not. The Administrator confirmed that both R6 and R7's responsible parties were notified and the police. The Administrator stated both residents failed to have any insight during the incident. Review of a facility's policy titled, Abuse, Neglect and Exploitation, dated 01/05/24, indicated .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.'Abuse' means the willful inflection injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 6) reviewed for abuse/neglect was protected from physical abuse by R7 of 31 sample residents. This had the potential to cause emotional and/or physical harm. Findings include:1. Review of R6's electronic medical record (EMR) titled admission Record located under the Profile' tab indicated the facility admitted the resident on 08/05/22.2. Review of R7's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/08/23. Review of a document provided by the facility titled Misconduct Incident Report, dated 11/22/25, indicated that Certified Nurse Aide (CNA) 9 heard R6 yelling out and went to his room. CNA9 found R7 hitting R6 in the chest. R7 stated I can't take it anymore. CNA9 separated the two residents. R6 was assessed for injuries and there were none. The investigation included a written statement by CNA9 and an attempt to interview R6 and R7. The investigation failed to include interviews with other staff and residents around the location of R6 and R7's room to rule out other instances of resident-to-resident abuse.During an interview on 12/29/25 at 3:14 PM, the Regional Nurse stated that it was important to interview other staff and residents, even if it was an isolated incident to rule out abuse. During an interview on 12/30/25 at 9:03 AM, the Administrator stated the resident-to-resident incident included the immediate separation of R6 and R7. The Administrator stated R6 was assigned a new room. The Administrator confirmed CNA9 was the only person interviewed since the staff member witnessed the resident-to-resident and it was an isolated event.Review of a facility's policy titled, Abuse, Neglect and Exploitation, dated 01/05/24, indicated .Investigation of Alleged Abuse.An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur.Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s).

Based on staff interview and record review, the facility did not monitor psychotropic medication use for 4 residents (R) (R3, R5, R94, and R104) of 5 sampled residents.R3 was prescribed antipsychotic, antianxiety, and antidepressant medications. The facility did not monitor R3 for adverse reactions to the medications. R5 was prescribed antipsychotic and antidepressant medications. The facility did not monitor R5 for adverse reactions to the medications.R94 was prescribed antipsychotic, antianxiety, and antidepressant medications. The facility did not monitor R94 for adverse reactions to the medications.R104 was prescribed antipsychotic and antidepressant medications. The facility did not monitor R104 for adverse reactions to the medications.Findings include:The facility's Psychotropic Medication Management policy, dated 11/28/17, indicates: Residents prescribed psychoactive medications will receive adequate monitoring .16) Appropriate monitoring for mood/behavior/sleep, along with monitoring for side effects and medication efficacy, will be reviewed and/or initiated .18) Care plan will be initiated or revised to reflect pharmacological and individualized non-pharmacological interventions along with monitoring for efficacy. Care plan will also include monitoring for drug specific side effects such as: gait disorders, movement disorders, cognitive or behavioral changes, discomfort (constipation etc.), signs of hypotension, dry mouth, etc. 19) Resident and resident representative will be involved in the development of the care plan, to include conditions, risks, needs, behaviors, preferences, measurable goals, and individualized interventions .Adverse Consequence Procedure: 1. Residents on psychoactive medications are monitored daily for adverse consequences. 2. Side effects may include but are not limited to allergic reaction, sedation, acute onset of signs or symptoms or worsening of chronic disease, involuntary movements, behavioral distress, decline in function or cognition, addition or discontinuation of medications and/or non-pharmacological interventions, addition or discontinuation of care and services such as enteral feeding, significant change in diet that may affect absorption of medication .1. From 9/15/25 to 9/17/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, insomnia, vascular dementia, anxiety disorder, and epilepsy. R3's Minimum Data Set (MDS) assessment, dated 7/24/25, had a Staff Interview for Mental Status that indicated R3 had severe cognitive impairment. R3's physician orders indicated R3 was prescribed the following medications:~ Risperidone (antipsychotic medication) 0.5 milligrams (mg) twice daily (BID) for dementia related agitation related to vascular dementia, dated 8/21/25. ~ Buspirone (antianxiety medication) 10 mg three times daily (TID) for major depressive disorder and anxiety disorder, dated 4/3/24. ~ Venlafaxine (antidepressant medication) 37.5 mg once daily for major depressive disorder and anxiety disorder, dated 4/17/25. ~ Trazadone (antidepressant medication) 50 mg once daily for anxiety, dated 6/5/24. R3's medical record did not include monitoring for adverse reactions to the psychotropic medications. On 9/17/25 at 12:49 PM, Surveyor interviewed Director of Nursing (DON)-B and Regional Nurse Consultant (RNC)-N. DON-B confirmed there was no adverse reaction monitoring in place for R3's psychotropic medications. RNC-N confirmed all psychotropic medications should have adverse reaction monitoring in place. 2. From 9/15/25 to 9/17/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, adjustment disorder, major depressive disorder, anxiety disorder, dementia with mood disturbance, and alcohol abuse. R5's MDS assessment, dated 8/7/25, had a Staff Interview for Mental Status that indicated R5 had moderate cognitive impairment. R5's physician orders indicated R5 was prescribed the following medications:~ Quetiapine fumarate (antipsychotic medication) 25 mg via tube feeding at bedtime for anxiety disorder, dated 7/21/25.~ Sertraline (antidepressant medication) 50 mg via tube feeding once daily for adjustment disorder, dated 7/22/25.~ Mirtazapine (antidepressant medication) 15 mg, give half tablet via tube feeding at bedtime for anxiety disorder, dated 7/21/25. ~ Valproic acid (anticonvulsant medication) 250 mg, give 10 milliliters (ml) via tube feeding TID for seizures, dated 7/21/25. R5's medical record did not include adverse reaction monitoring for the psychotropic medications or a care plan for seizures.On 9/17/25 at 12:49 PM, Surveyor interviewed DON-B and RNC-N. DON-B confirmed there was no adverse reaction monitoring in place for R5's psychotropic medications. RNC-N confirmed all psychotropic medications should have adverse reaction monitoring in place. DON-B and RNC-N also confirmed R5 did not have a care plan for seizures. 3. From 9/15/25 to 9/17/25, Surveyor reviewed R94's medical record. R94 was admitted to the facility on [DATE] and had diagnoses including insomnia, major depressive disorder, and general anxiety disorder. R94's MDS assessment, dated 6/30/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R94 had intact cognition. R94's physician orders indicated R94 was prescribed the following medications:~ Abilify (antipsychotic medication) 2 mg, give 3 tablets by mouth in the morning for depression adjunct related to major depressive disorder, dated 6/19/25.~ Buspirone 15 mg TID for generalized anxiety disorder, dated 8/29/25.~ Trazodone 100 mg, give 2.5 tablets at bedtime for insomnia, depression, and anxiety related to insomnia, dated 8/12/25.~ Lexapro (antidepressant medication) 10 mg, give 2 tablets in the morning related to major depressive disorder and anxiety disorder, dated 6/19/25.~ Wellbutrin XL (antidepressant medication) 150 mg, give 2 tablets in the morning for major depressive disorder, dated 6/19/25. R94's medical record did not include adverse reaction monitoring for the psychotropic medications. On 9/17/25 at 12:49 PM, Surveyor interviewed DON-B and RNC-N. DON-B confirmed there was no adverse reaction monitoring in place for R94's psychotropic medications. RNC-N confirmed all psychotropic medications should have adverse reaction monitoring in place.4. From 9/15/25 to 9/17/25, Surveyor reviewed R104's medical record. R104 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, dementia, alcohol dependence, insomnia, and depression. R104's MDS assessment, dated 8/20/25, had a BIMS score of 11 out of 15 which indicated R104 had moderate cognitive impairment. R104's physician orders indicated R104 was prescribed the following medications:~ Risperidone 1 mg BID for dementia related agitation/behaviors, dated 9/16/25.~ Olanzapine (antipsychotic medication) 5 mg, give 1.5 tablets at bedtime for dementia related agitation/behaviors, dated 9/16/25.~ Trazodone 50 mg, give 1.5 tablets at bedtime for insomnia, dated 7/31/24.~ Mirtazapine 15 mg at bedtime for depression, dated 7/29/24. R104's medical record did not include adverse reaction monitoring for the psychotropic medications or a care plan for dementia.On 9/17/25 at 12:49 PM, Surveyor interviewed DON-B and RNC-N. DON-B confirmed there was no adverse reaction monitoring in place for R104's psychotropic medications. RNC-N confirmed all psychotropic medications should have adverse reaction monitoring in place. RNC-N also confirmed R104 did not have a dementia-specific care plan.

Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 4 residents (R) (R3, R5, R104, and R12) of 29 sampled residents.R3's Quarterly MDS assessment, dated 7/11/25, indicated R3 received hypnotic medication. R3 was not prescribed hypnotic medication. In addition, R3's Comprehensive MDS assessment, dated 10/8/24, indicated R3 did not have a serious mental illness. R3 had diagnoses including major depressive disorder and anxiety disorder.R5's Comprehensive MDS assessment, dated 7/28/25, did not indicate R5 received anticoagulant medication. R5 was prescribed anticoagulant medication.R104's Comprehensive MDS assessment, dated 8/5/25, indicated R104 did not have a serious mental illness. R104 had diagnoses including major depressive disorder and anxiety disorder. In addition, the MDS assessment indicated R104 received antianxiety medication. R104 was not prescribed antianxiety medication.R12's Comprehensive MDS assessment, dated 2/6/25, indicated R12 did not have a serious mental illness. R12 had diagnoses including anxiety, depression, and delusional disorder. Findings include The facility's Expanded Assessment Guideline policy, dated 11/28/17, indicates: The facility promotes and supports systems for quality resident care. The purpose of this guideline is to provide a process for comprehensive assessment of residents in order to develop an individualized, person-centered care plan to meet the preferences and care needs of the residents .The accuracy of assessment means the appropriate, qualified health professional correctly documents the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. 1.From 9/15/25 to 9/17/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, insomnia, and anxiety disorder. R3's MDS assessment, dated 7/24/25, had a Staff Interview for Mental Status that indicated R3 had severe cognitive impairment. R3 had an activated Power of Attorney for Healthcare (POAHC) who was responsible for R3's healthcare decisions. R3's Comprehensive MDS assessment, dated 10/8/24, indicated R3 did not have a serious mental illness. R3's diagnoses list indicated R3 had a diagnoses of major depressive disorder, dated 3/9/23, and anxiety disorder, dated 3/9/23. R3's Quarterly MDS assessment, dated 7/11/25, indicated R3 received hypnotic medication. R3's physician orders indicated R3 was not prescribed hypnotic medication. On 9/17/25 at 1:03 PM, Surveyor interviewed MDS Coordinator (MDSC)-G who stated MDSC-G did not complete R3's Quarterly assessment which should not have indicated that R3 received hypnotic medication. MDSC-G indicated R3 was previously prescribed antianxiety medication that a former MDS Coordinator may have miscoded. MDSC-G also did not complete R3's Comprehensive assessment that indicated R3 did not have a serious mental illness. MDSC-G reviewed R3's diagnoses list and confirmed R3 qualified as having a serious mental illness. 2. From 9/15/25 to 9/17/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, adjustment disorder, major depressive disorder, anxiety disorder, dementia with mood disturbance, and alcohol abuse. R5's MDS assessment, dated 8/7/25, had a Staff Interview for Mental Status that indicated R5 had moderate cognitive impairment. R5 had a legal Guardian who was responsible for R5's healthcare decisions. R5's physician orders included an order for apixaban (an anticoagulant medication), start date 7/21/25. R5's Comprehensive MDS assessment, dated 7/28/25 indicated R5 did not receive anticoagulant medication. On 9/17/25 at 12:48 PM, Surveyor interviewed MDSC-G who stated MDSC-G did not complete R5's Comprehensive assessment. MDSC-G verified the assessment should have indicated R5 received anticoagulant medication. 3. From 9/15/25 to 9/17/25, Surveyor reviewed R104's medical record. R104 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, dementia, alcohol dependence, insomnia, and depression. R104's MDS assessment, dated 8/20/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R104 had moderate cognitive impairment. R104's diagnoses list indicated R104 had diagnoses of depressive disorder, dated 7/29/24, and anxiety disorder, dated 7/29/24. R104's Comprehensive MDS assessment, dated 8/5/25, indicated R104 did not have a serious mental illness. The MDS assessment also indicated R104 received antianxiety medication. R104's physician orders did not include an order for antianxiety medication. On 9/17/25 at 12:50 PM, Surveyor interviewed MDSC-G who confirmed MDSC-G incorrectly coded the assessment to indicate R104 received antianxiety medication. MDSC-G also confirmed R104's MDS assessment should have indicated R104 had a serious mental illness. 4. On 9/17/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including anxiety, depression, and delusional disorder. R12's MDS assessment, dated 8/26/25, had a BIMS score of 11 out of 15 which indicated R12 had moderate cognitive impairment. R12 made R12's own healthcare decisions. R12's Comprehensive MDS assessment, dated 2/6/25, indicated R12 did not have a serious mental illness. R12's diagnoses list indicated R12 had diagnoses of anxiety, depression, and delusional disorder. On 9/17/25 at 12:40 PM, Surveyor interviewed MDSC-G who confirmed R12's Comprehensive assessment incorrectly indicated R12 did not have a serious mental illness. MDSC-G confirmed R12 had diagnoses of anxiety, depression, and delusional disorder.

Based on observation, staff interview, and record review, the facility did not ensure medications for 16 residents (R) (R97, R128, R81, R127, R136, R141, R78, R63, R118, R9, R124, R76, R72, R145, R165, and R35) in 4 of 6 medication carts were labeled or dated appropriately. In addition, the facility did not ensure expired medical supplies were removed from storage in 1 of 2 medication storage rooms.The 100, 300 and 400 unit medication carts contained insulin, inhalers, eye drops, and liquid medications that were not dated when opened.The 400 unit medication storage room contained expired medical supplies. The facility's Storage of Medications policy, revised [DATE], indicates: .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.The facility's Administering Medications policy, revised [DATE], indicates: .9. The expiration/beyond use date on the medication label must be checked prior to administration. When opening a multi-dose container, the date opened shall be recorded on the container .Albuterol nebulizer solution instructions indicate: Storage conditions: Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. Discard if the solution is not colorless.Lantus SoloStar pen manufacturer's instructions indicate: Once you take your SoloStar out of cool storage, for use or as a spare, you can use it for up to 28 days. During this time, it should be kept at room temperature (15 to 30 Celsius (C)) and must not be stored in the refrigerator. If there is any remaining insulin after 28 days, discard it.Novolin 70/30 manufacturer's instructions indicate for storage conditions and expiration dates: Dates for Novolin 70/30 not In-use (unopened) refrigerated (36 Fahrenheit (F) - 46 F (2 C - 8 C)). Not in-use (unopened) room temperature (see temperature below). In-use (opened) room temperature (see temperature below) 10 milliliter (ml) multiple-dose vial until expiration date 42 days up to 77 F (25 C) 42 days up to 77 F (25 C) (Do not refrigerate); 3 ml single-patient use FlexPen until expiration date 28 days up to 86 F (30 C) 28 days up to 86 F (30 C) (Do not refrigerate).1. On [DATE] at 8:50 AM, Surveyor observed Licensed Practical Nurse (LPN)-D prepare medication for R97. Surveyor noted R97's Breztri Aerosphere inhalation 160-9-4.8 micrograms per actuation (mcg/act) inhaler did not have an open date. LPN-D confirmed the inhaler should contain an open date.2. On [DATE] at 9:06 AM, Surveyor observed LPN-D prepare medication for R128. Surveyor noted R128's Wixela (fluticasone-salmeterol) 250/50 mcg/dose inhaler did not have an open date on the inhaler or package. LPN-D confirmed the inhaler should contain an open date.3. On [DATE] at 1:47 PM, Surveyor observed the 300 unit medication cart with Registered Nurse (RN)-E and noted the following:~ R81's timolol eye drops did not contain an open date.~ R127 and R136's latanoprost 0.005% eye drops did not contain open dates.~ R141's vial of Novolin 70/20 insulin did not contain an open date.~ R78's Lantus Solostar 100 unit/ml insulin pen and albuterol nebulizer vials did not contain open dates. ~ R63's chlorhexidine 0.12% solution did not contain an open date.~ R118's lactulose 10 grams/15 ml liquid did not contain an open date.~ R9's albuterol HFA 90 mcg inhaler did not contain an open date.~ R124's Advair Diskus 250/50 inhaler did not contain an open date.~ R76's Striverdi Respimat inhaler did not contain an open date. On [DATE] at 2:20 PM, Surveyor observed the 400 unit medication cart with RN-E and noted the following:~ R72's Wixela inhaler did not contain an open date.~ R145's Incruse Ellipta 62.5 mcg inhaler did not contain an open date.~ R165's Breyna 160/4.5 mcg inhaler did not contain an open date.~ R35's Zonisade 100 milligrams (mg)/5 ml inhaler did not contain an open date.Surveyor also observed the 400 unit medication room storage and noted 20 [NAME] Point 1 ml syringes that expired on [DATE].On [DATE] at 2:30 PM, Surveyor interviewed RN-E who confirmed the above medications did not contain open dates and the syringes were expired. RN-E indicated the above medications should contain open dates and the syringes should be disposed of.On [DATE] at 2:38 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated insulin vials, inhalers, and all of the above medications should contain open dates. DON-B also indicated the expired syringes should be disposed of.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R11, R13, and R132) of 29 sampled residents.During the provision of catheter care and peri-care for R11, CNA (Certified Nursing Assistant)-C did not wear a gown or complete appropriate hand hygiene.R13 and R132 had orders for doxycycline (an antibiotic medication). The facility did not include R13 and R132 on the infection control line list for antibiotic use. Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 5 residents (R) (R160, R6, R11, R13, and R132) of 29 sampled residents. R160 and R6 received dialysis and were on enhanced barrier precautions (EBP). During care observations, staff did not adhere to EBP for R160 and R6. R11 had an indwelling catheter and was on EBP. During the provision of care for R11, Certified Nursing Assistant (CNA)-C did not wear the appropriate personal protective equipment (PPE) or complete appropriate hand hygiene. R13 and R132 had orders for doxycycline (an antibiotic medication). The facility did not include R13 and R132 on the infection control line list for antibiotic use. Findings include: The facility's Enhanced Barrier Precautions policy, dated 4/1/24, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs). EBP refer to an infection control intervention designed to reduce the transmission of MDROs that employs targeted gown and gloves use during high-contact resident care activities .1. a. All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions .c. The facility will have discretion on how to communicate to staff which residents require the use of EBP as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, h. Wound care: any skin opening requiring a dressing .9. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . The facility's Hand Hygiene policy, dated 10/30/23, indicates: Purpose: To cleanse hands to prevent the spread of potentially deadly infections; To provide a clean and healthy environment for residents, staff, and visitors; To reduce the risk to the healthcare provider of colonization or infection acquired from a resident. Hand hygiene continues to be the primary means of preventing the transmission of infection. 1.From 9/15/25 to 9/17/25, Surveyor reviewed R160's medical record. R160 was admitted to the facility on [DATE] and had diagnoses including history of methicillin-resistant Staphylococcus aureus (MRSA) infection, autoimmune thyroiditis, end stage renal disease, vascular prosthetic device, and dependence on renal dialysis. R160 had an indwelling device used for dialysis. R160's Minimum Data Set (MDS) assessment, dated 9/8/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R160 had intact cognition. On 9/15/25 at 11:37 AM, Surveyor observed R160's room and noted a Centers for Disease Control and Prevention (CDC) EBP sign on the wall near the entrance. The sign indicated: Enhanced Barrier Precautions Everyone Must: Clean hands, including before entering the room and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing linens, Providing hygiene, Changing briefs, or Assisting with toileting. Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: Any skin opening requiring a dressing. Surveyor also observed a PPE cart in the hallway near the entrance to R160's room (1 door down) that contained gloves and gowns. Surveyor interviewed R160 who indicated staff wear gloves during cares but do not wear gowns. R160 was in bed in a gown. On 9/15/25 at 11:58 AM, Surveyor observed Physical Therapist (PT)-V and Occupational Therapist (OT)-Q enter R160's room. PT-V and OT-Q indicated they were going to get R160 up for therapy, lunch, and dialysis and then closed the door to provide care. On 9/15/25 at 12:22 PM, Surveyor observed PT-V and OT-Q exit R160's room. Surveyor observed soiled linens and clothing on the floor near the door and observed OT-Q remove gloves. PT-V was wearing gloves and left the room to retrieve a laundry bin. PT-V then put R160's soiled laundry in the bin and removed gloves. PT-V and OT-Q were not wearing gowns. R160 was fully dressed in a wheelchair. Surveyor noted there were no used gowns in the garbage in R160's room. Surveyor interviewed PT-V who indicated PT-V changed R160's clothing, got R160 out of bed, and stripped R160's bed. On 9/15/25 at 12:24 PM, Surveyor interviewed OT-Q who indicated OT-Q changed R160's clothing and got R160 out of bed. OT-Q indicated OT-Q and PT-V wore gloves to provide care and transfer R160 and stated there weren't any gowns at the entrance to R160's room. OT-Q indicated OT-Q would have worn a gown if OT-Q changed R160's brief, however, OT-Q just changed R160's clothing and got R160 out of bed. OT-Q indicated OT-Q would've gone to the nearest PPE cart to get a gown if OT-Q needed to change R160's brief. OT-Q confirmed OT-Q didn't know if R160's brief needed to be changed until R160 was undressed and in the middle of cares. On 9/17/25 at 9:33 AM, Surveyor interviewed R160 who indicated R160 needed assistance. Surveyor informed staff. On 9/17/25 at 9:36 AM, Surveyor observed CNA-R and CNA-S enter R160's room and touch R160's linens with R160 in bed. CNA-R placed CNA-R's hands on R160's body to reposition R160. CNA-R and CNA-S then boosted R160 with a sheet and readjusted R160's pillow, linens, and bedding. On 9/17/25 at 9:38 AM, Surveyor showed CNA-R the EBP sign on R160's door. CNA-R indicated CNA-R and CNA-S should have worn gowns to reposition and boost R160 since R160 was a dialysis patient. On 9/17/25 at 9:39 AM, Surveyor showed CNA-S the EBP sign on R160's door. CNA-S indicated CNA-S and CNA-R should have worn gowns to reposition and boost R160 but then stated CNA-S and CNA-R didn't change R160's brief. CNA-S indicated a gown was needed to change R160's brief but not for other cares. 2. From 9/15/25 to 9/17/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, congestive heart failure (CHF), stage 5 kidney disease, end stage renal disease, and dependence on renal dialysis. R6 had an indwelling device used for dialysis. R6's MDS assessment, dated 7/18/25, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition On 9/15/25 at 12:01 PM, Surveyor observed R6's room and noted a CDC EBP sign on the wall near the entrance. The sign indicated: Enhanced Barrier Precautions Everyone Must: Clean hands, including before entering the room and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing linens, Providing hygiene, Changing briefs, or Assisting with toileting. Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: Any skin opening requiring a dressing. Surveyor also observed a PPE cart in the hallway near the entrance to R6's room that contained gloves and gowns. On 9/15/25 at 12:01 PM, Surveyor observed CNA-T and a second staff enter R6's room and shut the door. CNA-T and the second staff did not don PPE prior to entering the room. On 9/15/25 at 12:04 PM, Surveyor observed CNA-T exit R6's room with a Hoyer lift. CNA-T was wearing gloves but not a gown. Surveyor noted there were no used gowns in the garbage near the door. CNA-T then reentered R6's room and made the bed. On 9/15/25 at 12:05 PM, Surveyor interviewed R6 who indicated staff wear gloves during cares but not gowns. R6 was dressed and in a wheelchair. On 9/15/25 at 12:15 PM, Surveyor interviewed CNA-T who indicated CNA-T transferred R6 from bed to wheelchair via Hoyer lift. CNA-T verified CNA-T wore gloves but not a gown. CNA-T indicated CNA-T didn't need to wear a gown because R6 was already dressed. CNA-T indicated that was CNA-T's usual practice for residents on EBP. On 9/16/25 at 10:45M, Surveyor interviewed Director of Nursing (DON)-B who indicated staff are trained on infection control practices, including EBP and should follow the facility's EBP policy. DON-B could not verify what type of training staff received and indicated the facility's Infection Preventionist did the training. DON-B indicated all staff should be familiar with EBP is and follow the protocol accordingly. On 9/17/25 at 11:17 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff are trained on EBP and should follow the facility's EBP policy, including wearing gowns and gloves as indicated for high-contact cares. 3. From 9/15/25 to 9/17/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including dementia, multiple sclerosis, quadriplegia, chronic kidney disease, and heart failure. R11's MDS assessment, dated 7/21/15, indicated R11 was severely cognitively impaired and was dependent on staff for transfers, hygiene, dressing, and mobility. R11 had an activated Power of Attorney for Healthcare (POAHC). R11 had an indwelling catheter and was on EBP. On 9/16/25 at 9:50 AM, Surveyor observed CNA-C complete peri-care and catheter care for R11. CNA-C filled a basin with water, washed hands, and donned gloves and a mask. CNA-C did not don a gown. CNA-C emptied R11's catheter bag into a urinal, removed gloves, washed hands, and donned clean gloves. CNA-C washed R11's face with a wash cloth, removed the top of R11's gown, and washed R11's chest, underarms, arms, and hands. CNA-C then removed gloves, washed hands, and donned clean gloves. CNA-C applied lotion to R11's arms and hands and put a shirt on R11. CNA-C then removed gloves, washed hands, and donned clean gloves. CNA-C partially removed R11's brief, washed R11's peri-area, and cleansed R11's catheter tubing. CNA-C then set R11's uncovered catheter bag on the bed, rolled R11 onto the right side, and washed R11's buttocks. With the same soiled gloves, CNA-C put a clean brief next to R11 and removed the soiled brief from underneath R11. With the same gloved hands, CNA-C rolled R11 onto the left side and put R11's catheter bag in a dignity cover. CNA-C then removed gloves but did not wash or sanitize hands before donning clean gloves. CNA-C put a clean brief on R11 and removed the soiled brief and linens from R11's room. CNA-C then returned to R11's room, removed gloves, washed hands, and donned clean gloves. CNA-C put lotion on R11's feet, put socks on R11, adjusted R11's position, and put cloth pads under R11's ankles and knees. On 9/16/25 at 10:06 AM, Surveyor interviewed CNA-C who was not aware CNA-C needed to wear a gown while providing catheter and peri-care. CNA-C verified CNA-C did not change gloves and cleanse hands at times while providing catheter and peri-care and was not aware CNA-C should have done so. 4. From 9/15/25 to 9/17/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including amyotrophic lateral sclerosis (ALS), colostomy status, and dysphagia. R13's MDS assessment, dated 6/15/25, had a BIMS score of 11 out of 15 which indicated R13 had moderate cognitive impairment. R13 had an activated POAHC. R13's medical record contained an order for doxycycline 100 milligrams (mg), 1 capsule three times daily (TID) for gastrointestinal illness (GI). R13 was currently taking doxycycline. On 9/17/25, Surveyor reviewed the facility's infection control line list and noted R13 was not on the line list for antibiotic use. On 9/17/25 at 1:11 PM, Surveyor interviewed Infection Preventionist (IP)-I who verified R13 was not on the infection control line list for antibiotic use. IP-I indicated IP-I would add R13 to the line list. 5. From 9/15/25 to 9/17/25, Surveyor reviewed R132's medical record. R132 was admitted to the facility on [DATE]/25 and had diagnoses including osteomyelitis, schizophrenia, and epilepsy. R132's MDS assessment, dated 6/15/25, had a BIMS score of 15 out of 15 which indicated R132 had intact cognition. R132 had an activated POAHC. R132's medical record contained an order for doxycycline 100 mg, 1 capsule two times daily (BID) indefinitely for chronic osteomyelitis. On 9/17/25, Surveyor reviewed the facility's infection control line list and noted R132 was not on the line list for antibiotic use. On 9/17/25 at 1:11 PM, Surveyor interviewed IP-I who verified R132 was not on the infection control line list for antibiotic use. IP-I indicated IP-I would add R132 to the line list.

Based on staff interview and record review, the facility did not ensure protective placement was obtained for 2 residents (R) (R5 and R116) of 3 sampled residents. R5 and R116 had legal Guardians. The facility did not ensure an annual review of court-ordered protective placement ([NAME] Reviews) was obtained for R5 and R116.Findings include:Wisconsin State Statute Chapter 55.03(4) indicates: No guardian or temporary guardian may make a permanent protective placement of his or her ward unless ordered by a court .Wisconsin State Statute Chapter 55.055(1)(b) indicates: The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required for a period not to exceed 60 days .Following the 60-day period, the admission may be extended .for an additional 30 days .Wisconsin State Statute Chapter 55.18 indicates: Protective placement must be reviewed annually to ensure the resident remains in the least restrictive residential environment.1.From 9/15/25 to 9/17/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including dementia, traumatic subdural hematoma, hemiplegia affecting the left nondominant side, congestive heart failure, and chronic obstructive pulmonary disease (COPD). R5's Minimum Data Set (MDS) assessment, dated 7/28/25, indicated R5 was rarely/never understood. R5 had a Guardian for healthcare decisions.R5's medical record contained a Guardianship and Protective Placement document dated 1/24/19.R5's most recent Order for Continuing Protective Placement was filed on 7/7/23.Surveyor requested R5's most recent annual Continuing Protective Placement document.2. From 9/15/25 to 9/17/25, Surveyor reviewed R116's medical record. R116 was admitted to the facility on [DATE] and had diagnoses including dementia, hemiplegia and hemiparesis after a stroke, and functional quadriplegia. R116's MDS assessment, dated 6/7/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R116 had moderate cognitive impairment. R116 had a Guardian for healthcare decisions.R116's medical record contained a Guardianship and Protective Placement document dated 3/21/13.R116's most recent Order for Continuing Protective Placement was filed on 7/7/23.Surveyor requested R116's most recent annual Continuing Protective Placement document.On 9/17/25 at 10:00 AM, Surveyor interviewed [NAME] President of Success (VPOS)-M who attempted to contact the County Probate office on 9/16/25 and 9/17/25 to obtain the most recent annual review of protective placement for R5 and R116. VPOS-M verified Continuing Protective Placement reviews should be completed annually On 9/17/25 at 2:42 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who contacted the Clerk of Courts who would not release the protective placement information and indicated reviews were sent to the residents' Guardians. NHA-A contacted R5's Guardian who indicated the only protective placement review R5's Guardian had was from 2019. NHA-A attempted unsuccessfully to contact R116's Guardian. NHA-A verified the facility did not find another [NAME] Review aside from what was in R116's medical record. NHA-A agreed the Social Services Designee (SSD) should have obtained an annual Protective Placement Review or requested R5 and R116's Guardians initiate one.

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R3, R5 and R4) of 5 sampled residents had documentation that indicated the residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medication.R3 was prescribed buspirone (an antianxiety medication), venlafaxine (an antidepressant medication), and trazadone (an antidepressant medication) for depression and anxiety. The facility did not ensure informed consent for the medications was completed timely with R3's Power of Attorney for Healthcare (POAHC).R5 was prescribed Seroquel (an antipsychotic medication) for anxiety, sertraline (an antidepressant medication) for adjustment disorder, mirtazapine (an antidepressant medication) for anxiety, and valproic acid (an anticonvulsant medication) for seizures. The facility did not ensure informed consent for the medications was completed timely and/or thoroughly with R5's Guardian.R4 was prescribed sertraline for depression. The facility did not ensure informed consent was completed with R4's POAHC before the medication was administered. Findings include: The facility's Psychotropic Medication Management policy, dated 11/28/17, indicates each psychoactive medication will be given to treat clearly defined targeted conditions and to promote or maintain the highest practicable physical, functional, and psychosocial well-being .Psychoactive Medication Data Collection Procedure: .11) Risks and benefits will be explained and a copy provided to the resident and/or responsible party. 12) Informed consent, including potential side effects, will be obtained from the resident and/or the resident's representative for each psychoactive medication. 13) If verbal consent by the resident representative is provided, document on informed consent and place copy in chart until signature is obtained. 14) If informed consent is refused by the resident and/or the resident's representative, risk versus benefits will be explained and documented 1.From 9/15/25 to 9/17/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, insomnia, vascular dementia, anxiety disorder, and epilepsy. R3's Minimum Data Set (MDS) assessment, dated 7/24/25, indicated R3 had severe cognitive impairment. R3 had an activated POAHC who was responsible for R3's healthcare decisions. R3's physician orders indicated R3 was prescribed the following medications: ~ Buspirone for major depressive disorder and anxiety disorder, dated 4/3/24. ~ Venlafaxine for major depressive disorder and anxiety disorder, dated 4/17/25. ~ Trazadone for anxiety, dated 6/5/24. R3's medical record contained informed consents for buspirone (completed 4/5/24), venlafaxine (completed 4/5/24), and trazodone (completed 6/11/24). On 9/16/25 at 2:40 PM, Surveyor interviewed Dirctor of Nursing (DON)-B who stated informed consents should be completed yearly or with a change. DON-B stated more recent consents should have been completed for R3's psychotropic medications. 2. From 9/15/25 to 9/17/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, adjustment disorder, major depressive disorder, anxiety disorder, dementia with mood disturbance, and alcohol abuse. R5's MDS assessment, dated 8/7/25, indicated R5 had moderate cognitive impairment. R5 had a Guardian who was responsible for R5's healthcare decisions. R5's physician's orders indicated R5 was prescribed the following medications: ~ Seroquel for anxiety disorder, dated 7/21/25. ~ Sertraline for adjustment disorder, dated 7/22/25. ~ Mirtazapine for anxiety disorder, dated 7/21/25. ~ Valproic Acid for seizures, dated 7/21/25. R5's medical record included informed consents for mirtazapine (completed 4/16/24), sertraline (completed 2/1/19), and valproic acid (completed 4/16/24). Surveyor noted R5's sertraline consent was incomplete and did not contain a signature from R5's Guardian. R5's valproic acid consent listed R5's diagnosis as mood disturbance, however, R5's medical record indicated R5 was prescribed the medication for seizures. On 9/17/25 at 12:49 PM, Surveyor interviewed DON-B and Regional Nurse Consultant (RNC)-N who confirmed R5 did not have an informed consent form for seroquel and R5's mirtazapine, sertraline, and valproic acid consent forms were out of date or incomplete. DON-B also confirmed R5's diagnosis for valproic acid was seizures and R5's consent was incorrect. DON-B and RNC-N stated informed consents should be reviewed and completed annually or with a change. 3. From 9/15/25 to 9/17/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, psychotic disorder with delusions, anxiety, and major depressive disorder. R4's MDS assessment, dated 8/4/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R4 had intact cognition. R4 had an activated POAHC. R4's medical record indicated R4 was prescribed the following medications: ~ Sertraline hydrochloride (HCL) oral tablet 50 milligrams (mg), give 1 tablet by mouth daily for depression and anxiety ~ Sertraline HCl oral tablet 25 mg, give 1 tablet daily for depression (take with 50 mg = 75 mg) R4's medical record did not contain an informed consent form for sertraline. On 9/17/25 at 1:28 PM, Surveyor interviewed DON-B who confirmed R4 did not have an informed consent form for sertraline and verified the form should have been completed before sertraline was administered.

Based on staff interview and record review, the facility did not ensure notification of coverage change and the financial liability for continued stay at the facility was provided timely when Medicare Part A benefits ended for 2 residents (R) (R22 and R113) of 3 sampled residents.The facility did not have documentation that an Advanced Beneficiary Notice (ABN) (which documents daily rate liability for continued cost of stay) or a Notice of Medicare Non-Coverage (NOMNC) form with appeal rights was provided to R22's representative when R22's Medicare Part A coverage ended and R22 remained in the facility.The facility did not have documentation that an ABN or NOMNC form was provided to R113's Guardian when R113's Medicare Part A covrerage ended and R22 remained in the facility.Findings include:The Centers for Medicare and Medicaid Services (CMS)-10123 form indicates a Notice of Medicare Non-Coverage (NOMNC) form must be delivered at least two calendar days before Medicare-covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48-hour requirement .The provider must ensure the beneficiary or representative signs and dates the NOMNC form to demonstrate the beneficiary or representative received the notice and understands the termination decision can be disputed.The CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicates: The ABN provides information to the beneficiary so the beneficiary can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .The ABN is only issued if the beneficiary intends to continue services and the skilled nursing facility believes the services may not be covered under Medicare.1.From 9/15/25 to 9/16/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease, metabolic encephalopathy, and dependence on renal dialysis. R22's Minimum Data Set (MDS) assessment, dated 9/12/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R22 had moderate cognitive impairment. R22 had an activated Power of Attorney for Healthcare (POAHC) who was responsible for R22's healthcare decisions. On 9/16/25, Surveyor reviewed documentation regarding R22's Medicare Part A stay that indicated R22's last covered day was 5/3/25. Surveyor noted R22's NOMNC form indicated it was issued to R22's POAHC on 5/1/25 at 1:30 PM via phone and signed by MDS Coordinator (MDSC)-G. R22's ABN indicated R22's last covered day was 5/3/25. The ABN did not include a date or signature from R22's POAHC. In addition, R22's medical record did not indicate R22's POAHC was informed of coverage and service changes or appeal rights when R22 remained in the facility.On 9/16/25 at 8:43 AM, Surveyor interviewed MDSC-G who stated MDSC-G spoke with R22's POAHC via phone and issued the NOMNC form. MDSC-G indicated the only documentation MDSC-G had regarding issuing the NOMNC form and ABN was noted on the NOMNC form and a handwritten note that MDSC-G provided to Surveyor. MDSC-G indicated MDSC-G did not document the information in R22's medical record.2. From 9/15/25 to 9/16/25, Surveyor reviewed R113's medical record. R113 was admitted to the facility on [DATE] and had diagnoses including dehydration and dementia. R113's MDS assessment, dated 8/4/25, had a BIMS score of 00 out of 15 which indicated R113 had severe cognitive impairment. R113 had a Guardian who was responsible for R113's healthcare decisions. On 9/16/25, Surveyor reviewed documentation regarding R113's Medicare Part A stay that indicated R113's last covered day was 8/14/25. Surveyor noted R113's NOMNC form did not include a signature or the date that it was issued to R113's Guardian. R113's ABN did not indicate if an option was chosen for appeal and did not include a signature or the date that it was issued to R113's Guardian. In addition, R113's medical record did not indicate R113's Guardian was informed of coverage and service changes or appeal rights when R113 remained in the facility.On 9/16/25 at 8:43 AM, Surveyor interviewed MDSC-G who stated MDSC-G called R113's Guardian on 8/12/25, 8/13/25, and 8/14/25 and showed Surveyor a handwritten note. MDSC-G stated MDSC-G went on vacation after that and did not receive a return call from R113's Guardian prior to that. MDSC-G provided Surveyor with email communication from R113's Guardian, dated 9/8/25, that indicated R113's Guardian did not receive the communication regarding the end of coverage and services for R113. MDSC-G stated R113's Guardian changed and MDSC-G was not aware. Per the Guardian's email, dated 9/11/25, contact information was corrected, however, R113's Guardian had not yet received R113's NOMNC form or ABN. MDSC-G stated MDSC-G did not document in R113's medical record when MDSC-G issued the NOMNC form or ABN and just wrote the information in a handwritten note.

Based on staff and resident interview and record review, the facility did not document, investigate, or thoroughly resolve a grievance for 1 resident (R) (R79) of 29 sampled residents. R79's reported missing clothing to staff. The facility did not appropriately document, investigate, or thoroughly resolve R79's grievance.Findings include: The facility's Grievance Guideline policy, revised 4/23/23, indicates: It is the practice of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment that has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their stay. The facility will ensure prompt resolution within five calendar days to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process .G. Response: Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility grievance official .From 9/15/25 to 9/17/25, Surveyor reviewed R79's medical record. R79 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, congestive heart failure (CHF), diabetes, depression, and anxiety. R79's Minimum Data Set (MDS) assessment, dated 9/4/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R79 had intact cognition. On 9/15/25 at 12:55 PM, Surveyor interviewed R79 who indicated R79 was upset because the facility had lost R79's clothing which had been missing for a week. R79 indicated R79 was missing at least three military T-shirts worth approximately $15 each and one or two pair of sweatpants worth $20 each. R79 indicated R79 didn't have much clothing and especially valued the shirts and wanted them back. R79 indicated R79 told staff the clothes were missing and did not come back from the laundry. R79 indicated staff looked for the clothes but came back with other residents' clothing for R79 to wear. R79 indicated R79 had been wearing other residents' clothing for several days and wanted R79's own clothes back. When asked if anyone talked to or followed-up with R79 about the missing clothing, R79 indicated no one had talked to R79 other than the staff R79 reported it to who brought R79 other residents' clothing.Surveyor reviewed the facility's grievance log and noted there were no grievances for R79. On 9/17/25 at 9:28 AM, Surveyor again interviewed R79 who had not gotten any of R79's clothes back yet. R79 was not wearing a shirt during the interview and stated, Let me put my shirt on. Well, not mine. It's someone else's shirt because I don't have my own clothes. R79 was unhappy that R79's clothing had been missing for over a week. R79 asked staff for the clothing since R79 spoke with Surveyor (on 9/15/25). Staff told R79 the facility is supposed to do a major laundry washing day and R79 will probably get the clothing back after that. R79 indicated another staff said they would look for the clothing but instead [NAME] R79 another resident's clothing. Surveyor observed a stack of folded clothes on R79's chair that was not there on 9/15/25. R79 confirmed the clothes were not R79's and stated R79 wished someone would find R79's clothing. R79 expresed frustration with the lack of help that R79 received. R79 indicated neither management staff or the Grievance Officer had spoken to R79 about the clothing. R79 was sure if a grievance was filed.On 9/17/25 at 10:38 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should follow the grievance protocol when a resident reports a missing item. DON-B indicated the protocol includes reporting to the Grievance Officer right away.On 9/17/25 at 11:36 AM, Surveyor interviewed Grievance Officer (GO)-U who was not aware of R79's missing clothing and was not familiar with R79. GO-U indicated it is not acceptable that a grievance was not generated for R79's missing clothing and that staff had not notified GO-U. GO-U indicated staff should have checked the laundry, reviewed R79's inventory sheet, and notified GO-U of the missing clothing so a grievance could be started. GO-U indicated R79 should be reimbursed if the missing clothing is not found.On 9/17/25 at 12:03 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should have reported the missing items and should have communicated with the Housekeeping Supervisor and GO-U. NHA-A indicated GO-U handles all grievances and should have been notified and involved. NHA-A indicated the missing items will be reimbursed if not found.

Based on staff interview and record review, the facility did not ensure timely transmittal of a Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessment for 1 resident (R) (R105) of 29 sampled residents.R105 discharged from the facility on 5/7/25. R105's Discharge MDS assessment was not completed/transmitted as required.Findings include:The RAI Manual pages 2-19 indicate a Discharge MDS Assessment-Return Not Anticipated is to be completed no later than the discharge date plus 14 calendar days and transmitted 14 calendar days from the completion of the MDS Discharge Assessment. From 9/16/25 to 9/17/25, Surveyor reviewed R105's medical record. R105 was admitted to the facility on [DATE] with a diagnosis of non-traumatic brain injury and was discharged from the facility on 5/7/25. R105's medical record did not include a Discharge MDS Assessment.On 9/17/25 at 12:43 PM, Surveyor interviewed MDS Coordinator (MDSC)-G who stated R105 was sent to the hospital and a Discharge MDS assessment should have been completed. MDSC-G reviewed another resident's Discharge MDS assessment to confirm the timeframe for completion and stated the timeline for completion was 7 days.

Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen when a newly evident mental disorder and/or change in medication was identified for 2 residents (R) (R5 and R94) of 5 sampled residents.R5 was prescribed Seroquel (an antipsychotic medication). The facility did not update R5's PASRR Level I Screen and submit for PASRR Level II reevaluation.R94 was prescribed Abilify (an antipsychotic medication) for major depressive disorder, buspirone (an antianxiety medication) for anxiety disorder, trazodone (an antidepressant medication), Lexapro (an antidepressant medication), and Wellbutrin (an antidepressant medication) for major depressive disorder. The facility did not update R94's PASRR Level I Screen to include all psychotropic medications that R94 was prescribed. In addition, the facility did not have a PASRR Level II Screen for R94.Findings include:1.From 9/15/25 to 9/17/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including adjustment disorder, major depressive disorder, anxiety disorder, dementia with mood disturbance, and alcohol abuse. R5's Minimum Data Set (MDS) assessment, dated 8/7/25, had a Staff Interview for Mental Status that indicated R5 had moderate cognitive impairment. R5 had a legal Guardian who was responsible for R5's healthcare decisions.R5's physician orders indicated R5 was prescribed the following psychotropic medications to treat symptoms of a serious mental illness:~ Seroquel for anxiety disorder, dated 7/21/25.~ Sertraline (an antidepressant medication) for adjustment disorder, dated 7/22/25.~ Mirtazapine (an antidepressant medication) for anxiety disorder, dated 7/21/25.R5's PASRR Level I Screen, admission date of 9/25/23, indicated R5 had a serious mental illness and was prescribed sertraline and mirtazapine. R5's Level I Screen did not include Seroquel.R5's PASRR Level II Screen, determination date 7/2/24, did not include R5's order for Seroquel.On 9/17/25 at 2:40 PM, Surveyor interviewed Admissions Director (AD)-F who completed PASRRs for the facility. AD-F stated there is a meeting each morning to review medications, however, AD-F was not aware that an antipsychotic medication was added for R5. AD-F stated AD-F is currently working with unit managers on a new process to ensure more accurate PASRRs. AD-F verified R5's PASRR Level I should have been updated and submitted for a new Level II review.2. From 9/15/25 to 9/17/25, Surveyor reviewed R94's medical record. R94 was admitted to the facility on [DATE] and had diagnoses including insomnia, major depressive disorder, and general anxiety disorder. R94's MDS assessment, dated 6/30/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R94 had intact cognition. R94 was responsible for R94's healthcare decisions.R94's physician orders indicated R5 was prescribed the following psychotropic medications:~ Abilify for major depressive disorder, dated 6/19/25.~ Buspirone for anxiety disorder, dated 8/29/25.~ Lexapro for major depressive disorder and anxiety disorder, dated 6/19/25.~ Wellbutrin for major depressive disorder, dated 6/19/25.R94's undated PASRR Level I Screen indicated R94 had a severe mental illness and was prescribed Lexapro. R94's Level I Screen did not include R94's orders for Abilify, buspirone, or Wellbutrin.R94's medical record included a PASRR Level II Referral Summary, dated 9/11/24, that indicated a partial Level II Screen should be completed. Surveyor requested the Level II Screen. The facility did not provide the Level II Screen.On 9/17/25 at 2:30 PM, Surveyor interviewed AD-F who confirmed R94's Level I Screen did not contain all of R94's medications. AD-F indicated AD-F is not always aware when a new medication is added but is working with unit managers on a new process to ensure more accurate PASRRs.

Based on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R103) of 7 sampled residents.R103 had a diagnosis of schizophrenia. R103's PASRR Level I Screen indicated R103 did not have a mental illness. R103 did not have a PASRR Level II Screen. According to the State of Wisconsin Department of Health Services, PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability (ID)/developmental disability (DD) and/or mental illness (MI). This is called a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or MI. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or MI for PASRR purposes. This is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. Nursing facilities may seek county exemption for applicants with ID/DD and/or MI whose stay in the facility is expected to be recuperative care or short-term, as evidenced by receipt of County Review of Nursing Home, IMD or ICF/IID Referrals (F-20822).From 9/15/25 to 9/17/25, Surveyor reviewed R103's medical record. R103 was admitted to the facility on [DATE] and had diagnoses including schizophrenia and paranoid schizophrenia. R103's Minimum Data Set (MDS) assessment, dated 8/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R103 had intact cognition. R103 was responsible for R103's healthcare decisions. R103's medical record contained a PASRR Level I Screen, completed on 11/10/23, that indicated R103 did not have a current mental illness diagnosis, however, R103's medical diagnoses included schizophrenia and paranoid schizophrenia (dated 11/10/23).R103's MDS assessment, dated 11/17/23, under Section I (active diagnoses) indicated R103 had schizophrenia. R103's medical record did not contain a PASRR Level II Screen.On 9/17/25 at 10:32 AM, Surveyor interviewed Director of Nursing (DON)-B and asked if a PASRR Level II Screen should have been completed for R103. DON-B indicated the admissions department starts the PASRR process which should be completed prior to the resident entering the facility.On 9/17/25 at 2:27 PM, Surveyor interviewed Admissions Director (AD)-F who indicated AD-F did not complete R103's PASRR Level I Screen. AD-F verified R103's PASRR Level I Screen incorrectly indicated R103 did not have a major mental disorder. AD-F indicated if AD-F had completed R103's PASRR, AD-F would have indicated R103 had a major mental disorder and submitted for a Level II Screen due to R103's diagnosis of schizophrenia.On 9/17/25 at 3:12 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R103 had a diagnosis of schizophrenia. NHA-A indicated R103's PASRR Level I Screen should have indicated R103 had a major mental disorder.

Based on observation, staff and resident interview, and record review, the facility did not ensure 3 residents (R) (R5, R116, and R161) of 3 sampled residents who were unable to carry out activities of daily living (ADLs) were provided nail care, oral hygiene, or shower assistance. R5 and R116 did not receive consistent nail care or oral hygiene assistance. R161 did not receive showers per R161's request. In addition, R161's shower documentation was incorrect.Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 5/7/20, indicates: The facility provides care and services taking into consideration residents' needs and choices for the following activities: hygiene, bathing, dressing, grooming, and oral care. The facility's Care of Fingernails/Toenails policy, revised 10/2010, indicates: The purpose of the procedure is to clean the nail bed, keep nails trimmed, and prevent infection .1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 1. From 9/15/25 to 9/17/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including traumatic subdural hematoma, hemiplegia affecting left nondominant side, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia. R5's Minimum Data Set (MDS) assessment, dated 7/28/25, indicated R5 was rarely/never understood. R5 had a Guardian for healthcare decisions. R5's care plan, revised 1/16/25, indicated R5 had potential for an ADL self-care performance deficit related to dementia. The care plan contained an intervention for personal hygiene and oral care: (limited assistance) by 1 staff (dated 12/13/24). In addition, R5's plan of care, revised 7/27/25, indicated R5 had oral/dental health problems related to being edentulous (without teeth). The care plan contained an intervention to provide mouth care as per ADL personal hygiene (dated 7/21/25). A podiatry progress note, dated 6/17/25, indicated the toenails on R5's left foot and the second, third, and fourth toenails on the right foot were trimmed and reduced in length and thickness to 1 millimeter (mm). The note indicated R5 had a diagnosis of onychodystrophy (abnormal changes in the shape, color, texture, and growth of the fingernails or toenails). On 9/15/25 at 11:46 AM, Surveyor observed R5's fingernails which were approximately 1/4 inch long and contained a dark substance underneath the nails on the right hand. On 9/15/25 at 12:05 PM, Surveyor observed Certified Nursing Assistant (CNA)-J leave R5's room to get assistance with morning cares. On 9/15/25 at 12:19 PM, Surveyor observed R5's great toenails which were approximately 1/2 inch long. On 9/15/25 at 12:19 PM, Surveyor interviewed Speech Therapist (ST)-K who was assisting CNA-J with R5's morning cares. ST-K verified R5's fingernails were approximately 1/4 inch long and R5's right nails appeared dirty. ST-K also verified R5's great toenails were approximately 1/2 inch long and appeared gnarly. During the observation, Surveyor noted staff did not provide oral care for R5. On 9/15/25 at 1:01 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who confirmed oral care should have been provided with morning cares. Surveyor reviewed R5's oral hygiene documentation for 9/3/25 to 9/12/25. Oral hygiene was not documented as completed on 9/6/25 (AM), 9/8/25 (AM), 9/12/25 (AM and PM), 9/13/25 (AM and PM), 9/14/25 (AM and PM), and 9/15/25 (AM). On 9/16/25 at 9:57 and 11:55 AM, Surveyor interviewed Director of Nursing (DON)-B who verified trimming nails and oral care should be part of a resident's care. DON-B also verified R5's medical record contained dates that indicated oral hygiene was not completed. DON-B indicated if the task was not documented, it was not done. 2. From 9/15/25 to 9/17/25, Surveyor reviewed R116's medical record. R116 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis after a stroke, dementia, and functional quadriplegia. R116's MDS assessment, dated 6/7/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R116 had moderate cognitive impairment. R116 had a Guardian for healthcare decisions. On 9/15/25 at 1:10 PM, Surveyor observed R116's left hand and noted R116's fingernails were approximately 1/2 inch long. On 9/16/25 at 9:57 AM, Surveyor interviewed DON-B who verified trimming nails should be part of a resident's care. Surveyor reviewed R116's oral hygiene documentation for 9/3/25 to 9/15/25. Oral hygiene was not documented as completed on 9/8/25 (PM), 9/11/25 (PM), 9/12/25 (AM), 9/13/25 (AM and PM), 9/14/25 (AM and PM), and 9/15/25 (AM). On 9/16/25 at 11: 55 AM Surveyor interviewed DON-B who verified R116's medical record contained dates that indicated oral hygiene was not completed. DON-B indicated if the task was not documented, it was not done. 3. From 9/15/25 to 9/17/25, Surveyor reviewed R161's medical record. R161 was admitted to the facility on [DATE] and had diagnoses including spinal stenosis, cervical region disease of spinal cord, atrial fibrillation, and anxiety. R161's MDS assessment and BIMS score were not available due to R161's recent admission. R161's plan of care, initiated on 9/8/25 upon admission, indicated R161 received showers on the Thursday PM shift. R161's care plan was not complete and did not indicate R161's self-care performance deficits, related diagnoses, or goals related to showers and ADLs. Surveyor noted nearly all of the fill in the blank areas on R161's care plan used to personalize the care plan and inform staff of R161's needs were blank. The care plan indicated: ~ The resident has (specify) actual /potential for an ADL self-care performance deficit (related to) (dated 9/8/25). ~ The resident will demonstrate the appropriate use of (specify adaptive device(s) to increase ability in (specify) (dated 9/8/25). ~ The resident will maintain current level of function in (specify) through the review date (dated 9/8/25). ~ The resident has (specify: urge, stress, functional, mixed) bladder incontinence (related to) (dated 9/8/25). ~ The resident has impaired visual function (related to) (dated 9/8/25). On 9/15/25 at 12:40 PM, Surveyor interviewed R161 who indicated R161 does not receive showers. R161 indicated R161 keeps asking staff for showers but has been told R161 can't have one. Surveyor noted R161's hair appeared oily and unkempt and noted R161 wore a neck collar. R161 indicated staff refuse to give R161 a shower and state the neck brace cannot come off. R161 indicated R161 has had the neck collar for a long time and can take it off for showers. R161 indicated staff stated they don't know how to put the neck collar back on and have also told R161 the shower was broken. R161 indicated R161 had a couple of bed baths which isn't enough and R161 wants a full shower. On 9/17/25 at 9:08 AM, Surveyor again interviewed R161 who indicated R161 still had not had received a shower. R161 again indicated staff won't give R161 a shower even though they were told they can take R161's neck brace off for a shower. R161 did not think staff contacted R161's physician to ask because they still refused to shower R161. On 9/17/25 at 10:38 AM, Surveyor interviewed DON-B who indicated a resident should receive a shower if they ask for one. DON-B indicated a care plan should be created and followed and the resident should be added to the shower schedule. Surveyor requested R161's bathing/shower documentation and the facility's ADL policy. On 9/17/25 at 12:27 PM, DON-B provided the ADL policy and a post it note. The note indicated R161 prefers bed baths and was offered a shower that day but declined. On 9/17/25 at 12:30 PM, Surveyor interviewed DON-B who indicated DON-B wrote the note regarding R161's shower. When asked if DON-B had talked to R161 since the note was in contrast to what R161 had stated earlier, DON-B indicated the unit nurse talked to R1. When asked why the note indicated R161 prefers bed baths when R161 has been requesting a shower, DON-B indicated DON-B would call the physician to see if R161's neck collar can be removed. DON-B confirmed DON-B had not spoken to the physician on R161's behalf. On 9/17/25 at 12:36 PM, DON-B approached Surveyor and indicated DON-B made a mistake on the note and wanted to clarify that R161 can't have showers because R161's neck collar can't be removed. On 9/17/25 at 12:39 PM, Surveyor again interviewed R161 and noted R161's shirt was changed and hair was combed. R161 stated R161 was given a bed bath that morning after Surveyor left R161's room. R161 indicated R161 was offered a shower after the bed bath but declined due to just having received a bed bath. R161 was happy R161 had been offered a shower on Thursday evenings and stated R161 would be receiving the first shower tomorrow evening. R161 indicated Unit Manager (UM)-W offered the shower tomorrow evening and on Thursday evenings going forward. On 9/17/25 at 12:41 PM, Surveyor interviewed UM-W who indicated R161 gets bed baths because R161 wears a cervical neck collar. UM-W indicated R161's discharge paperwork indicated R161 wears a neck collar at all times. UM-W confirmed the physician was not asked about showers for R161 per R161's request and stated R161 will receive a bed bath Thursday evening instead of a shower. UM-W indicated there is no difference on the bathing schedule between a bed bath and a shower. UM-W indicated even though R161's care plan and bathing schedule indicate R161 will receive a shower and R161 was told R161 will get a shower, R161 will actually get a bed bath because R161 can't have showers. On 9/17/25 at 1:25 PM, DON-B gave Surveyor two handwritten bathing sheets for R161. One sheet, dated 9/11/25, indicated R161 received a shower and a skin check was completed. The second sheet, dated 9/17/25, indicated R161 received a shower and a skin check was completed. Writing on the corner of the sheet indicated bed bath only, collar 24/7. The box for bed bath (under showers) was not marked. When asked why the 9/11/25 shower sheet indicated R161 had a shower when R161 did not have a shower, DON-B indicated R161 can't have a shower and Surveyor should speak to UM-W. On 9/17/25 at 1:28 PM, Surveyor interviewed UM-W who indicated UW-M completed and signed R161's shower sheets on behalf of other staff but did not provide care for R161. UM-W indicated UW-M completed the paperwork because others had not completed it. UM-W indicated it is UM-W's regular practice to complete and sign paperwork on behalf of others. When Surveyor asked UM-W why the shower sheets indicated R161 had a shower and skin check when UM-W and DON-B indicated R161 can't have showers, UM-W retracted the statement that a shower was completed and stated it was a bed bath. UM-W indicated the shower and bed bath portions of the form are the same. On 9/17/25 at 1:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated a resident who wants a shower should receive one. NHA-A indicated the physician should have been called regarding R161's shower request and the order should have been clarified. NHA-A confirmed UM-W should not complete and sign paperwork for others and indicated no one should create shower sheets for showers that did not occur.

Based on observation, staff interview, and record review, the facility did not ensure the provision of care and treatment to prevent pressure injuries from developing and/or promote healing for 2 residents (R) (R50 and R7) of 4 sampled residents.R50 had a history of facility-acquired pressure injuries. R50's plan of care indicated R50's heels should be floated. The intervention was not consistently followed.R7 had a history of a facility-acquired pressure injury due to a medical device. R7's plan of care indicated R7 should wear a left heel bootie at all times. The intervention was not consistently followed. Findings include: The facility's Pressure Injury/Skin integrity policy, dated 10/21/24, indicates: It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Ulcer Advisory Panel (NPUAP). Based on the comprehensive assessment of a resident, this facility will ensure: A resident receives care consistent with professional standards of practice to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable. A resident with pressure injuries receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .Interventions will be implemented to mitigate the risk for breakdown based on individual risk factors and may include, but are not limited to: a. The use of pressure redistribution devices such as mattresses or cushions; devices to eliminate or reduce friction and shearing; or the implementation of individualized turning or repositioning and/or off-loading schedules. b. Interventions should be documented in the resident's medical record, including in the resident's individualized resident-centered plan of care. 1. From 9/15/25 to 9/17/25, Surveyor reviewed R50's medical record. R50 was admitted to facility on 5/7/25 and had diagnoses including cerebral vascular accident, myocardial infarction, hemiplegia, diabetes, osteoarthritis, coronary artery disease (CAD), and lymphedema. R50's Minimum Data Set (MDS) assessment, dated 8/11/25, indicated R50 was dependent on staff for transfers, hygiene, and mobility and was severely cognitively impaired. R50 had an activated Power of Attorney for Healthcare (POAHC). R50's plan of care indicated R50 had impaired skin integrity and a right lateral heel pressure injury. The plan of care contained an intervention to float heels (initiated 5/15/25). R50's medical record indicated R50 had a history of pressure injuries including: ~ A left lateral lower leg pressure injury acquired on 5/6/25 that was resolved on 7/11/25. ~ A right lateral heel pressure injury acquired at the facility on 5/14/25 that measured 11.5 centimeters (cm) x 4.3 cm x 3.55 cm upon discovery and measured 0.16 cm x 0.34 cm x 0.65 cm on 8/12/25. ~ A right lateral forefoot pressure injury acquired at the facility on 5/14/25 that was resolved on 7/11/25. ~ A left lateral foot pressure injury acquired at the facility on 5/23/35 that was resolved on 6/6/25. On 9/15/25 at 2:06 PM, Surveyor observed R50 in bed. R50's heels were not elevated and were in direct contact with the mattress. On 9/16/25 at 11:36 AM, Surveyor observed R50 in bed. R50's heels were not elevated and were in direct contact with the mattress. On 9/17/25 at 7:52 AM, Surveyor observed R50 in bed. R50's heels were not elevated and were in direct contact with the mattress. On 9/17/25 at 2:36 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R50's heels should be elevated per R50's plan of care. 2. From 9/15/25 to 9/17/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including epilepsy, atrial fibrillation, diabetes type 2, and dementia. R7's MDS assessment, dated 6/18/25, indicated R7 was dependent on staff for transfers, hygiene, and dressing and had moderately impaired cognition. R7 had an activated POAHC. R7's plan of care indicated R7 had impaired skin Integrity related to a medical device and indicated R7 should wear a left heel bootie at all times. R7 acquired a left lateral shin pressure injury at the facility on 5/5/25 due to a chronic medical device. R7 wore a leg brace due to foot drop. A Nurse Practitioner (NP) order, dated 5/5/25, indicated to discontinue the brace due to immobility and a left heel bootie was applied. The pressure injury resolved and R7's treatment was discontinued. On 9/16/25 at 11:42 AM and 12:22 PM, Surveyor observed R7 in the dining room without a left heel bootie. On 9/16/25 at 2:43 PM, Surveyor observed R7 in bed without a left heel bootie. On 9/17/25 at 8:04 AM, Surveyor observed R7 in the dining room without a left heel bootie. On 9/17/25 at 8:10 AM, Surveyor interviewed Registered Nurse (RN)-H who reviewed R7's Treatment Administration Record (TAR) and verified R7 had an order for a left heel bootie that was on R7's plan of care. RN-H verified R7 did not have a left heel bootie on as ordered and put R7's left therapeutic boot on.

Based on staff interview and record review, the facility did not ensure neuro checks were completed after unwitnessed falls for 1 resident (R) (R42) of 4 sampled residents.R42 had unwitnessed falls on 6/12/25, 6/19/25, 6/27/25, 7/10/25 and 8/26/25. Following the falls, staff did not ensure neuro checks were completed in accordance with the facility's policy. Findings include:The facility's Falls Investigation Guideline, dated 12/20/20, indicates: .4. If the fall was unwitnessed or involved a resident who hit their head, initiate neurological evaluation .Monitor the resident and observe for changes for a minimum of 72 hours.The facility's Neurological Flow Sheet indicates: Vital Signs and Neuro Checks: Every 15 minutes x 1 hour, then every 30 minutes x 1 hour, then every hour x 4 hours, then every 4 hours x 24 hours.On 9/15/25, Surveyor reviewed R42's medical record. R42 had diagnoses including hemiplegia and hemiparesis following a stroke, vascular dementia, and polymyalgia rheumatica. R42's Minimum Data Set (MDS) assessment, dated 8/6/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R42 had severe cognitive impairment. The MDS assessment indicated R42 was independent with transfers from bed to wheelchair and required assistance with wheelchair and walker use. R42 had an activated healthcare decision maker. R42's care plan, dated 6/20/25, indicated R42 required assistance to lay down and for toileting.R42's medical record indicated R42 had unwitnessed falls on the dates below. R42's care plan was not updated with interventions following the falls. No injuries were noted. Neuro checks were started but not completed in accordance with the facility's neuro check form.~ On 6/12/25, R42 had an unwitnessed fall in R42's room and was found lying on top of a wheelchair. R42 indicated R42 attempted to self-transfer from bed to wheelchair and lost R42's balance. Staff completed 15 of 16 neuro checks. ~ On 6/19/25, R42 had an unwitnessed fall in R42's room and was found sitting on the floor with a walker in front of R42. R42 indicated R42 stood up to go to the bathroom and fell to the floor. Staff completed 13 of 16 neuro checks. ~ On 6/27/25, R42 had an unwitnessed fall in R42's room and was found sitting on the floor. R42 indicated R42 lost R42's balance while ambulating from bed to sink. Staff completed 14 of 16 neuro checks. ~ On 7/10/25, R42 had an unwitnessed fall in R42's room and was found on the floor next to R42's bed. R42 indicated R42 attempted to go from bed to the bathroom. Staff completed 14 of 16 neuro checks.~ On 8/26/25, R42 had unwitnessed falls at 7:45 AM and 1:00 PM. At 7:45 AM, R42 was found sitting on the floor in R42's bathroom. R42 indicated R42 bumped R42's head and when R42 attempted to go to the bathroom. Neuro checks were started and ended after the 11:30 AM check. Staff did not complete the 12:30 PM neuro check. At 1:00 PM, R42 was found on the floor in R42's room on the right side next to R42's bed. R42 indicated R42 attempted to put R42's legs on the bed and fell to the floor. Neuro checks were started at 2:30 PM (instead of 1:00 PM). Staff completed 14 of 16 neuro checks. On 9/16/25 at 12:05 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R42's neuro checks were started following the falls but not completed.

Based on staff interview and record review, the facility did not ensure monitoring for adverse reactions to high-risk medication was in place for 3 residents (R) (R3, R5 and R132) of 6 sampled residents.R3 was prescribed opioid and anticoagulant medication. The facility did not monitor R3 for adverse reactions to the medications.R5 was prescribed diuretic and anticoagulant medication. The facility did not monitor R5 for adverse reactions to the medications. In addition, the facility did not update R5's care plan to indicate R5 received diuretic and anticoagulant medication.R132 was prescribed antibiotic medication for osteomyelitis (a bone infection) on 9/5/25. The facility did not monitor R132 for adverse reactions to the medication.Findings include: According to Medlineplus.gov, oxycodone may cause side effects including, but not limited to: dry mouth, stomach pain, drowsiness, flushing, headache, mood changes, changes in heartbeat, agitation, hallucinations, fever, sweating, confusion, shivering, severe muscle stiffness or twitching, loss of coordination, diarrhea, nausea, vomiting, loss of appetite, weakness, dizziness, chest pain, rash, itching, hives, difficulty breathing or swallowing, swelling of the face, mouth, tongue, lips, throat, hands, feet, ankles, or lower legs, and seizures. According to Medlineplus.gov, apixaban may cause side effects including, but not limited to: bleeding gums, nosebleeds, red, pink, or brown urine, red or black tarry stools, coughing up or vomiting blood or material that looks like coffee grounds, swelling or joint pain, headache, rash, chest pain or tightness, swelling of the face or tongue, trouble breathing, wheezing, and feeling dizzy or faint. Apixaban prevents blood from clotting normally so it may take longer than usual to stop bleeding if you are cut or injured. The medication may also cause you to bruise or bleed more easily. Call your doctor right away if bleeding or bruising is unusual, severe, or cannot be controlled. According to Medlineplus.gov, furosemide may cause side effects including, but not limited to: frequent urination, blurred vision, headache, constipation, diarrhea, decreased urination, dry mouth, thirst, nausea, vomiting, weakness, drowsiness, confusion, muscle pain or cramps, rapid or pounding heartbeat, ringing in the ears, loss of hearing, itching, rash, hives, blisters, peeling skin, difficulty breathing or swallowing, and yellowing of the skin or eyes. Per the Federal Food and Drug Administration (FDA), some possible uncommon but serious side effects of doxycycline include: life-threatening allergic reaction (trouble breathing, closing of the throat, swelling of the lips, tongue, or face, and hives), blood problems (unusual bleeding or bruising), liver damage (yellowing of the skin or eyes, dark urine, nausea ,vomiting, loss of appetite, and abdominal pain), and irritation of the esophagus. Other more common, but less serious side effects, include nausea, vomiting, diarrhea, and increased sensitivity of the skin to sunlight. The facility's Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes policy, revised 7/2016, indicates: .4. All residents' antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: .l. Adverse events. 1.From 9/15/25 to 9/17/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, acute embolism and thrombosis of unspecified vein, and acute pain due to trauma. R1's Minimum Data Set (MDS) assessment, dated 7/24/25, had a Staff Interview for Mental Status that indicated R3 had severe cognitive impairment. R3's physician orders indicated R3 was prescribed the following medications: ~ Oxycodone (opioid medication) 5 milligrams (mg) every 6 hours as needed for pain, start date 4/2/24. ~ Apixaban (anticoagulant medication) 5 mg twice daily (BID) for acute embolism and thrombosis of unspecified vein, start date 4/3/24. R3's medical record did not include monitoring for adverse reactions to oxycodone and apixaban. On 9/17/25 at 2:28 PM, Surveyor interviewed Director of Nursing (DON)-B and Regional Nurse Consultant (RNC)-N who indicated the facility follows standards of practice to monitor for adverse reactions to opioid and anticoagulant medications. RNC-N and DON-B confirmed monitoring for adverse reactions to the medications should be in place for R3. 2. From 9/15/25 to 9/17/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, chronic systolic congestive heart failure, and paroxysmal atrial fibrillation. R5's MDS assessment, dated 8/7/25, had a Staff Interview for Mental Status that indicated R5 had moderate cognitive impairment. R5's physician orders indicated R5 was prescribed the following medications: ~ Furosemide (diuretic medication) 40 mg via tube feeding once daily for chronic systolic congestive heart failure, start date 7/22/25. ~ Apixaban 5 mg via tube feeding twice daily for anticoagulant, start date 7/21/25. R5's medical record did not include monitoring for adverse reactions to furosemide and apixaban and did not contain a care plan for diuretic and anticoagulant use. On 9/17/25 at 2:28 PM, Surveyor interviewed DON-B and RNC-N who stated the facility follows standards of practice to monitor for adverse reactions to diuretic and anticoagulant medications. RNC-N and DON-B confirmed monitoring for adverse reactions to the medications should be in place for R5. 3. On 9/17/25, Surveyor reviewed R132's medical record. R132 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis, cellulitis of right lower limb, and hypokalemia. R132's MDS assessment, dated 6/3/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R132 had intact cognition. R132 made R132's own healthcare decisions. R132's medical record indicated R132 was prescribed doxycycline hyclate (antibiotic medication) for osteomyelitis. R132's medical record did not indicate R132 was monitored for adverse reactions to doxycycline. On 9/17/25 at 12:27 PM and 1:32 PM, Surveyor interviewed DON-B who confirmed monitoring for adverse reactions to doxycycline should be in place for R132.

Based on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R3) of 1 resident (with the potential to affect 26 of 141 other residents) when R3 obtained a loaded firearm from a staff's bag and carried it onto a secured memory care unit and for 1 (R2) of 1 resident who incurred a third degree cryogenic burn from a portable oxygen tank that was placed on the foot pedals of the resident's wheelchair. R3 was on 1:1 supervision related to wandering and aggressive behavior toward staff. Certified Nursing Assistant (CNA)-C was assigned to complete 1:1 supervision for R3 on the 1/22/25 PM shift. CNA-C brought a loaded gun into the facility in a purse and brought the purse into R3's room. R3 removed the gun from CNA-C's purse and carried the gun onto a secured memory care unit. Staff intervened and removed the gun. In addition, Dialysis Registered Nurse (DRN)-R observed R2 in a wheelchair in the elevator on the way to a dialysis appointment. When R2 complained of pain, DRN-R observed a leaking portable oxygen tank on the foot pedals of R2's wheelchair that was placed there by staff. DRN-R noted a reddened area on R2's right foot and notified facility staff. The wound was not monitored or treated until 12/28/24 when staff discovered a full-thickness third degree cryogenic burn on R2's right lateral ankle/heel that required surgical debridement and antibiotic treatment for infection. The facility's failure to ensure a safe environment when staff placed a portable oxygen tank on the foot pedals of a resident's wheelchair led to a finding of immediate jeopardy that began on 12/24/24. The immediate jeopardy was removed and corrected on 12/28/24. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 2/21/25 at 4:15 PM. In addition, the facility's failure to ensure a safe environment when staff brought a loaded gun onto a secured memory care unit and a resident on 1:1 supervision retrieved the gun and carried it onto the unit led to a finding of immediate jeopardy that began on 1/22/25. NHA-A was notified of the immediate jeopardy on 1/29/25 at 4:14 PM. The immediate jeopardy was removed on 1/29/25, however, the deficient practice continues at a scope/severity level E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: According to Mental Health America, exposure to violent events cause trauma and lasting changes in the nervous system in both children and adults. Exposure to all types of violence, and the toxic stress caused by fear of violence, are shown to negatively impact psychosocial engagement and increase the likelihood of a person developing mental health conditions at all stages of life. (https://www.mhanational.org/gun-deaths-violence-and-mental-health) According to the American Society on Aging, firearm violence or exposure to it can affect both physical and mental health. Some people with exposure to firearm violence may experience post-traumatic stress disorder (PTSD), anxiety, or other conditions as a result. Disability, both short-term and long-term, also may result from firearm violence and vary in severity and impact. Such disabilities affect family structure, family financial status and family health. (https://generations.asaging.org/firearm-violence-and-older-adults#:~:text=Some%20people%20who%20have%20been,vary%20in%20severity%20and%20impact.) 1. On 1/29/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including dementia with agitation, metabolic encephalopathy, anxiety, and alcoholic cirrhosis. R3's most recent Minimum Data Set (MDS) assessment, dated 1/4/25, indicated R3's Brief Interview for Mental Status (BIMS) score was not assessed. A staff assessment indicated R3's memory and cognition were impaired. R3 had an activated Power of Attorney for Healthcare (POAHC) as of 1/14/25. R3's most recent comprehensive care plan, dated July 2024, indicated R3 had negative behavioral disturbances related to depression, insomnia, and general anxiety. R3's behaviors included verbal and physical aggression toward staff. R3's care plan did not contain an intervention for 1:1 supervision, however, progress notes stated to continue with 1:1 supervision and staff were specifically assigned 1:1 supervision for R3 on the schedule. On 1/29/25, Surveyor investigated an incident that occurred on 1/22/25 when CNA-C was assigned to provide 1:1 supervision to R3 on the secured memory care unit. During the shift, R3 retrieved a loaded gun from CNA-C's purse when CNA-C asked CNA-E to watch R3 while CNA-C took a break. R3 carried the gun onto the secured memory care unit where 26 other residents resided. On 1/29/25 at 9:45 AM, Surveyor interviewed CNA-F regarding residents who require 1:1 supervision. CNA-F indicated there was one resident who currently required 1:1 supervision (R4). When asked if there were any concerns with other residents who had been on 1:1 supervision, CNA-F stated there was an incident where R3 found a gun in R3's 1:1 staff's bag. On 1/29/25 at 10:51 AM, Surveyor interviewed CNA-E regarding the incident on 1/22/25. CNA-E verified CNA-E worked the 1/22/25 PM shift on the 500 unit. CNA-E stated CNA-E took over 1:1 supervision for R3 when CNA-C took a 15 minute break. CNA-E observed R3 in the dining room while CNA-E set up for dinner. CNA-E then observed R3 exit the dining room and walk toward R3's room (which was two doors down from the dining room). CNA-E followed R3 and observed from the hallway as R3 was rummaging through a black bag in the room. CNA-E then observed R3 walk out of the room with something in R3's hand. After approximately 30 seconds, CNA-E realized R3 was carrying a gun and immediately notified Licensed Practical Nurse (LPN)-D. CNA-E stated R3 was on 1:1 supervision related to aggressive behavior at that time. On 1/29/25 at 12:36 PM, Surveyor interviewed CNA-C regarding the incident on 1/22/25. CNA-C verified CNA-C was assigned to 1:1 supervision for R3 on the 1/22/25 PM shift. CNA-C stated CNA-C was sitting in the dining room with R3 just before dinner when CNA-C asked CNA-E to take over for 15 minutes so CNA-C could take a break. CNA-C was on break for approximately 10 minutes when CNA-C became aware of the incident. CNA-C verified the gun was in CNA-C's purse that was left in R3's room. CNA-C verified the gun was loaded and stated the safety was on. CNA-C indicated CNA-C was aware that guns were not allowed in the facility, however, CNA-C was in a hurry that morning and forgot about the gun. On 1/29/25 at 3:38 PM, Surveyor interviewed LPN-D regarding the incident on 1/22/25. LPN-D was checking on another resident on the unit when LPN-D observed R3 exit R3's room with something in R3's hand. At first LPN-D thought R3 was carrying a toy gun, but upon closer inspection noticed the gun was real. LPN-D asked R3 for the gun and put the gun back in a black bag in R3's room and closed the door. LPN-D then notified NHA-A and Director of Nursing (DON)-B. LPN-D stated LPN-D did not receive any training related to the incident. On 1/29/25 at 2:11 PM, Surveyor interviewed NHA-A regarding the incident on 1/22/25. NHA-A verified NHA-A was downstairs with administrative staff on 1/22/25 when NHA-A received a phone call that a resident had a gun upstairs. NHA-A instructed staff to notify the police and went upstairs to respond. By the time NHA-A arrived on the unit approximately 5 minutes later, LPN-D had retrieved the gun from R3. NHA-A verified camera footage showed R3 carried the gun onto the secured memory care unit. NHA-A indicated staff education was started on 1/22/25 regarding personal belongings in residents' rooms, active violence training, and active shooter drills. NHA-A indicated the police arrived and CNA-C was charged with bringing a firearm into the facility. NHA-A verified the police officer stated the gun was loaded and the safety was on. On 1/29/25, Surveyor reviewed a police report related to the incident. The report indicated police were dispatched for a subject with weapon complaint on the second floor of the facility on 1/22/25 at 4:05 PM. Officers made contact with NHA-A who informed them CNA-C came to work with a gun in CNA-C's purse despite the fact there was a sign on the front door that stated employees were prohibited from possessing firearms in the building. CNA-C was arrested and a black 9 mm gun was recovered. The failure to ensure the resident environment was as free from accident hazards as possible and prevent a cognitively impaired resident access to a loaded gun created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 1/29/25 when it completed the following: 1. Notified the police and removed the employee and firearm from the building. 2. Educated all staff on personal belongings, active violence training, and active shooter drills. 3. Initiated psychosocial monitoring for all residents on the 500 unit. 4. Initiated audits to ensure weapons are not brought into the facility. 40449 2. On 1/29/25, Surveyor reviewed R2's medical record. R2 was readmitted to the facility on [DATE] following hospitalization for chronic hypoxemic respiratory failure and had diagnoses including right ankle soft tissue infection, neuropathy, diabetes mellitus, coronary artery disease, and anemia. R2's MDS assessment, dated 1/15/25, had a BIMS score of 13 out of 15 which indicated R2 had intact cognition. R2 had an activated Power of Attorney (POA) who assisted with R2's healthcare decisions. A health status note, dated 12/20/24 at 5:58 AM, indicated a transport oxygen tank was placed on a blanket near R2's right leg when R2 was getting ready to go to dialysis. R2 complained of right ankle irritation. An assessment indicated a reddened area was present with no break in the skin. The note stated, Continued to be monitored. A skin issue observation, dated 12/20/24 at 6:09 AM, indicated R2 had a reddened area on the right inner ankle. A skin issue observation, dated 12/20/24 at 1:44 PM, indicated R2 had a pre-existing wound on the right lateral ankle. The observation did not include wound characteristics or measurements. A weekly skin review and a skin and bath report, both dated 12/24/24, as well as diabetic foot checks completed from 12/20/24 through 12/27/24 did not indicate there were any concerns with R2's right ankle/heel. A skin observation, dated 12/28/24, indicated R2 had a flat dark-colored blister on the right lateral heel and a pre-existing wound on the right lateral ankle. A health status note, dated 12/28/24 at 11:25 AM, indicated R2 had a flat blister with dark discoloration on the right heel. The peri-wound (surrounding skin) was peeling with no drainage or odor. The wound measured 5.6 centimeters (cm) x 4.9 cm. A Nurse Practitioner (NP) visit note, dated 12/28/24, indicated R2 had a flat right heel blister with dark discoloration to the tissue that measured 5.6 cm x 4.9 cm. A skin and wound evaluation, dated 12/30/24, indicated R2 had an in-house acquired third degree burn on the right medial malleolus (note: the wound was on the lateral side of the foot) that contained eschar, redness, inflammation, erythema (swelling), and light serous (clear or pale yellow) exudate (drainage). The wound had blistered surrounding tissue and measured 4.5 cm x 4.3 cm. An NP visit note, dated 12/30/24, indicated R2 had a right medial ankle wound (an addendum was added to indicate the wound was on the right lateral ankle) status-post cryogenic burn from liquid oxygen in a tank that was placed between R2's legs in a wheelchair. The wound measured 4.5 cm x 4.32 cm x depth unable to be determined. R2 reported moderate to severe pain. Doxycycline (an antibiotic used to treat infection) and hydrocodone-acetaminophen (Norco) (an opioid medication used to treat pain) were ordered. R2 stated the incident occurred the previous Tuesday (12/24/24). (R2's December 2024 Medication Administration Record (MAR) contained an order initiated on 12/30/24 for doxycycline hyclate 100 milligrams (mg) twice daily for wound infection for 14 days.) A wound physician initial visit note, dated 1/3/25, indicated R2 had a full thickness burn (a severe burn that destroys all three layers of the skin) on the right lateral heel that measured 5.0 cm x 5.0 cm x 0.1 cm with light serous exudate and 100% necrotic tissue. The wound physician ordered silver sulfadiazine with an ABD pad and gauze roll twice daily for 30 days. The note indicated debridement was attempted but aborted due to pain and debridement with sharps was contraindicated due to R2's risk of bleeding. R2 was hospitalized from 1/5/25 to 1/9/25 for issues related to respiratory failure. A hospital discharge summary, dated 1/9/25, indicated R2 had a right ankle soft tissue infection from a burn caused by a frozen oxygen tank. The wound had eschar, surrounding erythema, and a foul odor. An infectious disease note, dated 1/8/25, indicated R2 had bedside mechanical debridement on 1/1/24 (note: should be 1/1/25) at the facility by an on-site wound care provider. The team was concerned about persistent and foul odor and a skin and soft tissue infection. On 1/29/25 at 10:23 AM, Surveyor interviewed Wound Care Consultant (WCC)-P who indicated R2's right heel wound was discovered on 12/28/24. WCC-P verified the wound on R2's right heel (which is the same wound that was described as a right lateral ankle wound) was a burn related to a portable oxygen tank. On 1/29/25 at 11:00 AM, Surveyor interviewed DON-B who indicated a new open area should be added to the 24-hour report board and the resident's physician and responsible party (if appropriate) should be updated. On 1/29/25 at 11:15 AM, Surveyor interviewed Registered Nurse (RN)-K who indicated when R2 was getting ready for dialysis on 12/20/24, a portable oxygen tank was put between R2's legs. R2 reported to RN-K that the skin on R2's right lower leg felt irritated. RN-K completed a skin check and observed a reddened area on R2's right ankle. RN-K indicated the change in R2's skin should have been documented on the 24-hour report and R2's physician and responsible party should have been notified. RN-K thought the proper documentation was completed but was later notified by DON-B that RN-K had not documented on the 24-hour report board. On 1/29/25, Surveyor reviewed the 24-hour report from 12/20/24. The 24-hour report did not contain documentation related to R2's right ankle irritation on 12/21/24, 12/22/24, 12/24/24, 12/25/24, 12/26/24, or 12/27/24. The 24-hour reports for 12/20/24, 12/23/24, and 12/28/24 were not provided. On 12/29/24, the 24-hour report indicated R2 had a right heel wound. On 1/29/25 at 11:45 AM, Surveyor interviewed R2 who indicated a portable oxygen canister was placed between R2's legs prior to dialysis. R2 reported to a nurse that R2's feet hurt. The nurse completed an assessment and told R2 there were no concerns. R2 reported the concern to a dialysis nurse as well. R2 indicated despite lower extremity neuropathy (a condition that damages the nerves), R2 could feel the increased pain. On 1/29/25 at 12:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q who indicated R2 complained of foot pain on 12/28/24. LPN-Q observed a wound on R2's right lateral heel. LPN-Q indicated the wound had a blister-like appearance with a flat and hard wound bed. The facility's investigation indicated the area was likely first irritated on 12/20/24 despite R2's statement that the injury occurred on 12/24/24. Staff believe the area was reinjured on 12/24/24 on R2's way to dialysis. A statement by NHA-A, dated 12/31/24, indicated NHA-A was informed on 12/28/24 of an open area on R2's leg and it was bad. The note indicated R2 was going to be sent to the hospital but an on-call NP did not want R2 to go to the hospital and wanted to assess R2 in the facility. The on-call NP assessed R2 and indicated the area was a stage 2 pressure injury and not a burn. A statement by DRN-R, dated 12/31/24, indicated DRN-R saw R2 in the elevator (the statement did not contain the date) and noticed air coming from R2's portable oxygen tank. When R2 arrived on the unit, R2 complained of lower right leg pain. DRN-R assessed R2, observed a red spot (the note did not specify where the red spot was observed), and notified facility staff of the observation. A statement by LPN-Q, dated 12/31/24, indicated R2 asked LPN-Q to look at R2's feet on 12/28/24 because R2's feet were burning. LPN-Q observed a flat wound on R2's right foot that was peeling around the edges and appeared to be a popped blister. R2 indicated an oxygen tank was lying down there when R2 was at dialysis. R2 stated the tank leaked, R2's covers were wet, and R2's foot was burning. R2 told staff who stated they didn't see anything at that time. While LPN-Q was talking to R2, CNA-T indicated there was blood on R2's sheets the day before and CNA-T did not know where the blood came from. An undated statement by CNA-T indicated CNA-T found blood like discharge and coffee like stains in R2's bed under R2's foot on 12/28/24. R2 reported pain. CNA-T observed the bottom of R2's foot and notified a nurse. A statement by Unit Manager (UM)-M, dated 12/30/24, indicated UN-M assessed the right side of R2's foot just below the ankle on 12/28/24 after R2 reported pain. R2 indicated a CNA put a portable oxygen tank between R2's legs on 12/24/24 prior to transporting R2 to dialysis. R2 reported pain to DRN-R who removed the tank and notified a facility nurse of R2's complaint. The failure to ensure liquid oxygen did not come in contact with a resident's skin and the failure to assess and treat the skin following a cryogenic burn led to serious harm for R2 who developed a full-thickness third degree burn and required antibiotic treatment for infection. The facility removed the jeopardy on 12/28/24 when it completed the following: 1. Educated licensed and certified staff on the facility's Oxygen Usage policy and procedure. 2. Checked all resident and stock portable oxygen tanks to ensure proper function. 3. Completed skin assessments on all residents who use portable oxygen tanks. 4. Reviewed and/or revised the care plans of all residents at risk for oxygen burns.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents with an indwelling catheter received appropriate catheter care and services. R1 had a Foley catheter inserted on 11/21/24 due to urinary retention. From 11/21/24 to 12/7/24, staff did not monitor R1's urine output or assess for genitourinary changes. On 12/7/24, R1 complained of penile pain. Urinary and catheter assessments were not completed on 12/8/24 and 12/9/24. On 12/10/24, R1 had increased confusion, low urine output, and a large amount of pus at the catheter site. On 12/11/24, R1 was transferred to the hospital due to severe penile pain. R1's catheter was blocked and drained thick gray material. R1 returned to the facility on [DATE] with diagnoses of urinary retention, UTI, and acute kidney injury. Findings include: The facility's Urinary Indwelling Catheter Management Guideline, dated 11/28/17, indicates: Indwelling catheters may be associated with significant complications, including bacteremia, febrile episodes, bladder stones, fistula formation, and erosion of the urethra, epididymitis, chronic renal inflammation, and pyelonephritis. Indwelling catheters are also prone to blockage. Risk factors for catheter blockage include alkaline urine, impaired urine flow, proteinuria, and pre-existing bladder stones .Urinary retention that cannot be treated or corrected medically or surgically for which alternative therapy is not feasible and which is characterized by: 1. Documented post-void residual volumes in a range over 200 milliliters (ml). 2. Inability to manage the retention/incontinence with intermittent catheterization, and 3. Persistent overflow incontinence, symptomatic infections and/or renal dysfunction .Additional care practices should include: Educating the resident and/or resident representative on the risks and benefits of catheter use; Recognizing and evaluating for complications and the root cause analysis contributing factors; Every shift evaluation, during cares, of urine appearance for changes and indication of pain and/or genitourinary changes; Attempting to remove the catheter as soon as possible when no indications exist for justification of placement .Ensuring the catheter is secured to eliminate dislodgement or irritation resulting from tension or pulling on the tubing. Each resident may require an individualized approach. On 1/7/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including urinary retention, urinary tract infection, diabetes mellitus, and benign prostatic hyperplasia (BPH). R1's Admission Minimum Data Set (MDS) assessment, dated 11/2/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 was not cognitively impaired. The MDS also indicated R1 was dependent on staff for toileting hygiene and transfers. A Hospital Discharge Summary, dated 10/30/24, indicated a Genitourinary referral was completed due to concerns related to urinary retention and indicated R1 should be seen by R1's primary care provider (PCP) in 1-2 weeks for an evaluation of urinary retention. The discharge summary indicated R1 was unaware of urination and retention and Infectious Disease recommended a Urology consult. A Bladder Evaluation, dated 10/30/24, indicated R1 had urinary retention and difficulty during urination. R1's care plan initiated on 12/24/24, indicated R1 had increased risk for UTI related to a Foley catheter and catheter obstruction. (R1's Foley catheter was placed on 11/21/24). R1's care plan contained interventions to monitor and document output, monitor and document for pain/discomfort due to catheter, monitor for signs/symptoms of UTI, and monitor/record/report to Medical Doctor (MD) signs/symptoms of UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. A Urology Clinic note, dated 11/21/24, indicated R1 was unable to urinate while at the clinic. A bladder scan indicated there were 1359 milliliters (mLs) of urine in R1's bladder. (Average bladder capacity is 400-500 mLs.) R1 was diagnosed with urinary retention. A 16 French (Fr) coude catheter (a catheter with a slight bend at the tip that helps navigate around blockages in the urethra or bladder neck) was inserted with 1300 mL of urine returned. An order to return to the clinic in 1 month was noted. A Health Status note, dated 12/7/24, indicated R1 complained of penile pain. A nursing assessment indicated a scant amount of yellow bloody drainage was present. Documentation indicated R1's catheter was patent, draining amber urine, and the area was tender to the touch. A Nurse Practitioner (NP) was contacted and ordered pain medication. A Fall Incident Report, dated 12/9/24, indicated R1 was found on the floor on R1's back. Documentation indicated R1 could not stand and was transferred back to bed via Hoyer lift. The note indicated R1's catheter was in place. R1's medical record did not contain documentation of urinary output, urine appearance, or genitourinary changes from 11/21/24 to 12/7/24 and did not contain urinary or catheter assessments on 12/8/24 and 12/9/24. A Health Status note, dated 12/10/24, indicated R1 had increased confusion, low urine output, and a large amount of pus from the catheter site. Antibiotics were ordered and pain medication was provided. On 12/11/24, R1 requested to be transferred to the hospital for severe penile pain. R1 was admitted to the hospital on 12/11/24 and returned to the facility on [DATE] with diagnoses of urinary retention, UTI, and acute kidney injury. Surveyor reviewed R1's Hospital History and Physical, dated 12/11/24, with Clinical Consultant (CC)-D. The History and Physical indicated R1 stated R1's catheter fell out during a fall and R1 re-inserted the catheter. CC-D was not aware R1 had stated R1's catheter fell out during a fall. A Discharge Summary, dated 12/13/24, indicated R1's catheter was blocked upon arrival at the Emergency Department (ED) and drained thick gray material. The catheter was removed and R1 had a large urine output (the Discharge Summary did not indicate the amount of urine in mLs.) A new Foley catheter was inserted which drained clear urine until R1 was discharged from the hospital. On 12/31/24, R1 was hospitalized due to low hemoglobin and hematocrit and was not available for interview during the survey. On 1/7/25 at 10:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who indicated catheter drainage bags are emptied every shift and as needed. CNA-G indicated nursing staff should document the amount of urine emptied in the resident's medical record. On 1/7/25 at 2:00 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated LPN-E was familiar with R1 but had not assisted R1 with catheter care. LPN-E indicated CNAs and nurses empty catheter bags and document the amount of urine in the resident's electronic medical record or Medication Administration Record (MAR). On 1/7/25 at 2:15 PM, Surveyor requested documentation of genitourinary assessments, including catheter care and urinary outputs, from 11/21/24 to 12/7/24. At 3:54 PM, CC-D indicated CC-D was unable to provide Surveyor with the requested documentation. On 1/7/25 at 4:30 PM, Surveyor interviewed [NAME] President of Clinical Operations (VPCO)-P who indicated several people assisted the facility with updating care plans which is why R1's care plan was revised on 12/24/24.

Based on interview and record review, the facility did not ensure 2 (R607 & R605) of 3 residents were free of significant medication errors. * R607 did not receive Lacosamide for seizures 11 times in July. In August R607 did not receive Lacosamide 2 times & Keppra 3000 mg one time. On 9/1/24 & 9/4/24 R607 did not receive the 7:00 a.m. dose of Divalproex Sodium 1500 mg. On 9/8/24 R607 did not receive the 7:00 a.m. dose of Keppra 3000 mg and on 9/9/24 R607 did not receive the 7:00 a.m. dose of Lacosamide 200 mg & Keppra 3000 mg. On 9/9/24 R607 was transferred to the hospital for seizures. On 9/10/24 R607 did not receive the 7:00 a.m. dose of Lacosamide 200 mg. * R605's physician order includes with an order date of 7/30/24 documents Clobazam oral tablet 10 mg (milligram) with directions to give one tablet by mouth two times a day for seizures. R605 did not receive Clobazam 13 times in August and 4 times in September. Findings include: The facility's policy titled, Administering Medications revised December 2012 under Policy Statement documents Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy interpretation and Implementation #3 documents Medications must be administered in accordance with the orders, including any required time frame. 1.) R607's diagnoses includes epilepsy. The resident has a seizure disorder r/t (related to) head injury care plan initiated 10/28/22 documents the following interventions: * Give medications as ordered. Monitor/document for effectiveness and side effects. Initiated 10/28/22. * Monitor labs and report any sub therapeutic or toxic results to MD (medical doctor). Initiated 10/28/22. * Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Initiated 10/28/24. * Post Seizure Treatment: Turn on side with head back, hyper-extended to prevent aspiration. Keep airway open, After seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC (level of consciousness), paralysis, weakness, pupillary changes. Initiated 10/28/22. * Seizure Documentation: location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Initiated 10/28/22. * Seizure Precautions: Do not leave resident alone during a seizure, protect from injury, if resident is out of bed, help to the floor to prevent injury, remove or loosen tight clothing, don't attempt to restrain resident during seizure as this could make the convulsions more severe, protect from onlookers, draw curtains, etc. Initiated 10/28/22. The physician orders with an order date of 6/11/24 documents Keppra Oral Tablet 1000 mg (milligrams) with directions to give 3 tablet by mouth two times a day for seizure activity (3000 mg total). The physician orders with an order date of 6/11/24 documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total) and Give 3 tablet by mouth at bedtime for seizure (300 mg total). The physician orders with an order date of 9/3/24 documents Divalproex Sodium Oral Tablet Delayed Release 125 mg. Give 12 tablet by mouth two times a day for seizures. The July 2024 MAR (medication administration record) on 7/12/24 at 2100 (9:00 p.m.) for Lacosamide Oral Tablet 100 mg. Give 3 tablet by mouth at bedtime for seizure (300 mg total) is not checked & initialed as being administered. The July 2024 MAR on 7/13/24 at 0700 (7:00 a.m.) for Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total) is not checked & initial as being administered. The eMar (electronic medication administration record) dated 7/14/24, at 09:03 (9:03 a.m.), by LPN (Licensed Practical Nurse)-V documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total). Awaiting delivery. The eMar note dated 7/20/24, at 10:30 a.m., by LPN-W documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total). Only 1 tablet available - will call Pharm (pharmacy). The eMar note dated 7/20/24, at 20:07 (8:07 p.m.), by Med Tech-X documents Lacosamide Oral Tablet 100 mg. Give 3 tablet by mouth at bedtime for seizure (300 mg total). On order. The eMar note dated 7/21/24, at 14:47 (2:47 p.m.), by LPN-Y documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total). Medication in route from pharmacy. The eMar note dated 7/21/24, at 20:23 (8:23 p.m.), by Med Tech-X documents Lacosamide Oral Tablet 100 mg. Give 3 tables by mouth at bedtime for seizure (300 mg total). On orders. The eMar note dated 7/22/24, at 8:07 a.m., by LPN-V documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total). Awaiting delivery. The July 2024 MAR on 7/22/24, at 2100 (9:00 p.m.), for Lacosamide Oral Tablet 100 mg. Give 3 tablet by mouth at bedtime for seizure (300 mg total) is not checked & initialed as being administered. The eMar note dated 7/23/24, at 10:35 a.m., by LPN-Z documents Lacosamide Oral Tablet 100 mg Give 2 tablet by mouth in the morning for seizure (200 mg total). Not Available. The July 2024 MAR on 7/28/24, at 2100 (9:00 p.m.), for Lacosamide Oral Tablet 100 mg. Give 3 tablet by mouth at bedtime for seizure (300 mg total) is not checked & initialed as being administered. The eMar note dated 8/12/24, at 9:03 a.m., by LPN-AA documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total). Pharmacy is currently out of this medication. It will be delivered from [Pharmacy Name] 8/12/24. The eMar note dated 8/12/24, at 17:53 (5:53 p.m.), by Med Tech-X documents Keppra Oral Tablet 1000 mg. Give 3 tablet by mouth two times a day for Seizure Activity (3000 mg total). On order. The eMar note dated 8/12/24, at 21:46 (9:46 p.m.), by Med Tech-X documents Lacosamide Oral Tablet 100 mg. Give 3 tablet by mouth at bedtime for seizure (300 mg total). On order. The eMar note dated 9/1/24, at 17:47 (5:47 p.m.), by Med Tech-X documents Divalproex Sodium Oral Tablet Delayed Release 125 mg. Give 12 capsule by mouth two times a day for seizure. On order. The eMar note dated 9/4/24, at 10:01 a.m., by LPN-BB documents Divalproex Sodium Oral Tablet Delayed Release 125 mg. Give 12 capsule by mouth two times a day for seizure. On order. The eMar note dated 9/8/24, at 11:58 a.m., by RN (Registered Nurse)-CC documents Keppra Oral Tablet 1000 mg. Give 3 tablet by mouth two times a day for Seizure Activity (3000 mg total). 9/8/24: Medication not available. The nurses note dated 9/9/24, at 7:41 a.m., documents Writer was notified by roommate that resident was shaking. Resident had been given medication and had vitals taken 10 mins (minutes) prior vitals WNL (within normal limits). Resident turned to left side. Seizure lasted approximately 6 minutes. Writer notified [Name] NP (Nurse Practitioner) [Name] and received order to do neuro checks every hour for 4 hours. Vitals after seizure as followed BP (blood pressure) 127/62 pulse 116 temp (temperature) 98.3. Pupils equal and reactive. Resident returned to baseline. This nurses note was written by LPN-DD. The nurses note dated 9/9/24, at 8:26 a.m., documents Writer notified by wound nurse that resident was seizing. Resident had last been seen 15 mins prior for neuro check. Vitals WNL. Resident turned to left side. Seizure lasted approximately 6 minutes. Vitals taken after seizure BP 122/80 pulse 120 pupils equal and reactive spo2 97% room air respirations 16. Notified NP [Name] received order to send to hospital. [Name] ambulance called. Resident sent to [Name] hospital. POA (Power of Attorney) made aware. VM (voice mail) left for case manager. ADON (Assistant Director of Nursing) aware. This nurses note was written by LPN-DD. The eMar note dated 9/9/24, at 11:29 a.m., by LPN-DD documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total). On order NP aware of missed dose. The eMar note dated 9/9/24, 11:34 a.m., by LPN-DD documents Keppra Oral Tablet 1000 mg. Give 3 tablet by mouth two times a day for Seizure Activity (3000 mg total). On order NP aware of missed dose. The hospital ED triage note dated 9/9/24, at 9:50 a.m., documents Pt (patient) arrives via [Name] EMS (emergency medical services) coming from [Facility's name]. Pt (patient) has been out of seizure meds since Friday. Pt had seizure x2 today. Pt a+ox3 (alert and orientated times three) baseline, on RA (room air) baseline. Pt. awake and looking around answers yes/no questions. The hospital ED note dated 9/9/24, at 9:55 a.m., documents Pt. started seizing during triage. [Physician name] at bedside, airway protected. Pt with upper body shaking and right sided gaze. The hospital lab for Lacosamide (Vimpat) dated 9/9/24 at 10:09 a.m. has a result of 4.3 (reference range 10 to 20) and Keppra dated 9/9/24 at 10:09 a.m. has a result of <1.0 (reference range 6-20). The hospital neurology consult note dated 9/9/24 under History of Present Illness documents [R607's name] is a 65 Y (year) male with history of medically refractory epilepsy following TBI (traumatic brain injury) with ICH (intracerebral hemorrhage) s/p (status post) VPS (ventriculoperitoneal shunt) who presents with breakthrough seizure in the setting of medication regimen nonadherence. Unfortunately history limited as patient postictal at time of interview. On discussion with the ED (emergency department), he had been living in his group home and him (sic) and doing well when unfortunately he ran out of medications at the beginning of the weekend. He then went the next 2-3 days without his medications. Home regiment per chart review is Keppra 3000 mg BID (twice daily), Vimpat 300 mg BID, Depakote 1500 mg BID. He had 3 seizures total today and was given Keppra 4.5 g (gram) versed 4 mg x (times) 2. Per reprt (report), the facility had been out of medications all weekend so he has been at least 3 days without medication likely. The nurses note dated 9/9/24, at 16:21 (4:21 p.m.), documents MD (Medical Doctor) [Name] of [Name] Hospital contacted facility to obtain status of Keppra order r/t (related to) possible d/c (discharge) from hospital. Writer contacted [Name] pharmacy, pharmacy tech reported medication will be delivered on PM (evening) shift. Contacted MD [Name], provided update. This nurses note was written by LPN-EE. The nurses note dated 9/10/24, at 04:20 (4:20 a.m.), documents Resident returned from hospital to facility in stable condition transported via [Name] Ambulance. NNO (no new order) noted. Seizure medication arrived via pharmacy. This nurses note was written by LPN-FF. The eMar note dated 9/10/24, at 11:22 a.m., by LPN-AA documents Lacosamide Oral Tablet 100 mg. Give 2 tablet by mouth in the morning for seizure (200 mg total). Waiting on pharmacy [NAME] (delivery). No s/s (signs/symptoms) of distress. Vss (vital signs stable). On 9/18/24, at 9:14 a.m., Surveyor asked LPN-Q how medication is reordered in order for a resident not to run out of medication. LPN-Q explained they reorder on demand when there are 5 to 7 pills left or they get a normal cycle fill. Surveyor asked LPN-Q what she would do if there isn't a medication for a resident available. LPN-Q informed Surveyor she would go downstairs to contingency and would also call the pharmacy and ask if they can send out the medication. On 9/19/24, at 10:48 a.m., Surveyor asked DON (Director of Nursing)-B how residents medication are reordered. DON explained they have on demand or cycle fill. Surveyor informed DON-B there were multiple times when R607's Lacosamide and Keppra wasn't available. DON-B informed Surveyor Lacosamide is a narcotic and they have to order the medication on demand. DON-B informed Surveyor PCC (pointclickcare) will let them know when a script is needed. DON-B informed Surveyor when there are 5 to 7 pills they need to start reordering the medication. Surveyor asked DON-B if she could look into why R607 did not have Lacosamide and Keppra available multiple times and get back to Surveyor. On 9/19/24, at 12:03 p.m., DON-B provided Surveyor with delivery slips for R607's Lacosamide which showed the facility received this medication on 7/13/24 at 9:11 p.m., 7/26/24 at 2:25 p.m., and 9/10/24 at 1:51 p.m. No additional information was provided to Surveyor as to why R607 did not have Lacosamide & Keppra available to be administered per physician orders. On 9/19/24, at 1:20 p.m., Surveyor informed NHA (Nursing Home Administrator)-A, DON-B, Regional Nurse-S and Regional Director of Clinical Operations-T of the above. No additional information was provided as to why R607's seizure medication was not available. 49011 2.) R605 was admitted to the facility on [DATE] with diagnoses which include epilepsy, type 2 diabetes mellitus, and dementia. R605's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/19/2024 indicated R605 had a Brief Interview for Mental Status score of 10 (moderate cognitive impairment). R605 has an activated power of attorney. No behaviors were documented during the look back period of the assessment. R605's MDS showed that upper and lower extremities have no impairment. R605's care plan documents resident has a seizure disorder Date Initiated: 02/14/2024 Goal: The resident will be/remain free of seizure activity through review date. Date Initiated: 02/14/2024 Target Date: 07/01/2024 Interventions: Give medications as ordered. Monitor/document for effectiveness and side effects. Date Initiated: 02/14/2024 Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 02/14/2024 POST SEIZURE TREATMENT: Turn on side with head back, hyper-extended to prevent aspiration, Keep airway open, After seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC, paralysis, weakness, pupillary changes. Date Initiated: 02/14/2024 SEIZURE DOCUMENTATION: location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Date Initiated: 02/14/2024 SEIZURE PRECAUTIONS: Do not leave resident alone during a seizure, Protect from injury, If resident is out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, Don't attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain etc. Date Initiated: 02/14/2024 R605 has a physician order that started 7/30/2024 for Clobazam Oral Tablet 10mg, give one tablet by mouth two times a day for seizures. Surveyor reviewed R605's Medication Administration Record (MAR) and saw that Clobazam was not given 13 times in August and 4 times in September through the 14th. Surveyor notes this is 17 out of 90 opportunities that the medication was not given. On 9/18/24, at 9:08 AM, Surveyor interviewed Unit Manager (UM)-P and asked about the Clobazam medication not being given multiple times in August and September. The UM-P asked to look into the issue and get back to Surveyor. Later UM-P followed up with Surveyor and stated that the pills were in the Facility. The best guess is that nurses didn't know what the medication was. It is a narcotic so kept in the locked narcotic drawer. UM-P will do follow up training as one was a staff person and the others were agency that did not administer the medication. On 9/18/24, at 11:30 AM, Surveyor interviewed Director of Nursing (DON)-B about the missing administrations of Clobazam and was told the medication was on the cart in a locked box and figured staff didn't know to look there. On 9/18/2024, at 3:03 PM, during the end of day meeting, Surveyor let the Nursing Home Administrator-A, DON-B, Regional Nurse-S and Regional Director of Clinical Operations-T know of the concern that R605's Clobazam was not being administered regularly. No further information was provided as to why the facility did not ensure that R605 was free from this significant medication error.

Based on record review and interviews, the facility did not comprehensively provide medically related social services, to attain the highest psychosocial well-being, of a resident for 1 (R124) of 30 residents reviewed. *R124 verbalized, and attempted, to leave the facility to go home. The facility did not look at whether R124 still needed activation of power of attorney for health care and could, thus make own health decisions, did not look at alternatives to Sertraline, an antidepressant that R124 refused to take, did not look at discharge alternatives, and did not develop a plan of care for supervising R124 when agitated and expressing a desire to leave. On 6/23/24 R124 verbalized a desire to leave the facility and kept setting off alarms on the unit trying to leave, R124 was not permitted to do so. R124 then utilized their bed sheets to climb out a second-story window. This resulted in R124 falling and fracturing both of their ankles and a leg. The facility failure to provide comprehensive social services created a finding of immediate jeopardy that began on 6/23/24. Surveyor notified (Nursing Home Administrator) NHA-A of the immediate jeopardy on 7/1/24 at 1:33 PM. The facility removed the immediate jeopardy on 7/12/24. The deficient practice continues at an E (potential for harm pattern) as the facility implements their action plan. Findings include: Reassessment of need for Power of attorney R124 is a [AGE] year that was admitted on [DATE] due to a stroke. R124 has diagnoses of anxiety and depression. R124's POA-HC (Power of Attorney for Healthcare) was activated 3/30/23. R124's POA-HC was activated in a hospital setting due to delirium. R124 does not have a diagnosis of dementia or indications of ongoing delirium. R124's Admission MDS (minimum data set) assessment was completed on 5/22/23. The BIMS (Brief Interview for Mental Status) shows moderate cognitive impairment. R124's Annual MDS assessment was completed on 3/20/24. The BIMS shows no cognitive impairment. R124 requires set-up assist for activities of daily living. R124 is able to perform their own tasks. R124 had a BIMS (brief interview of mental status) completed on 6/20/24. This assessment documents no cognitive impairment. Despite assessments showing no cognitive impairment, the facility did not reassess R124 to determine if the power of attorney should or could be deactivated and if R124 could be allowed to make their own health care decisions. On 7/01/24, at 01:45 PM, Surveyor spoke with (Nurse Practitioner) NP-Q. NP-Q stated they were not asked about deactivating the POA-HC status. On 6/26/24, at 11:21 AM, Surveyor spoke with (Social Worker) SW-P. SW-P stated they did not discuss any POA-HC de-activations. SW-P shared R124 did not ask for de-activation. Reassessment of antidepressant R124's Psychiatric Progress Note documents the following: - 3/12/24 (R124) is tolerating taking Sertraline 100 mg every day. This provider called and spoke with the POA-HC, to discuss medication changes, due to increased agitation. The POA-HC did not want to start or change any medication at this time. The POA-HC stated (R124) is upset because they want to come home. and needs to stay on the antidepressant. The POA-HC stated (R124) has had depression their whole life. -3/18/24 (R124's) Sertraline was increased to 125 mg every day for depression. This provider received a phone call from the POA-HC to discuss medications. The POA-HC felt (R124's) antidepressant could be increased due to (R124) feeling down. - 4/2/24 (R124) stated Does not want to take the antidepressant and does not think they need it. No change in Treatment Plan. - 4/9/24 4/17/24 (R124) stated Does not want to take the antidepressant and does not think they need it. No change in Treatment Plan. - 4/17/24 (R124) stated Does not want to take the antidepressant and does not think they need it. No change in Treatment Plan. -4/23/24 (R124) stated does not want to take the antidepressant and does not think they need it. The Treatment Plan (sic) this provider called the POA-HC about refusing the medication and throwing the pill out. (R124) isolates in their room with the lights out. The POA-HC stated they will talk with (R124). - 4/30/24 R124 stated does not want to take the antidepressant and does not think they need it. The Treatment Plan (sic) this provider called the POA-HC last week. They discussed (R124) refusing to take the antidepressant and throws the pill out. (R124) keeps isolating in their room and keeps the lights out. Discussed with facility staff to monitor (R124) taking their pills. The POA-HC stated they would talk with (R124). - 5/7/24 (R124) stated does not want to take the antidepressant, does not need it and takes the antidepressant and throws it away. The Treatment Plan (sic) 2 weeks this provider spoke with the POA-HC. They discussed (R124) refusing medication most days and throwing it out. They talked about (R124) isolating in their room. The POA-HC will talk with (R124). The facility staff will monitor (R124) taking their medications. -5/14/24 (R124) stated does not want the antidepressant, does not need it' and takes the antidepressant and throws it away. The Treatment Plan (sic) discussed with facility staff to monitor (R124) taking medications. - 5/21/24 (R124) stated does not want to take the antidepressant, does not need it and takes the antidepressant and throws it away. The Treatment Plan (sic) facility staff to monitor (R124) taking their medications. - 5/29/24 (R124) stated does not want to take the antidepressant, does not need it and takes the antidepressant and throws it away. The Treatment Plan (sic) facility staff to monitor (R124) taking their medications. - 6/4/24 (R124) stated does not want to take the antidepressant, does not need it and takes the antidepressant and throws it away. The Treatment Plan (sic) facility staff to monitor R124 taking their medications. - 6/18/24 (R124) stated does not want to take the antidepressant, does not need it and takes the antidepressant and throws it away. The Treatment Plan (sic) facility staff to monitor R124 taking their medications. On 6/27/24, at 1:47 PM, Surveyor spoke with (Regional Nurse Consultant) RNC-O. RNC-O has overseen R124's unit the last few weeks. RNC-O stated R124 refused the Sertraline because they were not depressed. R124 stated they feel better and do not want the medication. RNC-O stated NP-Q comes in weekly. On 7/01/24, at 01:45 PM, Surveyor spoke with (nurse Practitioner) NP-Q, who took over R124's psych visits March 1st, at which time R124 was already on Sertraline 100 mg for a history of depression NP-Q stated R124 did not want to take the antidepressant and denied any anxiety or depression. R124 did mention they wanted to go home. NP-Q shared, a resident wanting to go home is a very common statement. NP-Q did talk with the POA-HC about going home. The POA-HC could not care for R124 at home. NP-Q did not do a cognitive or a living assessment. NP-Q was not involved in any Care Conferences to discuss R124's plan of care. NP-Q stated that R124 did not have suicidal thoughts or self-harm behaviors. R124 denied any negative behaviors. There was no collaboration to offer alternatives to antidepressant medication. Discharge planning R124 had 1 Care Conference on 10/11/23 for a Quarterly review. This included (Social Worker) SW-P and R124's POA-HC. The section for Discharge Plan states the resident will be long term care until an alternative and safe environment can be planned. There is no evidence the facility followed through on establishing an actual discharge plan and sought out an alternative and safe environment for R124 to discharge to. R124 has a Social Worker note on 2/2/24 that states Family members wanted to take the resident home for the evening, but were unable to reach the POA-HC. They were not able to reach the POA-HC. The family was asking questions regarding POA-HC and how to get a new one. The Writer informed them the POA-HC is a legal document and they couldn't do anything. There is no evidence R124's cognitive status was reassessed to assist in establishing an individualized discharge plan. R124 was not in protective placement nor did R124 have a Guardianship. R124 wanted to go home and was not permitted to do so. R124 has a Social Worker note on 2/5/24 that states Writer left a message with the POA-HC to discuss discharge planning. There was no documented discharge planning process. R124 has a Social Worker note on 3/12/24 that states Writer called POA-HC to schedule a care plan conference. On 7/01/24, at 9:06 AM, Surveyor spoke with SW-P. SW-P stated the only care plan conference that was completed was on 10/11/23. Surveyor noted the only individuals present at that conference were SW-P and POA-HC. R124 was not included. On 6/26/24, at 11:21 AM, Surveyor spoke with SW-P about R124's typical day in the facility. SW-P stated R124 would just walk around the unit, and would try to leave, to go home. R124 was aware their daughter placed them here. R124 wanted to leave the facility to go home. There was discharge planning discussed with another family member. The POA-HC stated that family member was not home to supervise resident. They did not discuss any alternative placements for R124. R124's POA-HC was working on taking R124 home and has not secured that yet. When discussing the level of supervision provided to R124, SW-P shared R124 has never been on 1:1 (one on one) supervision at the facility. R124 will try to leave to go home and is easily redirected. SW-P stated R124 was determined to leave and go home. R124 was frustrated with their family taking so long to decide. On 7/01/24, at 9:13 AM, (Regional Nurse Consultant) (RNC)-D and (Nursing Home Administrator) NHA-A spoke to Surveyor. They shared R124's POA-HC did not have the ability to take R124 home. RNC-D and NHA-A stated R124 would not be safe to discharge on their own. R124 agreed to stay at the facility and liked their room upstairs. RNC-D is aware R124 does not take their antidepressant and has a history of depression. R124 wants to go home but is content with staying at the facility. There was no collaboration to offer alternatives to antidepressant medication, discharge planning, and cognitive status. Elopement risk R124's Wander/Elopement Risk Evaluations document the following: - Admission on 5/15/23, states there is no elopement history. There is no risk for elopement. - Quarterly on 8/17/23, states there is no elopement history. There is a risk to wander/elope. There are no behaviors triggered. - Re-Admission on 9/17/23, states there is no elopement history. There is no risk to wander/elopement. On 7/01/24, at 9:13 AM, RNC-D and NHA-A spoke to Surveyor. RNC-D stated that on 12/1/23 R124 was sitting outside the facility waiting for the POA-HC to pick them up. R124 decided to start walking from sitting outside. The facility treated it as an elopement just to be safe. They talked to R124 and the POA-HC to move R124 upstairs on the alarmed unit. This unit was also the dementia unit. R124's Wander/Elopement Risk Evaluations document the following: - (Untitled) on 12/4/23, states there is now a wander/elopement. (R124) does not accept placement, paces, attempt to exit facility, trying to find family and makes repetitive statements about going home. The Wander/Elopement Risk Care Plan added a secured unit and staff aware of wander risks. On 6/27/24, at 01:58 PM, Surveyor spoke with SW-P regarding R124's room change to a secured unit. SW-P stated R124 would pack their bags and voiced they wanted to leave. R124 agreed to move to the secured unit upstairs. The upstairs unit was quieter. R124's family would take them home to visit. R124 wanted to go home. R124 did not want to take any medication for depression. R124 would become anxious/ obsessive about leaving the facility. There is a phone for the residents to use on the unit. R124's POA-HC would be called at times to assist with redirection. SW-P shared R124 wanted to be alone even when they were on a different unit; R124 would sit by themselves. They were working with the POA-HC on going back home. R124's Wander/Elopement Risk Evaluations document the following: - Quarterly on 1/5/24, states is a wander/elopement history and risk. (R124) does not accept placement, paces, attempt to exit facility, trying to find family and makes repetitive statements about going home. The Wander/Elopement Risk Care Plan remains a secured unit, staff aware of wander risks. - Quarterly on 4/6/24, states is a wander/elopement history and risk. (R124) does not accept placement, paces, attempt to exit facility, trying to find family and makes repetitive statements about going home. The Wander/Elopement Risk Care Plan remains a secured unit, staff aware of wander risks. R124's plan of care states the resident is an elopement risk/wanderer with altered mental status. Date Initiated 08/17/2023, with a goal: resident's safety will be maintained through the review date of 9/15/2024. Interventions added: - Secured unit dated 12/04/2023. -Staff aware of resident's wander risk dated 8/17/2023. - WANDER ALERT Personal Safety Device: Right ankle dated 5/16/2024. R124's plan of care states - The resident wishes to return to the community. Date initiated 8/14/23, with a goal: the resident will verbalize an understanding of the discharge plan and describe the desired outcome, by the review date of 9/15/24. Interventions added: - Resident discharging home with community services dated 8/14/2023. R124's plan of care states - Supervise resident with administration of medications. Date initiated 5/2024, with a goal the resident will take medications safely and as prescribed, by the review date of 9/15/2024. Interventions added: - Discuss medications with each supervised administration dated 5/2/2024. - Encourage resident to take meds prescribed. May not want to take certain medications dated 5/2/2024. - Supervise resident taking their medications dated 5/2/2024. - update MD (Medical Doctor) with refusals dated 5/2/2024. On 6/27/24, at 1:47 PM, (Regional Nurse Consultant) RNC-O stated R124 was moved to the alarmed unit on 12/1/2024. This was because R124 was outside, and the upstairs is more secured. When asked about the creation of R124's care plans RNC-O stated there is not a designated staff that completes the resident plans of care. RNC-O stated the facility did complete a Facility Reported Incident for the 12/1/2023 occurrence. R124's Psychiatric Progress Notes document the following: -3/6/24 (R124) called 911, went to the hospital, and eloped from the hospital to their sister's house. (R124) has been more agitated and disoriented. (R124) has had verbal outbursts. (R124) continues on Sertraline 100 mg every day and tolerating well. This provider left a voice message for the POA-HC to discuss medication changes due to increased agitation. (Per R124's progress note by (Licensed Practical Nurse) LPN-N on 3/3/2024, at 11:35 PM Writer received a call from (Officer-V) regarding the resident's wear (sic) about. Writer was told that the resident was found safe at their sister's house, after the resident left the hospital on foot. (Officer-V) also stated that the resident had caught 3 buses from the hospital to arrive at her sister house. The (Officer-V) stated that he will transport the resident back to the facility.) R124's progress note by LPN-M states on 3/8/24, at 7:54 PM Resident noted wandering and trying to open exit doors. Redirected resident to their room. On 7/01/24, at 9:13 AM, RNC-D and NHA-A spoke to Surveyor. RNC-D and stated R124 left from the hospital and not the facility on 3/3/24. There is no additional documentation of an assessment or root cause about what happened to R124 on 3/3/24 and what services were provided to R124 upon their return to the facility. There is no individualized plan of care that identifies triggers, and appropriate interventions, to address R124's desire to leave the facility and live elsewhere. On 5/14/2024, at 9:32 PM R124's progress note by (Registered Nurse) RN-U states Resident did not try to leave unit all evening. Ate supper in their room. Writer placed a wander guard to resident's right ankle per order and resident did not refuse the placement. The wander guard was added to the plan of care as an intervention. There is not a correlating comprehensive assessment to determine the reason for this intervention/change in the plan of care. On 6/26/24, at 11:10 AM, Surveyor spoke with LPN-K. LPN-K is familiar with R124. LPN-K stated the wander guard was placed on R124 in May 2024 as a precaution. R124 had returned from a visit with the family and was agitated. R124 only attempted to leave through the alarmed doors and was easy to redirect. On 6/9/2024, at 10:23 PM R124's progress note by LPN-T states, At approximately 5:00 PM writer was in hallways and observed several Paramedics on unit. This writer was informed (R124) called 911 and stated they was (sic) having chest pain. (R124's) vital signs was (sic) taken and they were stable. This writer was informed resident would be transported to Hospital for Evaluation. POA-HC was informed and stated, this is not the first she done this (sic), am (sic) going to call this hospital to make sure they watch (R124). (R124) will escape. The facility did not send an escort to the hospital with R124. Surveyor noted R124 previously called 911 on 3/3/24 and left the hospital. R124 shows the cognitive ability to circumvent the alarmed doors on the unit by seeking 911 attention. This was demonstrated on 3/3/24 as well. On 6/26/24, at 11:30 AM, Surveyor spoke with Certified Nursing Assistant (CNA)-L. CNA-L worked the Day shift on 6/23/24. CNA-L stated the unit alarm was beeping towards the end of their shift. R124 stated someone was picking them up. CNA-L shared R124's family would sometimes take them out. R124 was always redirected when the doors alarms went off. R124 did not ever get to the elevators. CNA-L shared R124 preferred to stay in their room including eating in their room. On 6/23/24, at 11:49 PM R124's progress note by (Licensed Practical Nurse) LPN-E documents beginning of shift (R124) was anxious but easily redirected by PM staff. (R124) did not display further anxious behavior. (R124) was in good spirits for a while but (R124) did get upset later because (R124's) daughter wasn't answering the phone when (R124) was calling their daughter but (R124) didn't display any abnormal behaviors from that. (R124) tolerated meds well and ate 100% supper and (R124) was compliant with staff with directives. During the evening at approximately 2015 (8:15 pm) the two (Certified Nursing Assistants) CNAs came to writer while writer on the hall passing meds and asked writer would writer speak with (R124) regarding refusal to allow them to put bed linen on the bed. Writer approached (R124) and writer asked (R124) did (R124) refuse linen on their bed to the CNAs. (R124) stated No I didn't refuse, I do want linen on my bed. Staff then put linen on (R124's) bed after writer spoke with (R124). (R124) still showed no further behavior. CNAs put (R124's) roommate in bed then when CNAs were done (R124) was noticed by CNA assisting on their bed. Writer continued to pass meds Writer finished med pass at 2030 (8:30 pm) and came to check with med tech regarding a resident's issue on unit 600 When writer was checking on another resident's medication that is when writer was notified that (R124) had climbed out window and was outside sitting on buttocks talking to other staff that found (R124) outside on ground. Writer and the 2 CNAs inside building noticed (R124) had took (sic) the window out the frame (sic) and tied sheets together in knots and tied the sheets to the bed and climbed out the window with the sheets hanging out the window in knots. (R124) was being assessed immediately by the staff that were nurses outside. Writer then came out to further assess. Ambulance called and present and assessed (R124) head to toe. (R124) c/o (complained of) right lower leg pain to writer and ambulance. Daughter notified and aware of above findings Director of Nurses (DON-B) notified and (NHA-A) notified of above findings (Nurse Practitioner) NP notified and updated NP and daughter aware of resident going to hospital for further evaluation. On 6/27/24, at 11:42 AM, Surveyor spoke with CNA-J who worked the shift R124 exited through the window. CNA-J stated R124 made knots tying the sheets together. CNA-J is not sure where they got the bed sheets from. R124 was setting off the unit door alarms wanting to go home during the shift. They were redirected back to their room. CNA-J shared R124 typically does not come out of their room. After supper they had no linen on their bed. R124 did not want their bed made. CNA-J told the floor nurse R124 did not want their bed made. Then R124 stated they could make their own bed. R124 was provided bed sheets. There were pictures obtained of the bed sheets out the window. There were bed sheets on the bed. CNA-J thought R124 did not show any different behavior before the discovery outside. On 6/27/24, at 12:58 PM, Surveyor spoke with CNA-I who worked the evening shift on 6/23/24. CNA-I stated R124 was dressed, with their jacket on, trying to go out the unit door. R124 stated they wanted to go home. R124's family was not answering the phone. R124 was getting frustrated about not getting a hold of their daughter. CNA-I stated around 7:30 - 8:00 PM they were assisting R124's roommate to bed. They noticed R124 had no sheets on their bed. They offered to make their bed and she said no. They told the floor nurse about the sheets. The nurse talked to R124 about the bed sheets. CNA-I brought the bed linen in the room. R124 stated they will make their own bed. About 30 - 40 minutes later they heard from other staff that R124 fell outside. CNA-I stated R124 took the window out and tied the sheets together from the bed frame. On 6/27/24, at 03:26 PM, Surveyor spoke with LPN-E. LPN-E worked the evening shift on 6/23/24. LPN-E is from an Agency and 6/23/24 was their 1st time working on the unit. LPN-E shared they relied on the 2 CNAs who were regular staff. R124 talked to the CNAs and wanted their daughter to answer the phone. LPN-E found out later R124's daughter was supposed to pick them up. The CNAs told LPN-E that the resident typically stayed in their room. LPN-E stated that when R124 paces or gets angry it means they want to leave. LPN-E stated R124 was doing that before this happened. R124 was on the 24-hour board, because the Day shift noted they were anxious. LPN-E was told they should watch the unit doors - staff said resident is anxious; watch the doors. LPN-E shared another staff told LPN-E that there was a resident on the ground. They went into R124's room and they noticed the sheets through the window. LPN-E stepped on the window glass pane that was laying on the floor. LPN-E thought the glass was pushed out and did not see it. LPN-E did not expect R124 to go through a window, The staff indicated to just keep an eye on the doors and R124 typically stayed in their room alone with the door closed. On 6/27/24, at 3:46 PM, during the daily exit meeting, Surveyor notified NHA-A and RNC-D concerns with R124. R124 did not have any comprehensive assessments/root cause analysis completed after leaving the hospital on 3/3/24 to determine R124's care needs. R124 took 3 different buses to get to their sister's house. There was not a plan of care to determine supervision needs when expressing to leave. A wander guard was placed on 5/14/24 with no correlating assessment. There was not an individualized plan of care to address R124's desire to leave the facility and the consequent behaviors of leaving or trying to leave the facility and repeatedly verbalizing wanting to go home. There was not a comprehensive assessment or plan of care to direct discharge from the facility. The facility did not provide interdisciplinary care to address medication needs, discharge requests and anxious behaviors. There was no documentation of alternatives for discharge to the community. There was not documentation or discussions for de-activating the POA. R124 performed their own cares and determined what medications they wanted to take. The facility's failure to provide medically related social services to R124 to address her desire to live at home, to assess R124's ability to make her own decisions and direct her care led to R124 to experience increased anxiety, isolation, and behaviors to convey her desire to leave. This created a situation of immediate jeopardy for R124 that resulted in R124 taking the extreme action of tying bed sheets together and removing a window to leave the facility from the second floor resulting in her falling to the ground and sustaining bilateral ankle fractures and a broken leg. The facility removed the immediate jeopardy on 7/12/24 when they implemented the following action plan: 1. R124 sent out to hospital 2. MD and POA notified. 3. Complete investigation with full RCA (root cause analysis). 4. All interviewable residents who have a BIM score 9 and above who scored high risk for Elopement and express desire to leave the facility while showing any signs and symptoms of anxiety and depression may have the potential to be affected by this alleged deficient practice. 5. Check resident's wanderguard device and ensure it is functioning properly. 6. Check all wanderguards and wanderguard/alarm doors for functionality 7. Education provided to Social Service staff on Medical Social Services, Discharge Planning, Care Conference and POA activation. 8. Staff educated on Wandering and Elopement, and Behavior Monitoring. 9. All interviewable residents who have a BIM score 9 and above who scored high risk for Elopement and express desire to leave the facility while showing any signs and symptoms of anxiety and depression will be also assessed for psycho-social well-being abuse/neglect evaluation. Care plans will be reviewed and updated as needed. Care conferences addressing discharge planning will be scheduled for those who express desire to leave. 10. All interviewable residents who have a BIM score 9 and above who scored high risk for Elopement and express desire to leave the facility while showing any signs and symptoms of anxiety and depression will be reviewed by DON/designee to ensure accurate, appropriate plan of care in place. 11. Elopement and wandering binders were reviewed and updated as needed. 12. Residents who are not-interviewable are upset, anxious, and need increased supervision will be put on 24-hour board and monitored closely. 13. DON or designee will conduct audits to ensure care conferences were scheduled and held to discuss discharge planning on people who desire to leave once a week for 4 weeks. Bring results to QAPI and readdress and adjust the plan as needed. Ad hoc education to be provided as immediately as possible when indicated. 14. Audits will be reviewed at the monthly QAPI meeting to determine trends or patterns of concern and/or if further education is needed until substantial compliance has been achieved. No additional information was provided.

Based on interview and record review, the facility did not ensure that residents with pressure injuries received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R109) of 5 residents reviewed for pressure injuries. On 05/29/2024, R109 developed a Deep Tissue Injury (DTI) and did not receive the care and treatment necessary for the healing of a pressure injury. Findings include: The facility's policy, titled Skin Management Guideline with an implementation date of 11/28/2017, documents: An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors. Interventions for prevention, removing and reducing predicting factors and treatment for skin may include: .Elevating heels: floating devices may vary, may include pillows and should be selected based on resident comfort and positioning needs. Inspection of skin daily with cares and weekly by a licensed nurse. B. Monitoring of skin integrity skin will be observed daily during cares by the nursing assistants. If any skin concerns are noted, they are to be reported to the licensed nurse. Weekly skin observation on the bath/shower day will be performed by a licensed nurse. If a skin concern is noted, refer to the skin and wound care formulary. The care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. The physician will be consulted with changes suggesting impairment in skin integrity. II. Treatment of pressure ulcers and lower extremity ulcers(arterial, [NAME], neuropathy/diabetic, or mixed) if a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 1. Review the wound formulary for guidance 2. Consult with the physician/NP and resident representative 3. Notify a supervisor/designee as assigned .6. Reevaluate turning and repositioning interventions 8. Initiate Braden scale and initiate investigation process if new onset 9. Update the care plan for skin integrity and nursing assistant care cards with skin concern, appropriate risk factors turning intervals and interventions as appropriate. R109 was admitted to the facility on [DATE] with diagnoses to include traumatic spinal cord dysfunction, Paraplegia, and pressure ulcer of sacral region. R109's Admission Minimum Data Set (MDS), dated [DATE] documents the following: R109 has an indwelling urinary catheter, is at risk of pressure ulcers and was admitted to the facility with a stage 2 pressure ulcer. R109's MDS documents behaviors not exhibited in regard to rejections of care. R109 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R109 is cognitively intact. R109's functional limitation in range of motion indicates R109 has impairment on both sides of the lower extremity. R109's MDS Care Area Assessment (CAA) Summary documents Pressure Ulcer area triggered and addressed in R109's care plan. Surveyor reviewed the facility provided roster matrix, which documented that R109 has an unstageable pressure injury that was not present on admission. Survey reviewed R109's electronic health record and noted the following: R109's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2024 documents: Skin Checks Weekly - complete Skin Evaluation on admission and weekly, on assigned day, every evening shift, every Tuesday - Order Date - 02/22/2024 - Discontinue Date - 03/28/2024. Surveyor noted weekly skin checks were to be completed on 03/05/2024, 03/12/2024, 03/19/2024, and 03/26/2024. R109's MAR/TAR, documents that above weekly skin checks were not completed or documented as completed on any of the dates listed. R109's care plan on 03/26/2024 documents: R109 is choosing not to wear pressure relieving boots. However, Surveyor noted that R109's Quarterly MDS, dated [DATE], documents R109 does not exhibit behaviors related to rejection of care. On 03/27/2024, R109 was admitted to the hospital for Sepsis due to a Urinary Tract Infection (UTI) and discharged back to the facility on [DATE]. R109's Wound/Skin Specialist Consult dated 03/28/2024 documents: Coccyx with intact scar tissue, surrounded by hyperpigmented tissue. No open wounds to coccyx, sacrum, or buttocks at this time.Left lateral ankle with collapsing blister. Hyperpigmented with loose layer of epidermis. No open areas at this time. 3M barrier and protective heel mepilex applied for added protection. Heel lift boots reapplied, air mattress and bed extender ordered. Surveyor noted no assessment or interventions were documented as implemented by the facility for R109's left ankle after R109's readmission to the facility. Surveyor reviewed R109's MAR/TAR for April 2024 which documents: Skin Checks Weekly - complete Skin Evaluation in PCC on admission and weekly on assigned day every evening shift every Tue - Order Date 03/30/2024 1349 Surveyor noted that weekly skin checks were to be completed on 04/02/2024, 04/09/2024, 04/16/2024, 04/23/2024, and 04/30/2024. Weekly skin checks were not completed or documented on 04/02/2024, 04/16/2024, or 04/23/2024. Surveyor reviewed R109's MAR/TAR for May 2024 which documents in part: Skin Checks Weekly - complete Skin Evaluation in PCC on admission and weekly on assigned day every evening shift every Tue - Order Date - 03/30/2024 1349. Weekly skin checks were to be completed on 05/07/24, 05/14/24, 05/21/24, and 5/28/24. Surveyor noted skin checks were not completed or documented on 5/14/24, 5/21/24, or 5/28/24. Surveyor reviewed document titled Consultation/Clinic referral, dated 05/29/2024. Consultation/clinic referral documents: New diagnosis - Left ankle - deep tissue injury (DTI). Surveyor reviewed R109's MAR/TAR for June 2024 which documents in part: Skin Checks Weekly - complete Skin Evaluation in PCC on admission and weekly on assigned day every evening shift every Tue -Order Date - 03/30/2024 1349. Weekly skin checks were to be completed on 06/04/2024, 06/11/2024, 06/18/2024, and 06/25/2024. Surveyor noted skin checks were not completed or documented for any of the dates listed above. On 06/25/2024, Surveyor was unable to locate any assessment, physician orders, treatment plan, or care plan addressing R109's left ankle DTI. On 06/26/2024 at 09:30 AM, Surveyor requested 1 year of all wound notes, Nurse Practitioner notes, and care plan with revisions for R109 from NHA-A. On 06/26/2024 at 10:55 AM, RN-Y informed Surveyor that all wounds for R109 are resolved. Surveyor then requested last assessment of all healed wounds, last 3 months of skin/wound notes, and information related to 05/29/2024 wound consult note regarding DTI to left ankle. On 06/26/24, at 01:16 PM, Surveyor went to speak with RN-Y to request that Surveyor observe RN-Y assess R109's left ankle DTI. RN-Y informed Surveyor that he already assessed R109's left ankle DTI and states that R109 told RN-Y the wound has been there awhile. RN-Y provided Surveyor with a wound evaluation document, dated 06/26/2024, which documents in part: Pressure - Deep Tissue Injury Body Location: Left Lateral Acquired: In-house Acquired. The documented dimensions are as follows: Area - 2.8 cm (centimeters) Length - 2.43cm Width - 1.59cm. Surveyor asked wound RN-Y if Surveyor could watch wound care be performed the following day. Wound RN-Y stated that R109 receives wound care early in the morning around 04:00 AM. Surveyor planned with wound RN-Y to allow Surveyor to observe wound care the next day after 07:30 AM. On 06/27/2024, at 07:42 AM, Surveyor was informed that wound care had already been performed on R109 and stated R109 refused to allow Surveyor to observe wound care. Surveyor spoke with R109 shortly thereafter, R109 stated he was never asked if Surveyor could observe wound cares. R109 then attempted to show left ankle wound to Surveyor but was unable without assistance. Surveyor explained to R109 that Surveyor would attempt to observe wound care another time. On 07/01/2024, at 07:42 AM, Surveyor asked R109 if Surveyor could observe wound RN-Y perform wound cares, however R109 refused. The facility initiated a care plan dated 06/26/2024 that documents: The resident has actual impairment to skin integrity left lateral ankle r/t (related to) suspected deep tissue injury. The facility initiated orders on 06/26/2024 that document: Skin prep to left lateral ankle every day, one time a day for wound care. Surveyor noted that the facility did not assess or treat R109's left ankle DTI until time of 6/26/24. No further information was provided by the facility during survey.

UNCORRECTED AT REVISIT Based on interview, observation and record review, the facility did not ensure 4 (R24, R27, R20 and R4) of 7 residents reviewed for quality of care, received treatment and care in accordance with professional standards of practice and a comprehensive plan of care. ~ R24 was a borderline diabetic with a HgA1c of 6.2 taken [DATE]. On [DATE] R24 was prescribed 60 mg Prednisone for scleritis for 4 weeks and then 6 weeks of tapering. (Prednisone raises blood glucose levels and should be monitored in long term use.) On [DATE] R24 was prescribed Seroquel for behaviors. R24 did not have an appropriate diagnosis for the medication, was not properly monitored for specific behaviors and did not have a care plan that address the psychotropic medication or any interventions for R24's behaviors. On [DATE] a Urinalysis (UA) with Culture and Sensitivity (C&S) was ordered for R24 for increased behaviors. The Nurse Practitioner (NP) prescribed Rocephin antibiotic for leukocytosis with no indication that it was effective against the infection because the C&S was not done due to sample being lost. The facility did not complete a McGeer's criteria sheet to verify that an antibiotic was warranted. During lab draws, R24's blood glucose levels rose in January to a 368 on [DATE] and neither the facility nor NP checked blood glucose levels on a regular basis for R24. No further labs were ordered. On [DATE] R24 had a change of condition and was hospitalized ; on admission R24's blood glucose level was critical, at 865. ~ R27 was admitted to the facility on [DATE] and had a history of uncontrolled Diabetes Mellitus II (DM). R27 had orders for 4 times daily blood glucose monitoring. This was not completed per order. On discharge from the hospital, it was recommended that R27 have Sliding Scale insulin ordered until diabetes was controlled, which was not completed. The resident also missed a dose of Janumet for blood glucose control. The resident's meal intake was also not accurately documented and blood glucose levels were in the 200's and 300's. The resident did not have a DM care plan addressing any blood glucose issues or monitoring. The resident was on a seizure medication with no care plan or seizure precautions in place. The resident missed two doses of seizure medication. The resident expired on [DATE] with cause of death as diabetic ketoacidosis. Examples regarding residents R24 and R27 are being cited at the scope and severity (s/s) of a G (actual harm/isolated). ~ R20 returned to the facility from a hospital stay on [DATE]. R20 experienced episodes of Hypoglycemia (low blood sugar) while in the hospital. The Discharge Summary from the hospital gave instructions to monitor R20's blood glucose [three times a day before meals]. The order was not transcribed by the facility. R20 was not monitored for hypoglycemia from [DATE] through [DATE]. ~ R4 was ordered a dental rinse and dental gel that were not ordered and not completed. Findings include: Surveyor reviewed facility's Behavioral Management Program with an effective date of [DATE]. Documented was: Purpose: The purpose of the Behavior Management Program is to promote and provide the highest practicable quality of life and a safe environment for residents and staff . b. For psychotherapeutic medications: - Orders contain diagnosis and symptoms, medication, dose, route, time, parameters as required - Complete Consent to explain risks and benefits to resident/responsible party - Gradual dose reduction is attempted per regulatory guidelines - If gradual dose reduction is not attempted, the physician completes the Psychotherapeutic Diagnosis and Risk vs. Benefit Form - Complete an AIMS for side effect monitoring form every 6 months, as needed and with changes in medication for residents receiving antipsychotic medications c. Continue or change and update care plans accordingly 8. Care plan interventions are updated and made available to care giving staff. Surveyor reviewed facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes with a revised date of [DATE]. Documented was: Policy Statement Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review all antibiotic starts within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified. a. Therapy is NOT justified if: (1) The organism is not susceptible to antibiotic chosen; (2) The organism is susceptible to narrower spectrum antibiotic; (3) Therapy was ordered for prolonged surgical prophylaxis; or (4) Therapy was started awaiting culture, but no organism was isolated after 72 hours. b. Interventions that may resolve unjustified therapy: (1) Dosage change; (2) Switch from IV to PO route; (3) Duration change; (4) Additional antibiotic added; (5) Obtain cultures; and (6) Check levels. c. If therapy remains NOT justified, proceed with: (1) Alternate antibiotic regimen; or (2) Discontinue therapy. 3. At the conclusion of the review, the provider will be notified of the review findings and recommendations. His or her response will be documented as follows: a. Agrees to make change; b. Needs to discuss with team before making change; or c. Will not make change because: (1) He or she does not agree with recommendations; and/or (2) Team does not agree with recommendations. 4. All resident antibiotic regimens will be documented on the facility -approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name and medical record number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic (see approved surveillance list); e. Start date of antibiotic; f. Pathogen identified (see approved surveillance list); g. Site of infection; h. Date of culture; i. Stop date; j. Total days of therapy; k. Outcome; and l. Adverse events. Surveyor reviewed facility's Insulin Administration policy with a revision date of [DATE]. Documented was: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation Preparation 1. Only appropriately licensed or certified personnel shall draw and administer insulin. 2. Only the person who draws up the insulin for injection can inject it. 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order . Surveyor reviewed facility's Administering Medications policy with a revision date of [DATE]. Documented was: Policy Statement Medications shall be administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . Surveyor reviewed facility's Seizures and Epilepsy - Clinical Protocol policy with a revision date of [DATE]. Documented was: Assessment and Recognition 1. As part of the initial assessment, the physician and staff will help identify individuals who have had a seizure or epilepsy, and individuals who are receiving antiepileptic medications for any reason; for example, seizure prophylaxis after a recent stroke or treatment for behavioral symptoms related to dementia. a. Seizures and epilepsy are not identical, as seizures may occur in individuals without epilepsy. b. Acute seizures may occur in relation to a metabolic disturbance (for example, hypoglycemia, hypo-natremia, or hypocalcemia) or an acute central nervous system (CNS) illness such as a stroke or head injury. Epilepsy refers to repeated, unprovoked seizures. 2. In addition, the nurse shall assess and document/report the following: a. Vital signs: b. Neurological assessment; c. Change in level of consciousness; d. Any seizure activity in detail (location, duration, severity, recurrence, etc.): e. Injury occurring with seizure; f. Resident's age and sex; g. Whether resident has a known seizure disorder or history of actual seizure a h. Date of most recent actual seizure activity, if occurred; i. How current seizure activity relates to usual patterns; and j. Last blood level of any anticonvulsants being given. 1.) R24 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Nontraumatic Intracerebral Hemorrhage, Spastic Hemiplegia Affecting Right Dominant Side and Other Speech and Language Deficits Following Cerebral Infarction. Surveyor reviewed R24's MDS (Minimum Date Set) annual assessment with an assessment reference date of [DATE]. Documented under Cognition was Staff Assessment for Mental Status which indicated severely impaired. Documented in R24's Progress Notes on [DATE] at 3:37 AM was Resident returned from ER in stable condition. New order for naproxen 250mg every 12 hours [related to (R/T)] scleritis of the right eye. Resident offers no [complaint of (c/o)] pain/discomfort. Will monitor. On [DATE] R24 had a change in condition. Documented in Progress Notes was: .[change of condition (COC)]: Behavioral (agitation, psychosis) and Wheezing Mental Status: Other [signs and symptoms (s/sx)] of delirium [Respiratory]: Abnormal lung sounds Summarize your [observations and evaluation]: [Nurse Practitioner (NP-D)] in this am shift and assessed resident wheezing noted. Resident also has been yelling out also new orders received Recommendations: see orders . labs . R24's lab results were sent to facility on [DATE] and contained results: HgA1C 6.2% Glucose 106 mg/dL The Reference Range for HgA1c is 4.6 to 6.2 noting R24 was a borderline diabetic. The Reference Range for Glucose was 64 - 112. Glucose was taken as part of routine Comprehensive Metabolic Panel (CMP) lab draw. Surveyor reviewed R24's Progress Notes. Documented on [DATE] at 3:30 PM was (NP-D) came to this writer and stated that she will start the pt (patient) on Prednisone 60 mg daily x4 weeks for bilateral eyes [both eyes]. Pt's eyes noted to be slightly reddened. Will monitor effect of prednisone. Surveyor reviewed R24's MD orders. Documented with a start date of [DATE] was predniSONE Oral Tablet (Prednisone); Give 60 mg by mouth one time a day for scleritis for 4 Weeks THEN Give 50 mg by mouth one time a day for scleritis for 1 Week THEN Give 40 mg by mouth one time a day for scleritis for 1 Week THEN Give 30 mg by mouth one time a day for scleritis for 1 Week THEN Give 20 mg by mouth one time a day for scleritis for 1 Week THEN Give 10 mg by mouth one time a day for scleritis for 1 Week THEN Give 5 mg by mouth one time a day for scleritis for 1 Week. Surveyor noted there were no orders for monitoring blood glucose levels. Documented in R24's Progress Notes on [DATE] at 6:22 AM was Resident awake in bed throughout the night, yelling out, calling her own name continuously. Trying to get out of bed, throwing her good leg over the side rail bar. Once resident gets into wheelchair she attempts to get on the elevator without assistance. Resident is non verbal but uses curse words to express self. No cough/congestion noted throughout shift. Will continue to monitor. Surveyor reviewed Nurse Practitioner (NP)-S visit note from [DATE]. Documented was: .[History of Present Illness (HPI)]: Nursing reports insomnia, [patient (pt)] not sleeping for over a week. Will initiate Seroquel short term . Assessment and Plan: Insomnia: reports from a nurse about pt not sleeping, monitor. Pt with behaviors and yelling frequently . Surveyor reviewed R24's MD Orders. Documented with a start date of [DATE] and was Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth at bedtime for behaviors. Surveyor noted there was no appropriate diagnoses for Seroquel. Surveyor reviewed MD Orders and Attachments in the electronic medical record (EMR) for behavior monitoring. Surveyor could not find resident specific behavior monitoring for R24. Surveyor reviewed Comprehensive Care Plan for R24. There was no care plan addressing psychotropic medication use and any non-pharmacological interventions for behaviors. (Cross-reference F758). R24's CMP lab results were sent to facility on [DATE] and contained results: WBC 14.6 x10E3/uL Reference Range for WBC's is 4.8 - 10.8 Glucose 79 mg/dL On [DATE] R24 had an unwitnessed fall. Documented in Progress Notes at 4:16 AM was Resident found laying on bedroom floor next to the bed with head slightly under the bed, legs extended towards the door. Resident was unsure how she fell , denies any pain. Regular caregivers at facility state over the past approximate two weeks resident has been attempting to get out of bed into chair. At start of shift resident was found by aid near the edge of the bed and moved over to center of bed. Call light was verified to be within reach of bed, resident did not use call light throughout the night to ask for assistance. There is a small approximately 25mm raised lump on forehead without redness or pain. It is unclear if this was on her head prior to fall. Resident is unable to recall if head was hit. Post fall resident appears to be in a good mood, continues to deny pain but is attempting to elope . Surveyor reviewed R24's Progress Notes. Documented on [DATE] at 2:55 was resident continues to be monitored due to [unwitnessed fall] on ,d+[DATE], resident denies pain, very verbal and calling out even after needs were met. [NP-D] on site and ordered one time dose of Seroquel and also changed Seroquel dosing starting tomorrow. Seroquel administered and effective. resident no longer calling out. NP also ordered UA (urinanalysis) with culture and sensitivity unable to collect this shift. Surveyor reviewed R24's MD Orders. Documented with a start date of [DATE] and an end date of [DATE] was Seroquel Oral Tablet 25 MG (Quetiapine Fumarate); Give 1 tablet by mouth one time only for anxiety until [DATE] 23:59 AND Give 1 tablet by mouth in the morning for generalized anxiety. Surveyor noted Anxiety was not an appropriate diagnoses for Seroquel. Lab results were sent to facility on [DATE] and contained results: WBC 18.5 x10E3/uL R24's Progress Notes documented on [DATE] at 5:29 PM Labs/Diagnostics Note Text: sent to [NP-D] Progress Notes documented on [DATE] at 11:19 AM UA collected and lab contacted to pick up specimen, resident tolerated procedure well. writer updated [NP-D] with collection. Surveyor reviewed R24's Progress Notes. Documented on [DATE] at 1:37 was writer received orders for Rocephin due to residents elevated white count, first dose administered today but only partial dose (about half) partial administration syringe malfunctioned during IM administration and medication started to leak from plunger side of syringe, writer called and updated [Nurse Practitioner (NP)-D] regarding partial administration (about half) and NP will amend order to have stop date of 4 days. resident otherwise tolerated procedure well. Surveyor reviewed R24's MD Orders. Documented with a start date of [DATE] was cefTRIAXone Sodium Injection Solution Reconstituted 1 GM (Ceftriaxone Sodium); Inject 1 gram intramuscularly one time a day for Leukocytosis for 2 Days Reconstitute with 2.5ml of 1% Lidocaine Give first dose today AND Inject 1 gram intramuscularly one time only for Leukocytosis until [DATE] 11:29. Give first dose today. Reconstitute with 2.5ml of 1% Lidocaine. Surveyor reviewed R24's Medication Administration Record (MAR) and noted Rocephin medication was signed out as administered [DATE] and [DATE]. Surveyor noted neither UA nor C&S had been returned to facility to see if resident had a UTI and if Rocephin would be an effective antibiotic. Surveyor noted there was no McGeer's criteria sheet for R24 to see if the antibiotic met the criteria to be administered. R24's CMP lab results were sent to facility on [DATE] and contained results: WBC 14.2 x10E3/uL Glucose 247 mg/dL Surveyor noted R24's glucose was now rising and out of normal range for resident. There was no documentation in chart or new orders. Documented in Progress notes on [DATE] at 9:12 AM was Order to be discontinued for UA. [NP-D] to see patient and discuss with writer if a new sample needs to be collected. Surveyor noted there was not a new UA ordered or collected. Documented in Progress notes on [DATE] at 5:27 AM was Resident continues to yell out through the night. R24's CMP lab results were sent to facility on [DATE] and contained results: Glucose 262 mg/dL R24's CMP lab results were sent to facility on [DATE] and contained results: Glucose 358 mg/dL Surveyor reviewed NP-D's notes, Progress Notes and MD Orders. There was no documentation of the trending upward glucose levels and no orders for increased monitoring. There were no future CMP orders. Surveyor noted there was no assessment of resident behaviors and alternate assessments such as UTI or hyperglycemia as cause. On [DATE] the resident was transferred to the hospital for altered mental status and tachycardia and admitted . Documented under Hospital Course was: [R24] . presented on [DATE] for concern of [Hyperosmolar hyperglycemic state (HHS)] and UTI. Initial presentation concerning for HHS given extremely elevated glucose at 845, sodium of 168 (corrected for glucose [Sodium (Na) was 172), UA [concern for] UTI give positive leukocyte esterase. Patient was on prednisone 60 mg for Right eye scleritis since [DATE], which thought to be the precipitating factor alongside new onset UTI. Patient was admitted to the ICU and initiated on insulin [drip] . On [DATE] at 2:45 PM Surveyor requested McGeer's criteria sheet for R24's Rocephin. On [DATE] at 1:07 PM Regional Nurse-F reported to Surveyor there was no McGeer's sheet for R24 for her antibiotic in [DATE]. Surveyor asked if there should be one. Regional Nurse-F stated yes. On [DATE] at 10:52 AM Surveyor interviewed Psych Nurse Practitioner (NP)-DD. Surveyor asked if Seroquel is indicated for anxiety. NP-DD stated no. Seroquel is only for delusions, hallucinations, as a mood stabilizer or depression. NP-DD reviewed R24's diagnoses and also noted R24 does not even have a diagnosis of anxiety. On [DATE] at 1:08 PM Surveyor interviewed NP-S. Surveyor asked what the HgA1c of 6.2 would indicate for R24. NP-S stated she would be borderline diabetic. Surveyor asked if she would order anything to follow up on that. NP-S stated she would recheck it in 3 months and watch for any acute signs of hyper and hypoglycemia. Surveyor noted her trending upward glucose levels in January. NP-S stated she was not involved in her care at that point because she was on vacation and MD-II and NP-D were following and there were too many cooks in the kitchen. Surveyor asked if she would do any monitoring or new orders with the rising blood glucose levels. NP-S stated she would at least want to do a daily or twice daily blood glucose level. Surveyor discussed the effect of prednisone on blood glucose levels. NP-S indicated awareness Prednisone can raise blood glucose levels. NP-S stated she would order another weekly CMP as well. Surveyor noted the 865 blood glucose on admission to the hospital. NP-S stated that makes sense. 2.) R27 was admitted to the facility on [DATE] with diagnoses that included Wedge Compression Fracture of First Lumbar Vertebrae, Multiple Fractures of Ribs, Peripheral Vascular Disease, Type 2 Diabetic Mellitus (DM), Chronic Kidney Disease Stage 3, Cerebral Infarction, Hemiplegia and Hemiparesis and Keratoconjunctivitis Sicca. Surveyor reviewed R27's Hospital Discharge Summary with a date of [DATE]. Documented was: Discharge Medication Reconciliation: . LANTUS SOLOSTAR SC Inject 28 Units into the skin nightly. linaGLIPtin-metFORMIN HCI ER ,d+[DATE] MG TABLET SR 24 HR Take 1 tablet by mouth daily (before breakfast). Topiramate 50 MG tablet Commonly known as: TOPAMAX Take 1 tablet by mouth every 12 hours. .Recommendations: Diabetes control Check glucose [before meals (a.c.)] and [bedtime (HS)] with sliding scale insulin until diabetes is controlled . Surveyor reviewed R27's MD Orders. An order with a start date of [DATE] documented Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine); Inject 28 unit subcutaneously at bedtime for DM. An order with a start date of [DATE] documented Blood sugar checks four times a day for DM for 7 Days. An order with a start date of [DATE] documented Topiramate Oral Tablet 50 MG (Topiramate) Give 1 tablet by mouth every 12 hours for seizure precautions. An order with a start date of [DATE] documented The order for linagliptin-metformin was discontinued and changed to Janumet XR Oral Tablet Extended Release 24 Hour ,d+[DATE] MG (Sitagliptin-Metformin HCl); Give 1 tablet by mouth one time a day for DM with a start date of [DATE]. There was no order for sliding scale Insulin or documentation explaining reconciliation of the discharge recommendation. Surveyor reviewed R27's Care Plan. There was no care plan for seizure precautions or Diabetes Mellitus. Surveyor reviewed blood glucose for R27 from [DATE] through [DATE]. Documented was: [DATE] 8:36 PM 309.0 mg/dL [DATE] 8:46 PM 325.0 mg/dL [DATE] 8:49 AM 249.0 mg/dL [DATE] 12:39 PM 200.0 mg/dL [DATE] 9:16 PM 216.0 mg/dL [DATE] 10:09 PM 317.0 mg/dL [DATE] 12:18 PM 200.0 mg/dL [DATE] 12:35 PM 295.0 mg/dL There was no blood glucose taken on [DATE] before dinner or before bedtime. Surveyor reviewed meal intake and PM snack intake for R27 from [DATE] through [DATE]. Documented was: [DATE] Dinner 0 - 25% [DATE] PM Snack 0 - 25% [DATE] Breakfast 51 - 75% [DATE] Lunch 51 - 75% [DATE] Dinner BLANK [DATE] PM Snack BLANK [DATE] Breakfast BLANK [DATE] Lunch BLANK [DATE] Dinner BLANK [DATE] PM Snack BLANK Surveyor reviewed Medication Administration Record for R27. There was no Janumet XR medication administration on [DATE]. There was no Topiramate administration on [DATE] PM or [DATE] AM. Documented in R27's Progress Notes on [DATE] at 7:24 AM was At around 0620 the nurse on duty was called to resident's room by CNA (certified nursing assistant). When nurse arrived to the room, resident was found to be unresponsive. 911 was called at 0625. CPR was initiated at 0630. At 0635, CPR was in progress. At 0640 [MD-II/NP-D] were notified. At 0636 [Fire Department] arrived to take over. At 0738 [Police Officers] remain at facility awaiting medical examiner to arrive. Documented at 8:32 AM was Upon entering the [patient (pt)] room writer observed the pt lying in bed on his right side, and bed was observed in a low position. This writer called the pt name to alert him. No response was received. This writer and the [Certified Nursing Assistant (CNA)] turned the pt onto his back. Writer observed foam at the pt mouth, and jaw clenched. Bilateral hands were appeared to be clenched as well. The pt was then lowered to the floor by this writer and CNA to initiate CPR. On [DATE] at 12:10 PM Surveyor interviewed Medical Examiner Assistant (ME)-RR. Surveyor asked what the cause of death for R27 was. ME-RR stated the manner of death was natural causes and the specific first cause of death was diabetic ketoacidosis. On [DATE] at 9:58 AM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked how orders are entered into the resident record. DON-B stated the admitting nurse enters them and then a second nurse checks and then herself or the unit managers do a third check. DON-B stated for R27 he was admitted on a Friday so the third check would not have been completed until Monday because the unit managers and herself are not there on the weekends. Surveyor asked about the recommendations and sliding scale insulin. DON-B was unsure but stated someone should have verified what to do with an MD. Surveyor asked what should be done when a missed dose of medication or blood glucose happens. DON-B stated call the doctor. Surveyor asked if that happened in this situation with R27. DON-B stated she does not see anything charted. On [DATE] at 2:57 PM Surveyor interviewed MD-II. Surveyor asked about the recommendation for the sliding scale insulin and other insulin order for R27. MD-II stated he would have ordered a short acting insulin prior to meals, kept the long acting Lantus and the 4 time daily blood glucose levels. Surveyor asked if it is important to take a blood glucose prior to insulin administration. MD-II stated yes. Surveyor noted R27 had a history of uncontrolled diabetes. MD-II stated then it is especially important. Surveyor asked what is the expectation of the staff for insulin administration. MD-II stated follow the orders and take a blood glucose prior to administration. Surveyor asked what should happen if insulin is administered and a blood glucose is not taken. MD-II stated the NP should be updated, and if they are not available call him. On [DATE] at 3:45 PM Surveyor interviewed Nursing Home Administer (NHA)- A, Director Of Nursing (DON)-B, Regional Nurse-F and Corporate Personal-H. Surveyor asked for any additional information for R24 or R27. No additional information was supplied. 3.) R20 was admitted to the facility on [DATE] with pertinent diagnosis including: Vascular Dementia, Blindness, and History of Hypoglycemia. R20 was hospitalized from [DATE] until [DATE] with a pertinent discharge diagnosis of Hypoglycemia. On [DATE] at 2:49 PM, Licensed Practical Nurse (LPN)-E documented in an Admission Summary Progress Note: Resident arrived to [name of facility] [at 1:30 PM] via [ambulance] from [local hospital]. [R20] returned to [R20's] room. [R20] educated on call light system. [R20's] vitals are within [R20's] baseline. [Power of Attorney] notified of return to facility. [NP-D] in facility examined patient and did [medication reconciliation] with MD. Complete skin assessment complete. No new findings. Surveyor reviewed R20's Hospital Discharge Summary. Listed beneath the title of Hypoglycemia was, in part: Monitor blood glucose [three times a day before meals] after discharge. Surveyor reviewed documentation that was completed in the facility on the day R20 returned from the hospital. Nurse Practitioner (NP)-D visit note dated [DATE]. NP-D documented, Will need to monitor for hypoglycemia within [Skilled Nursing Facility]. On [DATE], Surveyor reviewed R20's active MD (Medical Doctor) orders. Surveyor noted that R20 did not have an order for blood glucose monitoring. On [DATE] at 11:24 PM, R20 had a Basic Metabolic Panel (BMP) lab test completed at the facility. A BMP lab test includes glucose. R20's glucose was 64. According to the lab test documentation the reference range for glucose is ,d+[DATE]. Surveyor noted that the glucose result of 64 on [DATE] was on the very low end of normal. On [DATE] at 12:08 PM, Assistant Director of Nursing (ADON)-C documented in a progress note: Treatment team made aware of resulted labs. NO critical values noted, and no new orders given at this time. Will continue to monitor as ordered. On [DATE] at 9:23 PM, R20 had a Comprehensive Metabolic Panel (CMP) lab test completed at the facility. A CMP lab test includes glucose. R20's glucose was 53. According to the lab test documentation the reference range for glucose is ,d+[DATE]. Surveyor noted that the glucose result of 53 on [DATE] was low. The lab results were reviewed by NP-D on [DATE] at 8:35 AM. On [DATE] at 1:07 PM Surveyor interviewed NP-D. Surveyor asked if they had any concerns about the glucose result that she was aware of on [DATE]. NP-D stated Yes, we did an additional blood sugar, and it was normal. Surveyor reviewed R20's MD orders, Progress notes, MAR, Treatment Administration Record (TAR) and Lab results for documentation related to an additional blood sugar result on [DATE]. Surveyor noted that no new MD orders or documentation regarding the lab results were placed in the electronic medical record. On [DATE] at 11:50 PM, Surveyor interviewed ADON- C. Surveyor asked what the process is for entering orders when a resident is admitted back to the facility from the hospital. ADON-C indicated that a nurse on the unit will review the discharge paperwork from the hospital. After review, the nurse will enter orders and put a nursing note into the electronic medical record. After orders are placed, ADON-C, the Director of Nursing (DON)-B or the Unit Manager will review the orders to make sure they are correct. On [DATE] at 3:21 PM, Surveyor interviewed DON-B. Surveyor asked what the process is for entering orders when a resident is admitted back to the facility from the hospital. DON-B indicated that nurses on the unit will enter the orders. The unit nurse will notify the MD or NP to address if any changes need to be made to the orders. DON-B stated that 2 nurses are needed to verify the accuracy of the orders entered. After that process is complete, DON-B or ADON-C will review the Discharge Summary and the facility's orders to check for accuracy. Surveyor informed DON-B that R20's Discharge Summary indicated that R20's blood sugar should be monitored closely. DON-B pulled up the Discharge Summary on the computer and indicated that they saw this in the Discharge Summary. Surveyor asked if R20 has had any blood sugar monitoring completed since R20 was admitted back to the facility on [DATE]. DON-B could not find an order or any monitoring. Surveyor asked DON-B for contact information to speak to NP-D regarding the missing order and monitoring of blood glucose. DON-B stated that they would get back to Surveyor. Surveyor informed DON-B of the concern that R20 has not been monitored for hypoglycemia since they were admitted back to the facility when the Discharge Summary indicated that this should be completed. On [DATE] at 9:46 AM, Surveyor interviewed LPN-G. Surveyor asked if R20 has had any recent blood glucose monitoring completed. LPN-G stated that according to [the electronic medical record], the last blood glucose that was completed on R20 was on [DATE]. On [DATE] at 9:53 AM, Surveyor interviewed DON-B and Regional Nurse-F. Surveyor asked if there is any more information that could be provided for the concern of glucose monitoring not being completed as indicated on the Discharge Summary. DON-B stated that they had reached out to NP-D and were awaiting a reply. On [DATE] at 11:15, NP-D entered an order for glucose monitoring on R20. On [DATE] at 1:07 PM, Surveyor interviewed NP-D. Surveyor asked if there was a reason why the blood glucose order was not entered when R20 was admitted on [DATE]. NP-D stated she was not sure. Surveyor asked if they wanted R20 to have blood glucose monitoring three times a day. NP-D replied, yes. On [DATE] at 1445, at the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA), Corporate Personnel-H and Regional Nurse-F of the concern that R20 was not monitored for blood glucose as was indicated on the D[TRUNCATED]

Based on observation, interview and record review the facility did not ensure that 1 (R25) of 1 Residents reviewed received appropriate treatment and services to increase mobility and/or to maintain current mobility and/or prevent further decrease in mobility. *R25 was walking 10 feet with a walker and transferring from bed to chair with a walker in the hospital, prior to admission to the facility. R25 did not receive physical therapy (PT) and occupational therapy (OT) at the facility, which resulted in R25 being completely dependent for mobility and being transferred by a Hoyer lift from bed to chair. R25 was not placed in a restorative program to maintain mobility status while waiting for authorization for PT and OT. R25 became depressed with feelings of hopelessness. R25 was unable to tolerate being up in a wheelchair for more than 1/2 hour without getting dizzy. R25 had weight loss within one month and increased refusal of meals. Findings Include: R25 was admitted to the facility on [DATE] with diagnoses of Chronic Vascular Disorders of Intestine, Type 2 Diabetes Mellitus, Acquired Absence of Other Specified Parts of Digestive Tract, Edema, Old Myocardial Infarction, and Nontraumatic Hematoma of Soft Tissue. R25 is their own person. Surveyor reviewed R25's Admission Minimum Data Set (MDS) dated [DATE] which documents R25's Brief Interview for Mental Status (BIMS) score to be a 10, indicating moderately impaired skills for daily decision making. R25's MDS documents R25 has no upper and lower range of motion impairment at time of admission. Surveyor reviewed section GG of R25's admission MDS including prior admission performance noting the following significant documentation: Self Care E. Shower/bathe self-Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as (R25) completes activity. Mobility A. Roll left and right-Setup or clean-up assistance-Helper sets up or cleans up; (R25) completed activity. Helper assists only prior to or following the activity. B. Sit to lying-Independent-(R25) completes the activity by self with no assistance from helper. D. Sit to stand-Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as (R25) completes activity. E. Chair/bed-to-chair-Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as (R25) completes activity. Tub/shower transfer-Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as (R25) completes activity. At time of the facility admission MDS, dated [DATE], R25 was requiring partial to moderate assistance for eating, substantial to maximum assistance for upper body dressing, dependent for lower body dressing, dependent for transfers, and rolling from side to side is set-up assistance. No mood or behavior issues are indicated, including no concerns regarding refusal of cares. R25's Self-Care and Mobility Care Area Assessment (CAA) documents R25 is dependent with bed mobility, transfer, bathing, grooming, and dressing. R25's comprehensive care plan addresses with the following focused problems with interventions: (R25) has actual/potential for ADL (activities of daily living) self care performance deficit due to (this is blank) Initiated 12/30/23 -Bathing-encourage (R25) to shower. (R25) often refuses Initiated 12/30/23 -Encourage (R25) to get up from bed to sit in wheelchair. Will refuse Initiated 2/26/24 -Encourage (R25) to use bell to call for assistance Initiated 12/30/23 -Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self care deficit, expected course, declines in function. Initiation 12/30/23 (R25) has limited physical mobility due to (this is blank) Initiated 12/30/23 -Uses wheelchair (ensure foot pedals are in place) Surveyor noted R25's physician orders do not have documentation that PT (physical therapy) and ST (speech therapy) were ordered. On 2/21/24, ST was ordered to assess for potential difficulty chewing/swallowing. R25 never received a ST evaluation. R25's hospital discharge summary dated 12/29/23 documents that R25 was to have PT and OT. The note also documents that prior to R25's hospitalization , R25 was completely independent with mobility, transfers, ADLs . It is also documented in the hospital PT note dated 11/18/23 that R25 demonstrated gradual progression of mobility but remains well below R25's independent prior level of function. Continue to recommend post acute rehabilitation upon discharge. The note also stated that R25 tolerated the session fairly well and is progressing toward functional goals with cues and assist as needed. On 12/27/23, the hospital OT note documents that R25 tolerated the session well and is progressing toward functional goals with cues and assist as needed. The OT notes states that R25 required less physical assist for sit to stand compared to previous OT session. R25 would benefit from post acute rehabilitation to ensure optimal safety and independence with self cares and functional mobility upon discharge home. Surveyor reviewed the facility's PT evaluation and plan of treatment signed 2/15/24 for R25. It is documented that R25 demonstrates good rehab potential as evidenced by ability to follow 1-step directions, able to make needs known and high prior level of function. The evaluation also documents that R25 was walking 10 feet independently with a walker while in the hospital. 3 short term and 3 long term goals were documented for R25. The PT assessment summary states the following: (R25) requires PT services to assess functional abilities, enhance rehab potential, facilitate discharge planning, facilitate independence with all functional mobility, improve dynamic balance, increase functional activity tolerance, increase independence with gait, increase participation with functional daily activities, facilitate safe transition to next level of care and increase performance skills with functional skills. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, (R25) is at risk for falls, further decline in function and compromised general health. Surveyor notes there is no documentation that OT and ST completed an evaluation and plan of treatment for R25. On 12/29/23 Former Social Worker (SW-SS) documented an initial care management meeting was held with R25 in attendance. R25's discharge plan is live in R25's home and will require no caregiver assistance. It is documented there is no medical or functional barriers to the discharge plan. It is also documented that physical therapy (PT) is to be provided to R25. Surveyor reviewed nurse practitioner's (NP-S) documented visits with R25: -1/11/24 States she has not started therapy yet due to insurance. Agitation is documented. -1/17/24 States she has not started therapy yet due to insurance, insurance approval pending per PT. R25 is upset that she has not had therapy. Agitation is documented. -1/23/24 Upset that therapy is delayed. Insurance approval pending per PT. (R25) is upset that (R25) has not had therapy. Discussed starting early with PT due to (R25) being here 4 weeks without any therapy. Agitation is documented. -1/25/24 Insurance approval pending per PT. (R25) is upset that she has not had therapy, discussed starting early with PT due to (R25) being here 4 weeks without any therapy. (R25) is still very upset and wants to leave. Agitation is documented. -2/22/24 Still very upset that (R25) hasn't started PT. Agitation is documented. NP-LL documents on 2/4/24 that part of the Assessment/Plan for R25 is: 3. Edema-monitor and work with PT/OT 4. Decreased mobility-follow up with PT/OT NP-LL documents on 2/8/24 that part of the Assessment/Plan for R25 is: 3. Edema-monitor and work with PT/OT 4. Decreased mobility-follow up with PT/OT 5. Discharge plan-plan to return home NP-LL documents on 2/4/24 that R25 has anxiety and on 2/8/24, R25 has both anxiety and agitation. On 2/27/24, the registered dietitian (RD-O), in R25's evaluation for significant change, indicates R25's current food intake is 26-50% and has had an unplanned weight loss. Surveyor reviewed R25's meal intake record for the past 30 days. R25 has 20 meal refusals. 6 meals where R25 only ate 0-25% and 7 meals where R25 ate 26-50%. On 3/4/24 at 9:05 AM, Surveyor observed R25 in bed, with head of bed elevated, talking on the phone and the room is completely dark. On 3/4/24 at 1:15 PM, Surveyor interviewed R25. R25 informed Surveyor that she has not been receiving therapy because R25 was told by the facility that the Medicaid insurance has not given authorization yet, making R25 feels hopeless. R25 stated that R25 feels dizzy when gotten up in the chair right now, so why get up? R25 indicated R25 has only been able to tolerate no more than 1/2 hour up in the wheelchair. On 3/5/24 at 8:10 AM, Surveyor interviewed Social Worker (SW-N) regarding R25. SW-N stated that SW-N's guess as to why (R25) is not receiving therapy is due to depression. On 3/5/24 at 11:18 AM, Surveyor interviewed Rehabilitation Director (RD-R) regarding R25's failure to receive therapy. RD-R stated there was a miscommunication with the prior Regional Director and that is why R25 did not get evaluated until 2/15/24, approximately 1 and a 1/2 months after admission to the facility. RD-R stated RD-R emailed the prior Regional Director 2 times prior to 2/15/24 but does not have the documentation this was completed. RD-R stated that RD-R was informed on 2/26/24 that Medicaid insurance needed additional information other than what the evaluation documented. RD-R stated that RD-R is working on making the adjusted changes to re-send back to Medicaid for authorization, but it will still take another couple of weeks for approval. RD-R can not explain R25 going approximately 1 and a 1/2 months until the 2/15/24 evaluation other than it was miscommunication with RD-R and RD-R's former Regional Director. On 3/5/24 at 12:32 PM, Surveyor interviewed R25 again. R25 focused on not getting therapy and the physical decline R25 has had. R25 stated she feels awful. R25 stated she feels flat with no emotion, nothing to be emotional about. I just want to go home. I have no appetite. Nobody cares about anything. On 3/6/24 at 1:40 PM, NP-S was interviewed by Surveyor regarding R25 and failure to receive therapy. NP-S stated R25 has been extremely upset that R25 has not received therapy. NP-S described R25 as depressed with a flat affect. NP-S stated NP-S has been asking for updates from therapy 3-4 times a week. NP-S requested therapy start treating and back bill. NP-S informed Surveyor that R25 was taking 10 steps in the hospital and is not physically doing anything right now. NP-S stated NP-S found R25 to be abrasive, extremely upset, very untrusting, and depressed with a flat affect during NP-S's visits. NP-S stated R25 is very upset with the American healthcare system. Surveyor reviewed R25's Kardex as of 3/7/24 which does not document instructions for nursing staff on R25's level of mobility, transfer status, ADL required assistance. On 3/7/24 at 10:30 AM, Assistant Director of Nursing (ADON-C), who is the unit manager for R25, was unable to verbalize to Surveyor what the mobility, transfer, and ADL status is currently in place for R25. On 3/7/24 at 10:39 AM, Certified Nursing Assistant (CNA)-K informed Surveyor R25 needs a Hoyer lift for transfers, is dependent for everything except R25 can wash their upper body. On 3/7/24 at 10:40 AM, Surveyor interviewed R25 again. R25 stated to Surveyor: I'd rather be dead right now. I just want to go home. I've wasted 3 months here. I was walking with the walker in the hospital. Now I can't move at all. My leg is swollen. I am very angry, I just can't believe it. I don't know what to say. I told my son these people have let me die here. I haven't cried for 4 years, now look at me. I am crying. I was such a strong woman. R25 begged Surveyor to assist with discharge planning to get R25 home. I want to die at home. Surveyor notes that R25 is in the process of being sent to the emergency room due to abnormal labs and bleeding from an unknown source. Surveyor shared the concern with Administrator (NHA-A), Director of Nursing (DON-B), Regional Nurse (RN-F), and Corporate (CP-H) on 3/5/24 at 2:57 PM, R25 has not been receiving therapy services while residing at the facility and it resulted in a decline in mobility, overall function and mood for R25. No further information was provided by the facility at this time. On 3/7/24 at 12:25 PM, Surveyor discussed the concern with NHA-A and DON-B regarding the facility not ensuring R25's mobility did not decrease while at the facility. Surveyor expressed that R25 was walking with a walker 10 feet and transferring from bed to chair with a walker and now R25 is dependent and requires a Hoyer lift for transfers. R25 was to receive PT and OT to increase mobility status and did not. R25's decrease and/or lack of maintaining the current mobility status upon admission to the facility resulted in not ensuring the highest practicable physical, mental and psychosocial well-being of R25. R25 became depressed with feelings of hopelessness with the goal of wanting to get home so R25 could die at home. R25 lost their appetite, had many refusals of meals, and subsequently had a 1 month weight loss. Surveyor shared that NP-LL documented on 2 separate visits that R25 has had a decrease in mobility. The NP also documented R25 now has anxiety and agitation.

UNCORRECTED AT REVISIT Based on observation, record review, and interview, the facility did not ensure adequate supervision and assistance devices, or ensure the environment remained free of accident hazards to prevent accidents for 3 (R30, R29, and R22) of 6 residents reviewed for accidents. *R30 had multiple falls where the root cause of the fall was not determined, and interventions were not observed to be in place to prevent future falls. R30 sustained a laceration to the scalp that required staples. The example regarding R30 rises to the scope and severity of actual harm. *R29 did not have a Smoking Care Plan in place until after multiple incidents of smoking in bed. R29 was observed to not have a smoking apron on per care plan when smoking in the designated smoking area. *R22 was observed to be transferred without the use of a gait belt as per care plan. Findings include: The facility policy and procedure entitled Falls Investigation Guideline undated states: It is the practice of this facility to complete a Post Fall Investigation on each resident after every fall. PROCEDURE: 1. The Post Fall Investigation will be initiated, after each fall in Risk Watch and any changes in interventions, based on the root cause analysis, will be inputted on the resident's care plan and nursing assistant care cards. 2. The licensed nurse will complete the Risk Watch with data collected from any staff or other witnesses involved. 3. The Post Fall Investigation, in Risk Watch, will be reviewed on a daily basis to determine if further investigation of the incident is needed and will be reviewed for appropriate interventions and IDT review. 4. The IDT will meet at least weekly to review new falls within the past week, follow-up to previous falls and determine if appropriate interventions have been put in place. 5. The IDT will evaluate the resident's fall risk in conjunction with the care plan to develop, review and revise at a minimum quarterly with increased frequency as needed to reduce resident falls. 6. The physician, resident and/or resident representative will be notified of the resident's fall and will be requested to participate in the planning for reduction of falls. 7. The data collected from the Post Fall Investigations will be reviewed as part of the facility QAPI process. 1.) R30 was admitted to the facility after hospitalization for an ileus on 1/25/2024 with diagnoses of chronic embolism and thrombosis, end stage renal disease requiring dialysis, renal osteodystrophy, diabetes, chronic obstructive pulmonary disease, chronic respiratory failure, viral hepatitis C, and heart disease. R30's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R30 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R30 as being independent with bed mobility and needing supervision for transferring and walking. R30 had an activated Power of Attorney (POA). R30's Constipation Care Plan was initiated on 1/25/2024 with the intervention to record bowel movement pattern each day and describe amount, color, and consistency. On 1/31/2024, R30's Fall Risk Evaluation score was 10 indicating R30 was a high risk for falls. R30's At Risk for Falls Care Plan was initiated on 1/31/2024 with the intervention to anticipate and meet R30's needs. On 2/9/2024 at 3:31 PM in the progress notes, nursing charted R30 was sent to the hospital for possible embolism to the left arm. On 2/15/2024, R30 was readmitted to the facility. R30's Fall Risk Evaluation score was 7 indicating high risk for falls. R30's Bowel Incontinence Care Plan was initiated on 2/15/2024 with the following interventions: -Observe pattern of incontinence, and initiate toileting schedule if indicated. -Provide pericare after each incontinent episode. On 2/16/2024 at 3:17 AM in the progress notes, nursing charted a Post Fall Evaluation note indicating R30 had fallen with no injuries. New interventions put in place were the bed in low position, call light within reach, and a fall mat. At 6:42 AM in the progress notes, nursing charted a Certified Nursing Assistant (CNA) informed the nurse that R30 was on the floor. R30 was on the left side of the bed on the back with the legs on the bed. Oxygen cord was tangled and wrapped around the chest. R30 stated R30 was trying to get the blanket off the floor when R30 leaned over off the bed, R30 lost balance causing R30 to fall out of bed and onto the floor. Nursing charted the bed was lowered to the lowest position, the call light was in reach, and R30 did not sustain any injuries. Surveyor reviewed the Fall Packet associated with R30's fall on 2/15/2024 at 10:45 PM. The Interdisciplinary Team (IDT) reviewed R30's fall and determined R30 needed to be educated to use the call light for any assistance getting things off of the floor and at the beginning of night shift staff is to check on R30 for any needs. Surveyor noted the interventions listed were not added to the care plan until 2/17/2024, two days after the fall. R30's Actual Fall Care Plan was initiated on 2/16/2024 with the following interventions: -Date and description of other interventions put in place after fall. -Floor mat to side of bed. On 2/16/2024 at 5:42 PM in the progress notes, nursing charted R30 was found on the floor in the room sitting on the buttocks in front of the sink in front of the wheelchair. No injuries were noted. Surveyor reviewed the Fall Packet associated with R30's fall on 2/16/2024 at 5:00 PM. The IDT reviewed the fall and determined R30 was trying to pick up something off the floor in the bathroom and when R30 went to sit back down in the wheelchair, the locks were not engaged, and the wheelchair rolled back causing R30 to fall to the floor. The IDT concluded anti rollbacks were to be placed on the wheelchair and R30 was to use call light for assistance. R30's Actual Fall Care Plan was revised on 2/17/2024 with the following interventions: -Anti rollbacks to wheelchair. -Night staff to check on R30 at beginning of shift for any needs. -R30 educated on using call light for assistance and to lock wheelchair if need to stand up from chair. On 2/19/2024 at 12:20 AM in the progress notes, nursing charted R30 was found on the floor of the room stating R30 was trying to get up in the wheelchair and fell on the floor instead. R30 thought R30 could transfer by themselves. R30 did not sustain an injury. R30 was assisted into the wheelchair and transferred onto the toilet for a bowel movement. Surveyor reviewed the Fall Packet associated with R30's fall on 2/18/2024 at 11:30 PM. The IDT reviewed the fall and determined R30 needed to use the bathroom to have a bowel movement. R30 was noted to have a bowel movement earlier that day at 12:55 PM. The IDT concluded the PM shift was to ask R30 on last rounds if R30 needed to use the bathroom. R30's Actual Fall Care Plan was revised on 2/19/2024 with the intervention for PM shift to ask R30 on last rounds if R30 needs to use the toilet. On 2/19/2024 at 10:54 PM in the progress notes, nursing charted R30 had an unwitnessed fall. R30 had complained of constipation and around 9:50 PM, R30 was found on the floor by a CNA. R30 was observed lying on the floor with blood surrounding the head. Nursing charted vital signs were attempted to be obtained, but R30 refused and became argumentative about not wanting to move. Pressure was applied to the scalp laceration until ambulance personnel arrived. R30 stated R30 was trying to dig shit out of his butt. There were no visible signs of excrement on R30. R30 was transferred to the emergency room . On 2/20/2024 at 2:45 AM in the progress notes, nursing charted R30 returned to the facility. The CT scan was negative. Sutures, staples, and adhesive glue were used for the head laceration. Surveyor reviewed the Fall Packet associated with R30's fall on 2/19/2024 at 10:11 PM. Staff statements indicated the fall occurred at 9:50 PM. Per staff statements, the CNA had just completed cleaning R30 up from having a bowel movement when R30 complained of constipation. The CNA informed the nurse at 9:30 PM of R30's complaint and the nurse administered Senna S 8.6-50 mg at 9:30 PM, a laxative. The CNA stated the CNA heard R30 yell out and found R30 on the floor by the closet with the head bleeding at 9:50 PM. The nurse indicated R30 fell in the bathroom. Surveyor noted the conflicting reports. The IDT determined R30 fell due to trying to have a bowel movement after receiving Senna for constipation and attempting to self-transfer from the toilet. The IDT concluded a bedside commode should be used. R30's Actual Fall Care Plan was revised on 2/20/2024 with the intervention of a bed side commode with therapy to educate R30 on safety. Surveyor noted on 3/6/2024 at 9:59 AM that the commode in R30's room was against the wall across from the foot of the bed; the bathroom was closer in proximity than the commode to R30's bed. On 3/4/2024 at 11:13 PM in the progress notes, nursing charted at approximately 6:35 PM the nurse was alerted by the CNA that R30 was on the floor. R30 was observed to be in front of the wheelchair. R30 stated R30 fell but did not know how. On 3/5/2024 at 6:57 PM in the progress notes, Director of Nursing (DON)-B charted the IDT met to discuss R30's fall on 3/4/2024. R30 attempted to get out of bed without assistance and the wheelchair was not locked and it rolled away. The IDT determined antilock needed to be put on R30's wheelchair to keep it from rolling. R30's Actual Fall Care Plan was revised on 3/5/2024 with the intervention of antilock to wheelchair. Surveyor noted R30 had anti roll backs on the wheelchair added to the care plan on 2/17/2024. On 3/15/2024 at 3:40 PM, Surveyor observed R30 in bed independently washing themselves with a washcloth, towel, and basin of water. No staff were in the room. R30 stated R30 needed help. Surveyor talked to CNA-W about R30's request for help. CNA-W stated CNA-W had just brought R30 a water basin and washcloth and R30 had told CNA-W that R30 could do wash up by themselves. CNA-W stated CNA-W gave R30 the supplies and R30 said to close the door on the way out. CNA-W stated CNA-W would go and check on R30. Surveyor noted R30 had a fall mat on the floor next to the bed and the bed was in the lowest position. In an interview on 3/6/2024 at 9:28 AM, Surveyor asked DON-B for a clarification of the intervention for R30's Fall Care Plan of anti-rollbacks and antilocks for the wheelchair. DON-B stated those terms refer to the same device that is placed on a wheelchair so it will not go backwards when the brakes are not engaged preventing the wheelchair from rolling out of the way when a resident sits down. Surveyor shared with DON-B the anti-rollbacks were on R30's Fall Care Plan on 2/17/2024 and questioned DON-B why the same intervention would be put on R30's Fall Care Plan on 3/5/2024. DON-B stated R30 had anti rollbacks on the wheelchair on 2/17/2024 but the wheelchair was changed so the anti-rollbacks needed to be put on the new wheelchair. Surveyor asked DON-B who would be responsible for ensuring the anti-rollbacks were in place when a wheelchair is replaced. DON-B stated resident wheelchairs are cleaned once a week on their scheduled shower day and should be returned to the resident. DON-B stated the wheelchair is not always returned to the right resident. Surveyor asked DON-B what day of the week was R30's shower day. DON-B stated R30 is scheduled for showers on Thursday PM shift. Surveyor clarified that if R30 had anti rollbacks on the wheelchair on 2/17/2024, then the shower day would have been on 2/22/2024 or 2/29/2024 when the wheelchair would have been replaced with a wheelchair that did not have anti rollbacks in place. DON-B stated yes, R30 would not have had the anti-rollbacks in place after either of those dates. Surveyor asked DON-B who checks to make sure interventions are implemented after the IDT meeting. DON-B stated either DON-B or the Unit Managers check to make sure the new intervention is in place when it is put into the care plan. DON-B stated the CNA should make sure the anti-rollbacks are in place after the wheelchair is washed. Surveyor shared with DON-B that the fall on 3/4/2024 would have been prevented if R30 had the anti-rollbacks on the wheelchair as per care plan. DON-B agreed. On 3/6/2024 at 2:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R30 had a fall on 2/18/2024 at 11:30 PM that the IDT determined was due to R30 needing to have a bowel movement. Surveyor shared with NHA-A and DON-B no changes were made to R30's Bowel Incontinence Care Plan or Constipation Care Plan that addressed those needs with no scheduling of toileting or increase in supervision when toileting. R30 sustained a scalp laceration requiring staples after a fall on 2/19/2024 at 9:50 PM that was due to constipation and receiving a laxative without increasing supervision or assistance with toileting. On 3/7/2024 at 10:24 AM, Surveyor observed R30 sleeping in bed with the bed in low position, a fall mat on the floor at bedside, and a commode chair across the room from the foot of the bed. Surveyor observed a wheelchair next to R30's bed that did not have anti rollbacks on the wheels. Surveyor asked CNA-X if CNA-X was familiar with R30. CNA-X stated yes, and asked if Surveyor had a question. Surveyor asked CNA-X if CNA-X could look at the wheelchair in R30's room and be able to tell if that wheelchair was R30's wheelchair. CNA-X stated yes, CNA-X would know which wheelchair belonged to R30. CNA-X looked in R30's room and verified that the wheelchair next to R30's bed was R30's wheelchair. Surveyor asked CNA-X if R30's wheelchair should have anti rollbacks on the wheels. CNA-X stated no, because R30 was not a fall risk. CNA-X stated some wheelchairs have anti rollbacks, but R30 was pretty good with the wheelchair so does not need them. CNA-X stated therapy determines which resident needs anti rollbacks. On 3/7/2024 at 1:56 PM, Surveyor shared with DON-B the conversation with CNA-X and the observation of R30's wheelchair with no anti rollbacks in place as per care plan. DON-B stated maintenance was told about putting the anti-rollbacks on R30's chair the day before. DON-B paged maintenance to put the anti-rollbacks on R30's chair. No further information was provided at that time. 2.) R29 was admitted to the facility on [DATE] with diagnoses of pancreatitis, traumatic brain injury with hemiplegia and hemiparesis, fibromyalgia, schizophrenia, depression, anxiety, and chronic viral hepatitis C. R29's admission Minimum Data Set (MDS) assessment dated [DATE] assessed R29 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R29 as needing total assistance with all mobility and cares. R29 did not have an activated Power of Attorney. On 11/21/2023 a Smoking Risk assessment was completed due to R29 being a smoker. The assessment determined R29 was not interested in smoking cessation and smokes five or more cigarettes daily in the afternoon, evening, and night. The assessment determined R29 did not require any adaptive equipment or assistance with smoking. The facility safe smoking policy was reviewed with R29 along with identification of where smoking materials are stored, the designated smoking areas, and disposal units. R29's Smoking Care Plan was initiated on 11/21/2023 and was resolved on 11/22/2023. R29 continued to smoke with no Smoking Care Plan in place. On 12/29/2023 at 10:05 PM in the progress notes, nursing charted R29 was in their room smoking a cigarette in bed. R29 was instructed by a manager and floor nurses to give up the cigarette lighter and other cigarettes that R29 had. R29 was educated on the risks of smoking in the facility and nursing staff explained the facility policy on smoking and smoking materials. R29 would be monitored for this activity. On 12/30/2023 a Smoking Risk assessment was completed due to R29 smoking in bed. The assessment indicated R29 had a history or current demonstration of unsafe smoking in unauthorized areas and was careless with smoking materials. The assessment determined R29 inappropriately provides smoking materials to others and refuses to follow facility policy. The assessment indicated R29 was unable to extinguish smoking materials properly and is safe to smoke with supervision. R29 was not safe to keep any/all smoking materials and all materials would be stored by staff, but R29 can keep lighter/matches. R29 needs staff to light smoking materials. R29's Smoking Care Plan was initiated on 1/1/2024 with the following interventions: -Conduct Smoking Safety Evaluation on admission and as needed. -Educate R29 on the facility's tobacco/smoking policy. -R29 requires supervision while smoking. -R29 must utilize a smoking apron. On 1/3/2024 at 4:08 PM in the progress notes, nursing charted the nurse was called to R29's room by a Certified Nursing Assistant (CNA) who smelled smoke coming from R29's room. The nurse went into the room and also smelled smoke. The nurse asked R29 for permission to check R29's purse and found five to six cigarette buds and illegal drug paraphernalia in R29's purse. R29 handed over a lighter R29 had hidden in R29's bra area. At 4:13 PM in the progress notes, Social Services charted nursing made Social Services aware of R29 smoking in the room. Social Services spoke with R29 and informed R29 of the smoking rules for the facility and a 30-day notice violation would be given if the behavior continued. Nursing staff did obtain cigarette and lighter from R29. R29 expressed understanding and informed Social Services that it would not happen again. On 1/5/2024 at 11:38 AM in the progress notes, Social Services charted they were notified by a nursing manager that R29 was caught smoking in their room again. Social Services charted they will confirm if a 30-day notification would be put in place, as R29 was made aware on 1/3/2024. Social Services attempted to contact R29's family to inform them not to bring cigarettes on site for R29 but was unable to reach them. R29's Non-compliant Smoking in Room Care Plan was initiated on 1/9/2024 with the following interventions: -R29's smoking material will be secured by facility. -R29 will be educated on facility smoking policies. -R29 is a supervised smoker. On 2/3/2024 at 8:31 AM in the progress notes, nursing charted the Risk vs Benefits for smoking in room was completed and R29's family member was aware and educated. The Nurse Practitioner was notified. Surveyor asked Director of Nursing (DON)-B on 3/5/2024 at 2:59 PM if this progress note indicated R29 was smoking in the room again. DON-B nodded agreement. On 3/5/2024 at 3:21 PM, Surveyor observed R29 in bed. Surveyor asked R29 if R29 had been up in a wheelchair. R29 stated R29 had just gotten back in bed. Surveyor asked R29 if staff had taken R29 outside to smoke. R29 stated yes, R29 does not do anything by themselves. In an interview on 3/6/2024 at 10:03 AM, Surveyor asked R29 how often R29 goes outside to smoke. R29 stated R29 goes outside once a day to smoke. R29 stated the desk (at the nurses' station) gives R29 two cigarettes when R29 goes outside. R29 stated they hold onto R29's cigarettes and lighter because R29 was smoking in bed and cannot have them in R29's room. R29 stated R29's family member brings R29 cigarettes. In an interview on 3/6/2024 at 10:40 AM, Surveyor asked Health Unit Coordinator (HUC)-Y what the facility policy was for smoking. HUC-Y stated unsupervised smokers can go out to the smoking area at any time and the supervised smokers have specific smoking times. HUC-Y showed Surveyor a letter indicating changes to the smoking policy as of 3/22/2024. Surveyor asked HUC-Y what the difference was from the old policy to the new policy. HUC-Y stated the smoking times for supervised smokers changed. HUC-Y stated the smoking area has a code on the door to open it both from the inside and the outside and all the independent smokers know the code to access the area. On 3/6/2024 at 11:18 AM, Surveyor saw R29's door was closed and could hear staff in the room with R29. When the door opened, R29 was in a wheelchair with a jacket on. R29 stated they wanted to go outside to smoke. CNA-Z pushed R29 in the wheelchair down the hallway, stopping at the nurses' station. R29 asked HUC-Y if R29 had any cigarettes. HUC-Y checked and indicated no. CNA-Z proceeded down the hallway to the exit door leading to the smoking area. Inside the entryway were two fire blankets in pouches, multiple smoking aprons hanging on hooks, and a fire extinguisher. CNA-Z punched in the code three times before the door opened. CNA-Z pushed R29 across the smoking area to where two other residents were sitting and smoking. Surveyor observed another resident light up and hand a cigarette to R29 who proceeded to smoke the cigarette. R29 did not have a smoking apron on. CNA-Z then left the area leaving no staff supervising the smoking area. Approximately one minute after CNA-Z left the area, Licensed Practical Nurse (LPN) Unit Manager (UM)-E came outside and stood behind R29. Surveyor asked LPN UM-E if there is always a staff member in the smoking area during supervised smoking times. LPN UM-E stated they try to have a CNA with available time to come out during smoking times but sometimes all the CNAs are busy so that was why LPN UM-E was out there at that time. Surveyor asked LPN UM-E if R29 uses a smoking apron. LPN UM-E stated LPN UM-E did not know if R29 needed one. Surveyor shared with LPN UM-E that use of a smoking apron was on R29's Smoking Care Plan. LPN UM-E saw CNA-AA enter the smoking area with another resident that was wearing a smoking apron and called out to CNA-AA to get a smoking apron for R29. CNA-AA brought a smoking apron over to R29 and put it on R29. Surveyor left the smoking area by punching in the code to open the door. It took three attempts at punching in the code before the door opened. Surveyor noted the delay in opening the door could cause a delay in retrieving either fire blankets or the fire extinguisher. On 3/6/2024 at 2:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R29 was observed smoking outside that day without a smoking apron on and another resident provided R29 with a lit cigarette with no staff assistance. Surveyor shared the concern R29 did not have a Smoking Care Plan in place until 1/1/2024 and the Non-complaint Smoking Care Plan in place until 1/9/2024 when R29 had been smoking since admission on 11/20/2023 and was found smoking in the room multiple times from 12/29/2023 through 2/3/2024. No further information was provided at that time. 20483 3.) The Gait Belt Use policy and procedure with an effective date of 11-28-17 under purpose documents A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer. A gait belt can support a lower to the floor if the resident begins to fall or loses balance during transfer or ambulation. When combined with proper body mechanics a gait belt improves caregiver safety and prevents back injury. Under the section Transferring the Resident documents: * If the resident has one-sided weakness, position the destination surface (wheelchair, commode or chair) on the resident's unaffected side. * Position yourself close to the resident to face each other. * Grasp both sides of the gait belt using an underhand grip. * While firmly gripping the gait belt, keep your back straight, bend your knees slightly, position your feet in a wide stance to maintain proper body mechanics and begin rocking back and forth to overcome forces resisting transfer. Instruct the resident on a count of three to push off of the surface to encourage independence. * Allow the resident to stand for a moment to ensure balance. * Instruct the resident to pivot and to bear as much weight as possible on the unaffected side. Support the affected side because the resident will tend to lean to this side. * Pivot your back foot, guiding the resident to the destination surface. Maintain contact between the destination surface and the resident's legs to ensure proper positioning prior to the resident sitting. * Flex your knees and hips while assisting the patient onto the destination surface. Using good body mechanics prevents back injury by supporting weight with large muscle groups. * After reaching the destination surface, keep a firm grip on the gait belt and gently lower the patient onto the surface. Tell the patient to reach and grasp the arm rests using them to bear some weight if possible. R22 was admitted to the facility on [DATE] with diagnoses which includes cerebral infarction, hypertension and chronic pain. The admission MDS (minimum data set) with an assessment reference date of 1/4/24 has a BIMS (brief interview mental status) score of 12 which indicates moderate cognitive impairment. R22 is assessed as being dependent for toileting hygiene & chair/bed to chair transfer and substantial/maximal assistance for rolling left to right, sit to lying, and lying to sitting on the side of the bed. R22 fell month prior to admission & two to six months prior to admission. Since admission R22 is assessed as having two or more falls with no injury. The actual fall care plan initiated 12/31/23 documents the following interventions: * Date and description of other interventions put in place after a fall: (specify). Initiated 12/31/23. * Concave mattress. Initiated 1/1/24. * Concave mattress and centered in the bed. Initiated 1/2/24. * Keep items in reach while resident in room. Initiated 1/30/24. The at risk for falls care plan initiated 1/15/24 documents the following interventions: * Anticipate and meet the resident's needs. Initiate 1/15/24. * Concave mattress. Initiated 1/30/24. * Educate staff to elevate feet while in recliner. Initiated 1/15/24. The fall risk evaluation dated 1/30/24 has a fall risk score of 16. A total score of 5 or above is high risk. The CNA (Certified Nursing Assistant) Kardex as of 3/5/24 under the safety section documents concave mattress and centered in the bed, educate staff to elevate feet while in recliner, and keep items in reach while resident in room. Other sections on the Kardex are skin, resident care, bathing and mobility. Surveyor noted the CNA Kardex as of 3/5/24, R22's actual fall care plan initiated 12/31/23, at risk for falls care plan initiated 1/15/24 and R22's other care plans do not indicate how R22 should be transferred. On 3/6/24 at 9:01 a.m. Surveyor observed R22 sitting in a wheelchair with a half lap tray in her room. R22 informed Surveyor she had been to therapy doing the bike and will be going back to therapy. R22 informed Surveyor she wants to lay down, wheeled herself to the doorway and stated to LPN/UM (Licensed Practical Nurse/Unit Manager)-CC Do you see the girl with the colored braids? I want to lay down. On 3/6/24 at 9:05 a.m. LPN/UM-CC informed R22 the CNA went to laundry to get clothing labeled and then will be in to lay her down. On 3/6/24 at 9:12 a.m. R22 placed her call light on. On 3/6/24 at 9:14 a.m. CNA-BB entered R22's room asking R22 what she wants. R22 informed CNA-BB she wants to lay down. CNA-BB moved the blanket on R22's bed, placed gloves on, moved the left foot rest to the side of the wheelchair, and wheeled R22's wheelchair so R22 was facing the bed. CNA-BB stood on the left side of R22's wheelchair, put her arm under R22's left underarm, stating on three will stand up, and stood R22 up holding onto the back of R22's pants. CNA-BB stated to R22 I got you mamma, you're not going to fall. R22 was able to take a step and CNA-BB laid R22 on the bed. Surveyor observed R22 was placed at an angle on the bed with her right leg crossed over her left. CNA-BB picked up R22's legs, swung her legs so R22 was laying straight in the bed. CNA-BB removed R22's shoes, lowered and removed her pants. CNA-BB covered R22 with a sheet, placed the call light & bed control in R22's reach and moved the over bed table next to the bed. CNA-BB removed her gloves and left R22's room. Surveyor observed CNA-BB did not use a gait belt when she transferred R22 from the wheelchair into the bed. On 3/6/24 at 11:59 a.m. Surveyor asked Rehab Director-R if therapy makes recommendations on how a Resident should be transferred. Rehab Director-R replied yes. Surveyor asked Rehab Director-R how staff should be transferring R22. Rehab Director-R informed Surveyor she is still learning PCC (pointclickcare) and informed Surveyor she will get back to Surveyor. On 3/6/24 at 12:12 p.m. Rehab Director-R informed Surveyor R22 is an assist of one. Surveyor asked when a resident is an assist of one does staff use a gait belt with the transfer. Rehab Director-R replied yes, always use a gait belt even with supervision. On 3/6/24 at 12:42 p.m. Surveyor asked CNA-BB how she knows how to transfer a Resident. CNA-BB informed Surveyor she can look in the computer or she's new so she will ask other CNA's how a Resident transfers. CNA-BB informed Surveyor they help each other out. Surveyor asked CNA-BB how R22 transfers. CNA-BB she's a pivot like I did earlier. CNA-BB then informed Surveyor she just learned she's suppose to use a gait belt. CNA-BB informed Surveyor she didn't have a gait belt and haven't transferred [name of R22] before. Surveyor asked CNA-BB how she learned she was suppose to use a gait belt. CNA-BB informed Surveyor when she was getting R22 up for therapy R22 asked her about a gait belt. CNA-BB stated I didn't know had to use one and there wasn't one in her room. On 3/6/24 at 2:50 p.m. NHA (Nursing Home Administrator)-A, Regional Nurse-F and Corporate-H were informed of the above.

Based on interview and record review the Facility did not ensure 2 (R32 & R23) 6 Residents were free from significant medication errors. * R32 missed 15 doses of Divalproex Sodium during December 2023 and 5 doses during January 2024. On 1/3/24 the Facility was notified R32's Valproic acid level was low at 17 (reference range 50-100). On 1/4/24 R32 experienced two seizures and was transferred to the hospital. R32 did not return to the Facility. * R23 has a diagnosis of Crohn's disease. Crohn's disease causes inflammation in the digestive tract with symptoms that include diarrhea and cramping & pain in the abdomen. R23 missed 42 doses of Diphenoxylate-Atropine 2.5-0.025 mg (milligram), a medication to treat diarrhea, during October 2023 and 38 doses during November 2023. Findings include: 1.) R32 was admitted to the facility on [DATE] and discharged on [DATE]. The hospital discharge summary for date of discharge 10/23/23 documents reason for hospitalization AMS (altered mental status) secondary to seizures. Under discharge diagnoses includes Seizure. The nurses note dated 10/23/23 at 14:47 (2:47 p.m.) documents [R32's name] arrived to facility around 14:20 (2:20 p.m.) via ambulance and transported to room [number]. Vital signs upon arrival T (temperature) 97.6, P (pulse) 72, R (respirations) 18, B/p (blood pressure) 133/94, & SpO2 96% RA (room air). Resident was admitted to facility for seizures, altered mental status and dislocation bilateral jaw. He is alert and orientated x (times) 2 with some confusion and can be combative during cares. Skin warm, dry and intact without injuries or open areas. Resident is a mechanical soft diet with thin liquids. Takes medications crushed in food, pudding or applesauce. Incontinent of bowel and bladder. Resident is now resting in bed with water and call light within reach. This nurses note was written by LPN (Licensed Practical Nurse)-NN. The physician order dated 11/14/23 documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium) Give 4 capsule by mouth two times a day related to Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90). This order was discontinued on 12/28/23. The eMar (electronic medication administration record) note dated 12/7/23 at 13:27 (1:27 p.m.) documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg (milligrams) Give 4 capsules by mouth two times a day for Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90) medication was not available for administration writer updated [Name of NP (Nurse Practitioner)-S] and writer refilled from pharmacy. The eMar note dated 12/13/23 at 22:48 (10:48 p.m.) documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg Give 4 capsules by mouth two times a day for Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90) Medication not available. Contacted pharmacy, unable to reorder at this time. Pharmacy tech stated to call back during regular business hours to reorder. Will follow up in am (morning). The eMar note dated 12/14/23 at 18:26 (6:26 p.m.) documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg Give 4 capsules by mouth two times a day for Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90) Medication not available. The physician orders dated 12/15/23 documents Divalproex Sodium Oral Capsule Delayed release Sprinkle 125 mg (Divalproex Sodium) Give 4 capsule by mouth two times a day for Epilepsy Give 4 capsule to = (equal) 500 mg. This order was discontinued 12/18/23. The eMar note dated 12/15/23 at 21:57 (9:57 p.m.) documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg Give 4 capsules by mouth two times a day for Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90) Medication not available. The eMar note dated 12/16/23 at 17:43 (5:43 p.m.) documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg Give 4 capsules by mouth two times a day for Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90) on order. The eMar note dated 12/16/23 at 17:43 (5:43 p.m.) documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg Give 4 capsule by mouth two times a day for Epilepsy Give 4 capsules to = (equal) 500 mg. on order. The eMar note dated 12/26/23 at 20:41 (8:41 p.m.) documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg Give 4 capsules by mouth two times a day for Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90) medication unavailable. The physician orders dated 12/28/23 documents Depakote Sprinkles Oral Capsule Delayed Release Sprinkles 125 mg (Divalproex Sodium) Give 250 mg by mouth two times a day for impulsive behaviors, sz (seizure) d/o (disorder) give with brk (breakfast) and after midday meal. This order was discontinued on 1/5/24. The physician orders dated 12/28/23 documents Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium) Give 4 capsule by mouth one time a day for sz d/o impulsive behavior related to Epilepsy, unspecified, not intractable, without status epilepticus (G40.909), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (F03.90). This order was discontinued on 1/5/24. Review of R32's December 2023 MAR reveals R32 did not receive Divalproex Sodium delayed release sprinkles 500 mg on 12/7/23 at 0900 (9:00 a.m.), 12/13/23 at 1800 (6:00 p.m.), 12/14/23 at 6:00 p.m., 12/15/23 at 6:00 p.m., 12/16/23 at 6:00 p.m., 12/17/23 at 9:00 a.m., 12/18/23 at 6:00 p.m., 12/23/23 at 6:00 p.m., 12/26/23 at 9:00 a.m. & 6:00 p.m., 12/28/23 at 1900 (7:00 p.m.) and 12/31/23 at 7:00 p.m. and Divalproex Sodium delayed release sprinkles 250 mg on 12/30/23 at 1300 (1:00 p.m.) and on 12/31/23 at 0800 (8:00 a.m.) and 1:00 p.m. The eMar note dated 1/2/24 at 10:26 a.m. documents Depakote Sprinkles Oral Capsule Delayed Release Sprinkles 125 mg Give 250 mg by mouth two times a day for impulsive behaviors, sz (seizures) d/o give with brk (breakfast) and after midday meal Medication unavailable, will contact pharmacy. The eMar note dated 1/3/24 at 11:38 a.m. documents Depakote Sprinkles Oral Capsule Delayed Release Sprinkles 125 mg Give 250 mg by mouth two times a day for impulsive behaviors, sz (seizures) d/o give with brk (breakfast) and after midday meal Medication unavailable, will contact pharmacy. R32's lab report with a collection date of 1/3/24 and a reported date of 1/3/24 at 22:19 (10:19 p.m. ) for Valproic acid has a result of 17.3. The reference range is 50-100 which indicates the result is low. Review of R32's January 2024 MAR reveals R32 did not receive Divalproex Sodium delayed release sprinkles 500 mg on 1/2/24 & 1/3/24 at 1900 (7:00 p.m.), Depakote Sodium delayed release sprinkles 250 mg on 1/2/24 & 1/3/24 at 0800 (8:00 a.m.) and 1/4/24 at 1300 (1:00 p.m.). The nurses note dated 1/4/24 at 07:34 (7:34 a.m.) documents Resident had a seizure this am (morning), lasting about 2 mins (minutes) resident was stiff with arms and legs sticking straight out during the seizure. Staff remained with resident throughout the seizure. Window shades closed, resident made comfortable and safety ensured. Postictal state- Resident had increased confusion and stated he was going back to sleep. Family and NP (Nurse Practitioner) updated, Nurse manager made aware. This nurses note was written by LPN-OO. The nurses note dated 1/4/24 at 14:51 (2:51 p.m.) documents Resident being sent out. Floor manager came to get nurse stating resident having seizure. Resident had another seizure lasting 2-3 minutes, MD (medical doctor) wants resident sent out, family in room. This nurses note was written by LPN-OO. On 3/6/24 at 11:43 a.m. Surveyor asked LPN-QQ how Resident's medication are reordered. LPN-QQ informed Surveyor the medication is automatically reordered explaining they started a cycle fill for the last two months. Surveyor asked before the cycle fill how was medication being reordered. LPN-QQ informed Surveyor you had to click on each individual medication to reorder. Surveyor asked LPN-QQ if there was a certain number of pills left before the medication was ordered. LPN-QQ informed Surveyor he didn't think there were any guidelines and it was up to the nurses discretion when medication was reordered. LPN-QQ informed Surveyor he would order a week before the medication was going to run out. On 3/6/24 at 11:53 a.m. Surveyor asked LPN-JJ how Resident's medication are reordered. LPN-JJ informed Surveyor you click on the medication in the computer or put the sticker from the card and fax it to the pharmacy. Surveyor asked LPN-JJ if there is a certain number of pills left before the medication needs to be reordered. LPN-JJ informed Surveyor she goes by 7 pills left. At 11:57 a.m. ADON/RN (Assistant Director of Nursing/Registered Nurse)-C who was also in the nurses station informed Surveyor now the medication is being reordered on a cycle fill. On 3/7/24 at 7:43 a.m. Surveyor asked LPN-MM if a medication is not in the medication cart what does she do. LPN-MM informed Surveyor she will try to see if the medication is in the medication room and if its not in the medication room she will reorder the medication. LPN-MM informed Surveyor if it's a cardiac or seizure medication she will try to see if she can speak with upper management to get the medication right away. On 3/7/24 at 10:40 a.m. Surveyor met with DON (Director of Nursing)-B to discuss R32. Surveyor informed DON-B there are multiple days when R32's Divalproex Sodium was not available in December 2023 and January 2024 and inquired when should R32's medication be reordered so he would not miss any doses. DON-B informed Surveyor if there are 7 days left of the medication, the medication should be ordered. Surveyor informed DON-B R32 missed multiple doses, the Valproic acid lab reported on 1/3/24 was low at 17, R32 had two seizures on 1/4/24 was hospitalized on [DATE]. On 3/7/24 at 12:30 p.m. Surveyor informed NHA (Nursing Home Administrator)-A of the above. 2.) R23 was originally admitted to the facility on [DATE], discharged to the hospital on 10/22/23 and readmitted to the facility on [DATE]. R23 was discharged home on 11/24/23. R23 has a diagnosis which includes Crohn's disease. Crohn's disease causes inflammation in the digestive tract with symptoms that include diarrhea and cramping & pain in the abdomen. R23's physician orders include with an order date of 10/19/23 & 11/3/23 Diphenoxylate-Atropine oral tablet 2.5-0.025 mg (milligram) (Diphenoxylate w/ (with) Atropine). Give 2 tablet by mouth four times a day for diarrhea. The nurses note dated 10/20/23 at 01:32 (1:32 a.m.) under GI/GU (gastrointestinal/genitourinary) Gastrointestinal alterations: Diarrhea Hyperactive bowel sounds. There is no change in GI status. The eMar (electronic medication administration record) note dated 10/20/23 at 13:08 (1:08 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not available, pharmacy and MD (medical doctor) updated. The eMar note dated 10/20/23 at 19:42 (7:42 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not available, pharmacy aware, and MD updated. The eMar note dated 10/20/23 at 20:47 (8:47 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not available, MD and pharmacy aware, awaiting medication run. The eMar note dated 10/21/23 at 10:20 (10:20 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not available, pharm (pharmacy) and MD aware. The eMar note dated 10/21/23 at 12:36 (12:36 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not available, awaiting pharmacy run. The eMar note dated 10/22/23 at 08:05 (8:05 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unavailable, MD and pharmacy AWARE. The nurses note dated 10/23/23 at 01:30 (1:30 a.m.) includes documentation of Residents atropine-diphenoxylate not available and resident having frequent loose mucousy stools. Buttocks excoriated. Resident peri care done, zinc oxide ointment applied. This nurses note was written by RN (Registered Nurse)-FF. The eMar note dated 10/23/23 at 11:03 (11:03 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. Medication unavailable. The eMar note dated 10/23/23 at 22:07 (10:07 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. med not available. The eMar note dated 10/25/23 at 12:33 (12:33 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not available The eMar note dated 10/26/23 at 12:44 (12:44 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not avail (available), pharm (pharmacy) and MD aware. The eMar note dated 10/26/23 at 13:07 (1:07 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not avail. MD and pharm aware. The eMar note dated 10/27/23 at 10:20 (10:20 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not avail, pharm and MD aware. The eMar note dated 10/27/23 at 20:02 (8:02 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. med (medication) not available. The eMar note dated 10/28/23 at 11:06 (11:06 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not avail, pharm and MD aware. The eMar note dated 10/28/23 at 18:13 (6:13 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. On order. The eMar note dated 10/28/23 at 20:56 (8:56 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. On order. The eMar note dated 10/29/23 at 13:32 (1:32 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. On order. The eMar note dated 10/29/23 at 18:03 (6:03 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. On order. The eMar note dated 10/30/23 at 11:15 (11:15 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unavailable. The eMar note dated 10/30/23 at 14:07 (2:07 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unavailable. The eMar note dated 10/30/23 at 17:46 (5:46 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. medi (medication) not available. The eMar note dated 10/31/23 at 06:22 (6:22 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. NOT AVAILABLE. The eMar note dated 10/31/23 at 11:42 (11:42 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. on order. The eMar note dated 10/31/23 at 12:33 (12:33 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. on order. The eMar note dated 10/31/23 at 18:36 (6:36 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. on order. The eMar note dated 10/31/23 at 20:26 (8:26 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. on order. Surveyor reviewed R23's October 2023 MAR and noted on the follow up codes a check mark indicates the medication was administered. According to the October 2023 MAR R23 did not receive Diphenoxylate-Atropine Oral Tablet 2.5-0.025 on 10/20 at 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.) & 2100 (9:00 p.m.), 10/21 at 9:00 a.m. & 1:00 p.m., 10/22 at 9:00 a.m., 10/23 at 9:00 a.m., 1:00 p.m., 5:00 p.m. & 9:00 p.m., 10/24 at 9:00 a.m. & 1:00 p.m. and is blank at 5:00 p.m. & 9:00 p.m., 10/25 at 9:00 a.m. & 1:00 p.m. and is blank at 5:00 p.m. & 9:00 p.m., 10/26 at 9:00 a.m., 1:00 p.m., 5:00 p.m. & 9:00 p.m., 10/27 at 9:00 a.m., blank at 1:00 p.m., 5:00 p.m. & 9:00 p.m. 10/28 at 9:00 a.m., 1:00 p.m., 5:00 p.m., & 9:00 p.m., 10/29 at 9:00 a.m., 1:00 p.m., 5:00 p.m. & refused at 9:00 p.m., 10/30 at 9:00 a.m., 1:00 p.m., 5:00 p.m., & 9:00 p.m., and 10/31 at 9:00 a.m., 1:00 p.m., 5:00 p.m., & 9:00 p.m. R23 received Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg on 10/21 at 5:00 p.m. & 9:00 p.m. R23 missed 42 doses of Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg during October 2023. Surveyor reviewed R23's bowel report from 10/19/23 to 10/31/23 and noted R23 had loose/diarrhea on 10/21 two times, 10/24 two times, 10/25, 10/27, 10/28, & 10/29. The eMar note dated 11/1/23 at 21:00 (9:00 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. Pharmacy aware. The eMar note dated 11/2/23 at 09:13 (9:13 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unavailable. The eMar note dated 11/2/23 at 12:52 (12:52 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unavailable. The eMar note dated 11/2/23 at 17:02 (5:02 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unavailable. The eMar note dated 11/2/23 at 20:28 (8:28 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unavailable. The eMar note dated 11/3/23 at 09:01 (9:01 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. ordered. The eMar note dated 11/3/23 at 14:18 (2:18 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. order updated. The eMar note dated 11/4/23 at 20:27 (8:27 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. med unavailable. The eMar note dated 11/5/23 at 12:39 (12:39 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. Medication unavailable. The eMar note dated 11/6/23 at 13:26 (1:26 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. Pharmacy aware. The eMar note dated 11/16/23 at 20:26 (8:26 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. Unavailable. Contacted pharmacy, new script needed from NP (Nurse Practitioner). The eMar note dated 11/17/23 at 12:43 (12:43 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. on order. The eMar note dated 11/18/23 at 19:27 (7:27 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. med not on cart. The eMar note dated 11/20/23 at 18:18 (6:18 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unable to give on order. The eMar note dated 11/20/23 at 21:51 (9:51 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. unable to give on order. The eMar note dated 11/21/23 at 13:21 (1:21 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. pharmacy aware. The eMar note dated 11/21/23 at 21:16 (9:16 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. pharmacy aware. The eMar note dated 11/22/23 at 09:43 (9:43 a.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. pharmacy aware. The eMar note dated 11/22/23 at 14:11 (2:11 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. pharmacy aware. The eMar note dated 11/23/23 at 18:09 (6:09 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. not available. The eMar note dated 11/23/23 at 20:06 (8:06 p.m.) Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg Give 2 tablet by mouth four times a day for diarrhea. medication not available. Surveyor reviewed R23's November 2023 MAR and noted on the follow up codes a check mark indicates the medication was administered. According to the November 2023 MAR R23 did not receive Diphenoxylate-Atropine Oral Tablet 2.5-0.025 on 11/1, 11/2, 11/3, 11/4 at 9:00 a.m., 1:00 p.m., 5:00 p.m., & 9:00 p.m., 11/3 at 9:00 a.m. 11/5 at 9:00 a.m., 11/6 at 9:00 a.m., 1:00 p.m., 5:00 p.m., & 9:00 p.m., 11/10 at 9:00 p.m., 11/16 at 9:00 p.m., 11/17 at 1:00 p.m., 11/20 at 5:00 p.m. & 9:00 p.m., 11/21 at 1:00 p.m., 5:00 p.m., & 9:00 p.m., 11/22 & 11/23 at 9:00 a.m., 1:00 p.m., 5:00 p.m. & 9:00 p.m. R23 missed 38 doses of Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg during November 2023. Surveyor reviewed R23's bowel report from 11/1/23 to 11/24/23 and noted R23 had loose/diarrhea on 11/1, 11/3, 11/4, 11/5, 11/11, 11/13, 11/16, 11/17, 11/18, 11/19, 11/20, & 11/21. On 3/6/24 at 11:43 a.m. Surveyor asked LPN-QQ when a Resident is admitted to the Facility how are their medications ordered. LPN-QQ informed Surveyor they do the orders, put the orders into the computer, and at this facility we don't have to confirm the orders with the doctor we confirm the order ourselves. Surveyor then asked LPN-QQ how Resident's medication are reordered. LPN-QQ informed Surveyor the medication is automatically reordered explaining they started a cycle fill for the last two months. Surveyor asked before the cycle fill how was medication being reordered. LPN-QQ informed Surveyor you had to click on each individual medication to reorder. Surveyor asked LPN-QQ if there was a certain number of pills left before the medication was ordered. LPN-QQ informed Surveyor he didn't think there were any guidelines and it was up to the nurses discretion when medication was reordered. LPN-QQ informed Surveyor he would order a week before the medication was going to run out. On 3/6/24 at 11:53 a.m. Surveyor asked LPN-JJ when a Resident is admitted to the Facility how are their medications ordered. LPN-JJ informed Surveyor when a Resident comes in from the hospital the hospital gives a print out of the medications, we put the medications into the computer, check with the doctor, and call pharmacy to let them know there is a new patient. Surveyor asked LPN-JJ how Resident's medication are reordered. LPN-JJ informed Surveyor you click on the medication in the computer or put the sticker from the card and fax it to the pharmacy. Surveyor asked LPN-JJ if there is a certain number of pills left before the medication needs to be reordered. LPN-JJ informed Surveyor she goes by 7 pills left. At 11:57 a.m. ADON/RN (Assistant Director of Nursing/Registered Nurse)-C who was also in the nurses station informed Surveyor now the medication is being reordered on a cycle fill. On 3/7/24 at 7:43 a.m. Surveyor asked LPN-MM if a medication is not in the medication cart what does she do. LPN-MM informed Surveyor she will try to see if the medication is in the medication room and if its not in the medication room she will reorder the medication. LPN-MM informed Surveyor if it's a cardiac or seizure medication she will try to see if she can speak with upper management to get the medication right away. On 3/7/24 at 10:27 a.m. Surveyor met with DON (Director of Nursing)-B to discuss R23. Surveyor informed DON-B R23 had a diagnosis of Crohn's disease and had an order for Diphenoxylate-Atropine Oral Tablet 2.5-0.025 mg. Surveyor informed DON-B R23 did not receive this medication multiple times and inquired when should the medication be ordered. DON-B informed Surveyor when there are 7 pills left. Surveyor inquired if this medication is in contingency. DON-B informed Surveyor she will have to look at the log and get back to Surveyor. DON-B did not inform Surveyor whether this medication was available in contingency.

Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 (R1 and R4) of 18 residents reviewed for accidents. R1, who is severely cognitively impaired, was assessed to be at risk for wandering/elopement upon admission to the facility. The facility implemented the use of a wander guard and R1 was placed on a secure unit on the second floor upon admission. R1 eloped from the facility on 9/30/20. R1 again eloped from the facility on 10/29/2023 around 3:28 AM. R1 was found outside the facility around 4:26 AM. When the door alarm sounded, staff did not immediately search the stairwell, even though it led to a area with an unsecured/unalarmed door to the outside. The facility did not thoroughly investigate the incident to identify a root cause or implement interventions to prevent another elopement. The Facility failure to ensure R1 received adequate supervision to prevent an elopement created a finding of immediate jeopardy that began on 10/29/23. On 1/4/24, at 1:21 PM, NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, and Regional Director of Clinical Operations-C were notified of the immediate jeopardy. The immediate jeopardy was removed on 11/15/23. However, the deficient practice continues at a scope/severity of D (potential for harm/isolated) for R4 of 4 as the Facility continues to implement its action plan and as evidenced by; R4 experienced a fall on 11/2/23 and the facility did not conduct a thorough investigation to identify an accurate root cause and fall interventions (dycem) were not observed for 3 days of survey. Findings include: The facility's Policy and Procedure entitled; Wandering and Elopement Guideline, dated March 16, 2017, documents, Facility Procedures: Door security codes will be shared with staff members only. Security codes will not be shared with resident representatives or residents. It is the responsibility of staff to enter security codes to support with exiting the facility and/or units as indicated. Door Alarms: It is the Facility process to immediately investigate any activation of a door alarm. o When a door alarm is activated, the staff will immediately proceed to the door and investigate the cause. o If the cause cannot be determined, the staff member will exit through the door and search the surrounding area. (Emphasis added.) o If the search reveals no cause for the alarm, and immediate count of all residents will be conducted by the licensed staff. o Process: Bracelets will be checked for placement and functioning every shift look at policy. o Any suspected or confirmed malfunctioning of any door alarm will have an immediate 1:1 supervision of the exit until repairs can be made or alternate alarm accommodations can be applied. The facility's Elopement Evaluation Checklist policy and procedure, dated 03/14/2017, states: Purpose: The purpose of this process is to confirm the facts of the occurrence, to preserve the event accurately and completed, to identify opportunities and to have a standardized process for root cause analysis, communication, and plan for correction. Instructions: Immediately after the event, utilize the checklist to gather all the pertinent information related to the occurrence. The checklist will help guide you through the appropriate questions to evaluate the event. Once the checklist has been thoroughly completed, the Director of Nursing will assess and evaluate the findings determined what further actions to implement. In the event the Director of Nursing is not available, the designee will be able to utilize the checklist to obtain the standard relevant information. Interpreting the checklist information: 1. Understanding where the resident was found allows you to evaluate if the resident was in the correct location and determine if acceptable supervision was in place. 2. Evaluating the time, the resident was last seen will assist to determine if identification and monitoring were in place. 3. The evaluation of items that are related to the resident allows you to evaluate that the process for identifying an elopement or missing resident was in place, that it was executed, and addressed appropriately. Other aspects allow you to evaluate if your systems and process were in place. 4. Evaluating the competency of staff is important when identifying opportunities. Verify that they followed the correct steps prior to identifying that a resident was missing and that they responded appropriately thereafter. 5. The questions in the checklist will cue you to gather the facts of the event and all post occurrence action. 6. The communication to other health care providers and the resident's family or representative is a critical aspect of event management. Documentation of the time, content of communication and names of individuals involved in each communication should be included in the incident documentation. Additionally, the use of the checklist should provide you with they key facts that may be needed when engaging in such communications. 7. Factual, accurate, complete, and contemporaneous documentation of events, observations, and communications provides a clear picture of the even and support the identification of additional or alternative interventions, care and/or support to minimize the potential for a subsequent event or to minimize the potential for injury. The surveyor reviewed R1's medical record 12/28/2023-01/04/2024. R1 was admitted to the facility on [DATE]. R1's diagnoses include but are not limited to: Major Depressive Disorder, Anxiety Disorder, Cognitive Communication Deficit, Altered Mental Status, Chronic Obstructive Pulmonary Disease, Unspecified Severe Protein-Calorie Malnutrition, Chronic Kidney Disease stage 2, (Mild), Peripheral Vascular Disease. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 4 indicating R1 has severely impaired cognition. No Patient Health Questionnaire (PHQ-9) assessment completed; exhibits behavioral symptoms that are not directed towards others, such as pacing, 1-3 days over the last 7 days; wandering 1-3 days over the last 7 days; no documentation if the wandering behavior places the resident at significant risk of getting into a potentially dangerous place or if it intrudes on others privacy or activities; there is no documentation if the wandering behavior has remained the same, worse or improved since the last assessment. R1's MDS also indicates R1 requires 1-person physical assist for transfers, dressing, eating, toileting, personal hygiene; for mobility: requires supervision or touching assistance. R1 is independent with walking 150 feet in a corridor or similar space. R1's care plan dated 2/07/2019 documents: The resident is an elopement risk/wanderer r/t (related to) dementia/confusion. Interventions include: -Secure unit, date initiated: 2/07/2019; -Frequent monitoring, date initiated, 2/07/2019; -Photo on wander list, date initiated: 2/07/2019; -Wander Alert personal safety device: left ankle, date initiated: 2/07/2019; -Staff to be aware of [R1's] wander risk, date initiated: 5/07/2019. The facility completed a Wander/Elopement Risk-Observation/assessment upon admission on 02/04/2019 and identified R1 as being at risk to wander/elope with a score of 9. (A total score of equal to or greater than 6 is at risk.) R1's assessment documents R1 is physically able to leave the building on their own, is independently mobile, is ambulatory, and has a history of elopement/wandering off, getting lost. -R1's Wander/Elopement Risk Observation dated as completed on 7/10/2021, documents as score of 20. The assessment documents R1 has a history of wandering/elopement and has not made any recent attempts, however, will remain on the list through the next review date; Resident Representative reported yes, the resident has a history of attempts to wander/elope; resident exhibits behaviors of a perceived need to do something (i.e. go to work, get home, fix supper, do the chores) and exhibits signs of early evening confusion (sun downing); has a history of elopement/wandering off, getting lost, etc. and is at risk to wander/elope. -R1's Wander/Elopement Risk Observation dated as completed on 11/5/2021, documents a score of 8. The assessment documents Resident Representative reported the resident has a history of attempts to wander/elope; the resident doesn't have a history of elopement/wandering off, getting lost, etc.; is at risk to wander/elope. -R1's Wander/Elopement Risk Observation dated as completed on 8/6/2022, documents as score of 9 (at risk). The assessment documented R1 paces; Resident Representative reported no history of attempts to wander/elope; has a history of elopement/wandering off, getting lost, is at risk to wander/elope and R1is still an elopement risk/wanderer r/t cognitive deficit/confusion 9/30/2020, [R1's name] attempted to elope, he wanted to go home, left unit onto patio. Surveyor notes the facility did not assess R1's risk for wandering/elopement quarterly per their policy and procedure. The wander/elopement risk assessments that were completed documented conflicting information related to R1's history of wandering/elopement attempts however, all assessments identified R1 remained at risk for wandering/elopement. R1's care plan was revised on 7/10/21, which documented: 9/30/2020-[R1] attempted to elope, he wanted to go home, left unit onto patio. Interventions were revised to include: -Distract [R1] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. [R1] prefers: playing cards, date initiated: 9/30/2020. Surveyor notes R1's electronic medical record (EMR) documents R1's assigned room at the time of the 9/30/2020 elopement remained on the second floor of the facility on a secured unit. On 12/28/2023, at 10:47 AM, Surveyor observed R1 in dining room sitting at table with wander guard alert device on right wrist. Surveyor notes R1's care plan documents R1's wander guard is located on the left ankle. On 01/03/2024, at 9:34 AM, R1 is observed in the 500-unit dining room sleeping in a chair. Surveyor observed a wander guard on R1's right wrist. Surveyor reviewed the facility self-report submitted to the State Agency on 11/03/2023. The facility 24-hour report indicated Resident (R1) eloped on 10/29/23. R1 walked out the back patio doors and went through the back gate. The nurse found the resident in the front parking lot. The resident was assessed and okay. Admin (Administrator), DON (Director of Nursing), MD (Medical Doctor), and POA (Power of Attorney) were notified. The resident was placed on a 1:1 immediately. The completed facility self-report indicated R1 exited the building on 10/29/23. R1 had been a resident at the facility since 2/4/2019, had a BIMS of 4 and has and activated Health Care Power of Attorney. R1 had no history of exit seeking in the past that the facility was aware of. After reviewing the camera footage, on 10/29/2023 Resident set off the alarm system on the 500 unit that led him to the fire stairwell and outside at 0247 (2:47 AM) to the backyard of the building. The Certified Nursing Assistant (C.N.A.) was seen coming out of a resident's room about 15 seconds after the alarm sounded. The C.N.A. went to the door to turn off the alarm system. Two other staff members also reported to the sounding alarm system. They cleared the alarm, and they started looking in the rooms for a head count and noted [R1] was not in his room. The staff called other staff members to start looking for the resident and nurse called code. Half went outside and the other staff stayed in the building looking for resident. The charge nurse called 911, DON (Director of Nursing) and POA (Power of Attorney). The DON called Administrator. The resident was seen on the camera footage walking out the backyard doors and was wandering the walkway, then headed for the gate. The resident was seen wandering the parking lot of the building. There after the resident was not seen in any camera footage for a while until he was found. The staff found the resident about a block away walking on the sidewalk and returned into building at 3:42 a.m.The resident was placed on 1:1 until the alarm systems were checked and working properly and until we could figure out why the resident decided to exit the building to see if there are any other interventions that are needed for the residents (sic) safety. When asking the resident what he was doing, the resident stated that he wanted to go smoke. The resident hasn't smoked in years. The DON then called the POA to see if they had any idea why the resident would have wanted to leave the building. POA stated that they were visiting Saturday 10/28/23 and took the resident outside in the backyard and the resident was focused on the apartment buildings next door and tried to walk towards them. They were able to redirect the resident, but he kept heading in that direction when they were outside. The POA then brought the resident back into the building. The resident had a wander guard on and was working correctly. The alarm system worked correctly. The resident was wearing his jacket, jeans, and shoes. The temperature was around 43 degrees during the time the res was outside. No residents were interviewed due to the camera footage, there was no other resident seen during this time. Interviews with staff were conducted. Maintenance completed wander guard, alarm system checks, and they are working properly. Care plan was reviewed and there are no changes to the residents (sic) care plan. Wander guard will remain on the resident. Note: There are discrepancies in the times noted in the self-report as compared to times entered in the medical record and in the police logs. On 1/3/24, at 11:29 AM, Surveyor interviewed Maintenance Director-GG and asked if he could show Surveyor the path R1 used to leave the building. Maintenance Director-GG took Surveyor to the 500 wing on the second floor. Maintenance Director-GG informed Surveyor R1 left the unit through a stairwell exit door directly to the right of R1's room. Maintenance Director-GG stated the stairwell exit door is an emergency exit with an alarm that can be bypassed if a code is entered on the keypad prior to opening the door and if the code isn't entered an alarm will sound immediately. Maintenance Director-GG demonstrated the door alarm sound if the bypass code isn't entered. Maintenance Director-GG stated the exit door is not equipped with a wander guard system. Maintenance Director-GG then showed Surveyor R1 had to walk along the stairway landing to make it to the stairs, there are 16 concrete stairs to the lower level. R1 walked down the stairs then proceed straight out the smokers' door to the outdoor patio. Surveyor observed a keypad next to the smoking door. Maintenance Director-GG stated a code is not needed to open the outside door as the keypad/alarm does not work. Surveyor asked if the door has a wander guard system on the door. Maintenance Director-GG stated the door does not have a wander guard system only the door leading from the 1st floor unit (200 wing) to the stairwell area leading to the smoking door has a wander guard system. Surveyor noted the smoking door was slightly ajar and not latched closed. Maintenance Director-GG showed Surveyor how R1 walked across the cement patio, to a cement sidewalk that led to an uneven black top path around the side of the building, through a gate that cannot be locked (Per Maintenance Director-GG due to a prior Life Safety survey) and then out into a side parking lot. Surveyor notes had the staff that responded to the door alarm 15 seconds after it sounded, per the facility self-report documented, and gone out the door to see if anyone was visible, they would have observed R1 walking down the stairs or exiting the smokers' door. Surveyor notes the facility self-report does not document if R1's family had used the alarmed emergency exit door and stairs to go out to the patio for their visit before the elopement or if this was an exit door used frequently by staff, residents, or visitors. On 10/29/2023, at 04:45 AM, R1's medical record documents in the progress notes, Resident came up missing during bed checks at around 0345 (3:45 AM) after another resident was seen at the exit door on the 500 hallway and sounded the alarm. The patient seemed to have slipped past the door while the alarm was still sounding. Resident exited through the smoker's door and got outside through the open gate. Resident was found by the 600-hallway nurse. 600 hallway nurses got in his car and drove around and finally found the resident walking down the street after exiting the facility. Patient had no apparent injuries all his vitals were stable. Nurse manager was called and went straight to vm (voicemail), vm was left and no call was returned at this time. A phone call was made to the 1st contact (sister) she was also notified of his return to the facility. Patient is being kept in nurses' station to be kept an eye on. On 1/3/24, at 1:19 PM, Surveyor received a return call from CNA-HH who stated she worked the unit the night of the incident but doesn't remember a lot. CNA-HH stated she remembered the door alarms going off a lot that night with a lot of behaviors that night from other people pushing the doors. The last time CNA-HH checked on R1 was at beginning the shift at 11:00 P.M. and R1 was in bed. CNA-HH stated, we did not notice R1 was gone until we did bed checks around 3:45 A.M. I checked the first room, and the resident (R1) wasn't there. CNA-HH stated once they noticed R1 was gone they told the whole building, but no one could find him, a nurse looked in the neighborhood and a nurse called the police. On 1/4/24, at 10:53 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who provided Surveyor with a tour of the path R1 took when exiting the building. NHA-A stated R1 left the unit by the exit door to the right of R1's room. NHA-A confirmed the exit door has an alarm that will sound if the code isn't entered on the keypad prior to opening the door. NHA-A confirmed the exit door does not have a wander guard system on the door. NHA-A then showed Surveyor how R1 walked down the 16 cement steps to the first floor. NHA-A confirmed the smoking door does not have a functioning alarm system or a wander guard system in place at this time. NHA-A stated the door can be open with a touch to the handicap button. Surveyor observed the door appeared to be slightly ajar and not closed all the way and latched. NHA-A stated the door does have an alarm system however it is not on due to it making too much noise every time someone went out to smoke, so it is not programmed. NHA-A confirmed R1 walked along the patio, to the cement path, to an uneven blacktop path and out the gate to a parking lot. NHA-A stated the video footage of R1 then cuts out from anywhere from 5 seconds to 5 minutes and R1 is then seen walking towards the front of the facility in the parking lot and then it isn't clear where R1 goes. NHA-A stated the facility is looking into better lighting in the parking lot as well. NHA-A stated the video then picks up again with the staff returning R1 to the facility in their car. Surveyor asked where staff found R1. NHA-A stated she wasn't sure, but the video footage shows the staff car returning to the facility from the east, so she believes R1 walked east of the facility. Surveyor asked NHA-A what time R1 left the building and when R1 was returned since the facility investigation and the staff statements and nursing documentation do not document the same time. NHA-A stated today she realized the time stamp on the video footage had to have been off by 1 hour and that is why there are different times documented for the incident. NHA-A confirmed the video footage of R1's elopement did not include audio. Surveyor asked NHA-A if she received statements from the CNA's assigned to the 500 unit the night of the elopement. NHA-A stated she tried to but did not receive calls back. Surveyor asked if NHA-A received a statement from the staff that found R1 and NHA-A stated she did not. NHA-A stated the police did not respond to the facility when staff called 911 to report R1 was missing. NHA-A stated they did not receive a copy of a police report but could call the police to provide evidence of the facility's contact with the police. Surveyor reviewed AccuWeather (weather radar forecast), the weather on 10/29/2023 between 2:47 AM to 3:50 AM, documents the high was 41 degrees and the low was 39 degrees. Surveyor reviewed Detailed History for Police Call report dated 1/4/2024, provided by NHA-A which documents: -At 03:42:22, [address of the facility] had a missing person report. -At 03:48:32, Clarify: The person has been missing for about 20 minutes. The name of the facility was provided as well as the name, age and description of the resident as well as documenting the resident was wearing a BLK (black) shirt, BLU (Blue) pajama pants. -At 04:26:37, (Another call was placed to the police from the facility.) CLLR (Caller) said he drove around and found missing [R1], no longer in need of a SQD (squad). Using the documentation on the police logs, R1 was identified as being missing around 3:28 AM and was found outside at 4:26 AM. Surveyor notes R1 was assessed to be at risk to wander upon admission to the facility and throughout R1's stay at the facility. The facility implemented an elopement/wander risk care plan. Interventions included placement on the secure unit, use of the wander guard, frequent monitoring, photo in the wander list and for staff to be aware of R1's risk to wander. R1's care plan was revised on 9/30/2020 to indicate R1wanted to go home and was found off the secure unit and outside on the facility patio. Surveyor notes prior to R1's elopement on 10/29/23, R1 had eloped from the facility on 9/30/20. This indicates the facility had knowledge of R1's prior elopement from the building which conflicts with the facility investigation documentation which indicates R1 had no history of exit seeking in the past. Surveyor also notes the facility self-report documents R1 was found to have eloped at 0247 (2:47 AM) when facility staff responded to a sounding door alarm and noted R1 was missing however, and the nurse assigned to R1 documented R1came up missing at 0345 (3:45 AM) during bed checks after another resident was seen at the exit door on the 500 hallway and sounded the alarm. R1 seemed to have slipped past the door while the alarm was sounding. The facility self-report documents R1 was found walking about a block away on the sidewalk and returned to the building at 3:42 AM however, the nurse assigned to care for R1 documented on 10/29/23, at 04:45 AM, R1 was found by a nurse from another unit who went out driving around and finally found the resident walking down the street. The facility investigation does not include a statement from the staff that found R1outside and where exactly R1 was located. The facility investigation documents R1 was found wearing a coat, jeans, and shoes, however the investigation does not document the last time R1 was observed by facility staff in the building, if R1 was wearing at coat and shoes at that time, or if it was typical behavior for R1 to be up at this time of the night and fully dressed. (Report to police indicated R1 was wearing a black shirt and blue pajama bottoms.) Surveyor notes the facility investigation does not include statements from the Certified Nursing Assistance (CNA)s assigned to care for R1 the night of the elopement. Surveyor notes the facility did not complete a thorough investigation of R1's elopement on 10/29/23 to identify how R1 was able to exit a secure unit and the facility for almost an hour in the middle of the night, nor identify person centered interventions to prevent future elopements. Surveyor also notes R1's care plan was revised on 10/31/23, after R1's elopement from the facility on 10/29/23 and documented a new intervention of: Maintenance completed wander guard system checks. Educated staff on elopement process. Date Initiated 10/31/20203; Maintenance completed wander guard alarm system checks. Educated staff on elopement process. Surveyor notes R1 exited a unit through a door not equipped with a wander guard alert system and exited the building through a door not equipped with a wander guard alert system. On 01/04/2024 at 10:55 A.M. Surveyor discussed with NHA-A, DON-B and RDCO-C of the concern R1 was assessed to be at risk to wander/elope, was placed on a secure unit on the second floor of the building, had a prior elopement to the back patio, eloped again on 10/29/23 and was outside for close to an hour and was found at an unknown location. Surveyor also expressed concern for discrepancies in the timeline and details of events between the staff statements, nursing progress notes and facility investigation. Surveyor also expressed concern a thorough investigation was not completed to identify the root cause of R1's elopement allowing staff to identify person centered interventions to prevent a future elopement. The immediate jeopardy was removed on 11/15/24 when the Facility completed the following: Staff education conducted on the reviewed and updated elopement policy and procedure. Other residents at risk to wander/elope were identified. Door alarms and wander guard system were checked. Facility obtained a quote for the egress doors and wander guard for three doors. Also, a quote for additional cameras and lighting was obtained. Other residents at risk for elopement and wandering were reviewed/assessed by completing wandering and elopement assessment, care plans updated, wander guards checked for location on resident and functionality. Wandering and elopement policy and procedure reviewed and updated. Review of elopement binder to ensure is up to date. Reviewed elopement drill logs. The secured unit door will be monitored until a new system is implemented, so residents at risk for elopement remain safe. Audit of residents at risk for wandering/elopement to ensure that policy and procedures were followed and results brought to QAPI for any further recommendations. DON and /or designee will conduct drills 2/week on all 3 shifts for 8 weeks to ensure all required components are in place. Results of the audit will be reviewed by QAPI meeting for further recommendations. 46214 R4 experienced a fall on 11/2/23 and the facility did not conduct a thorough investigation to identify an accurate root cause and fall interventions (dycem) were not observed for 3 days of survey. The facility policy, entitled Falls Investigation Guideline, dated 12.20.2022, states: Purpose It is the practice of this facility to evaluate a resident following every fall. #2 Following a fall or when a resident is found on the ground without a witness to the fall, a nurse should not position, record vital signs, perform ROM on all extremities to evaluate for upper or lower extremity injuries, and evaluate the patient for possible injuries to the head, neck, spine or hips. #7 Notify the interdisciplinary team and perform team huddle to discuss fall and possible causal factors to identify the root cause analysis to support determination of the intervention with modifying the plan of care. #10 Obtain witness summaries from all involved. Include interviews with direct caregivers to learn more regarding . R4 was admitted to the facility on [DATE] with diagnoses that include atrioventricular block, acute and chronic respiratory failure, biliary acute pancreatitis without necrosis or infection, end stage renal disease, type 2 diabetes, acute cholecystitis, heart failure, vascular dialysis, major depression, anxiety and Bell's palsy. R4 Annual Minimum Data Set, dated dated dated [DATE] documents that R4 has a Brief Interview of Mental Status (BIMS) of 15 indicating R4 is cognitively intact. R4 is assessed to have functional limitations in range of motion of both upper and lower extremities on both sides and is dependent on staff for transfers with Hoyer lift. R4 is assessed to use O2 therapy. R4's care plan document R4 is high risk for falls due to edema and muscle weakness. Interventions include to lock brakes when sitting in wheelchair, nonskid socks/footwear and anticipate and meet the resident needs, date 11/25/21. It also documents the resident had an actual fall with (specify: no injury, minor injury, serious injury) date initiated 11/20/23. Interventions include Dycem to wheelchair, educated staff to offer to lay down after supper, date initiated 11/3/23. Surveyor notes that the care plan is generic and does not specify the date and type of fall. On 12/28/23, at 09:44 AM, Surveyor spoke with R4. R4 pointed to the wheelchair that R4 uses. Surveyor was unable to locate the dycem in the wheelchair. At 12:06 PM Surveyor observed R4 up in the wheelchair sitting in the dining room. On 1/2/24, at 09:11 AM, R4 informed Surveyor that they experienced a fall back in November after CNA-Q brought R4 back to their room because R4 wanted to be transferred back to bed after dinner. R4 stated that CNA-Q brought R4 to the bedroom and then left R4 in their wheelchair because CNA-Q received a personal phone call. R4 explained that it was while CNA-Q was gone that R4 slipped out of their wheelchair and was found sometime later by staff. R4 stated that they were very upset by this incident and didn't want to have CNA-Q work with them anymore. R4 stated that they told the scheduler about this. R4 stated that the scheduler told them that CNA-Q wouldn't work with them anymore. This CNA still currently works with the resident and makes R4 uncomfortable. R4 stated that they told family members about this incident and that the family members have also reached out to the facility Director of Nursing about the fall on 11/2/23 and CNA-Q. R4 explained that no one has gotten back to them. Surveyor looked at R4's wheelchair and was unable to locate a dycem. On 1/2/24, at 1:29 PM, R4 was sitting in the dining room in the wheelchair. Surveyor then spoke with CNA-W at 1:34 PM, who stated that she did assist getting R4 into the wheelchair today and was not aware if R4 uses a dycem in the wheelchair. Surveyor reviewed the facility grievance log for November 2023. There is one grievance dated 11/9/23 which has care concerns, but nothing related to a fall. The date of 11/9/23 was found to be a transcription error and the actual date of the grievance is 11/1/23 which is prior to the alleged fall on 11/2/23. Surveyor review R4's progress notes. On 11/2/23 at 20:05 Licensed Practical Nurse (LPN) documents, witnessed fall. Resident slid out of wheelchair after asking CNA to put them to bed. Alert and oriented. Vital sign stable. Range of motion at baseline. No injuries. Denies pain. ADON and physician notified. Surveyor requested the fall investigation for the fall on 11/2/23. The facility provided a fall investigation for a fall on 11/2/23 at 20:34. This fall documents the fall as unwitnessed in the resident room where R4 was found lying on the floor next to bed. Resident states they slid out of wheelchair. Vital taken and assessed for injuries. No injuries noted and resident removed off the floor via Hoyer lift and placed in bed. No witnesses found. POA and Physician notified. Summary of fall states that resident slid out of wheelchair. Intervention includes assessed resident, placed in bed, educated staff to offer resident to go to bed after supper. Included in the investigation packet is one Certified Nursing Assistant (CNA) statement from CNA-V who was walking past the room and observed R4 on the floor. In her statement another resident informed her that R4 was on the floor. She looked in the room and saw R4 on the floor. She then went to get the [TRUNCATED]

Based on observations, record review and staff interviews, the facility did not ensure they provided care and treatment, based on a comprehensive assessment and professional standards of practice, to 2 (R2 and R6) out of 18 residents who experienced changes in their condition and needed further evaluation. R2 began to experience symptoms of a cold with productive cough, secretions and wheezing. R2 began to have swallowing difficulties as a result and refused medications on 3 medication passes. The facility did not notify the Physician and did not provide further assessment of R2 until 4 days later when R2 requested to be sent to the hospital after having trouble breathing. R2 was diagnosed with Pneumonia. R6 tested positive for COVID-19 on 11/14/23. There was no monitoring of vital signs or lung assessments on subsequent days. On 11/20/23, R6's family transferred R6 to the hospital. There is no documentation in the record of this transfer. Findings include: According to N6.03(1), Wisconsin Nurse Practice Act, a registered nurse (RN) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. 1.) R2 was admitted to the facility on [DATE] and has diagnoses that included femur fracture (receiving therapy services), end stage renal disease, dependence on renal dialysis, congestive heart failure, chronic obstructive pulmonary disease and anemia. The admission MDS (minimum data set) dated 10/9/23 indicates R2 has a BIMs (brief interview for mental status) score of 15, indicating intact cognition. R2 is assessed to not have any behaviors, including rejection of cares. R2 is noted to not have any swallowing disorders. R2 receives dialysis treatments and is up-to date with immunizations including the Pneumococcal Vaccine. A review of the most current plan of care for R2 indicates that R2 has altered respiratory status/ difficulty breathing due to weakness and decreased stamina. This plan of care was initiated on 10/3/2023. Interventions include to monitor for signs/ symptoms of respiratory distress and report to MD as needed. Increased respirations; decreased pulse oximetry; increased heart rate; restlessness; diaphoresis; headaches; lethargy; confusion; hemoptysis (coughing up blood); cough; pleuritic pain (chest pain that worsens during breathing); accessory muscle usage; skin color changes to blue/ grey. Surveyor conducted a review of the nursing notes for R2 located in the EMR (electronic medical record). Nursing note dated 10/27/23 at 5:15 a.m.; (R2) complains of cold symptoms with productive cough, thick white secretions. Lungs are coarse with expiratory wheezing. Surveyor reviewed the vitals summary, located in the EMR for 10/27/23. It was noted that there was no data recorded for R2 for respiration, pulse, temperature, blood pressure or O2 (oxygen) stats. Surveyor also reviewed the MAR (medication administration record) for October 2023 and noted there was no documented vitals taken for R2 on 10/27/23. Contrary to the Wisconsin Nurse Practice Act, there was no systemic and continual collection and analysis of data by an RN concerning the condition of R2 on this date. Further review of the nursing notes did not indicate that R2's primary Physician or Nurse Practitioner was notified/consulted with regarding R2's change of condition. Nursing note dated 10/28/23 at 9:47 a.m., (R2) has refused all medications, states he can't swallow. There was no documentation that R2's primary Physician was notified of the refusal of medications and that R2 was having swallowing difficulty. Nursing note dated 10/28/23 at 7:53 p.m., (R2) has refused all medications. There was no documentation that R2's primary Physician or Nurse Practitioner was notified/consulted with the refusal of medications. Nursing note dated 10/29/23 at 9:53 p.m., (R2) has refused all medications. There was no documentation that R2's primary Physician or Nurse Practitioner was notified/consulted with the refusal of medications. Surveyor reviewed the vitals summary, located in the EMR for 10/28/23 and 10/29/23. It was noted that there was no data recorded for R2 for respiration, pulse, temperature, blood pressure or O2 stats. Contrary to the Wisconsin Nurse Practice Act, there was no systemic and continual collection and analysis of data by an RN concerning the condition of R2 on these dates. Nursing note dated 10/31/23 at 5:13 a.m., (R2) states he is having trouble breathing, O2 stats down to 84%. Lungs coarse throughout with wheeze, congested cough present. See Vital Signs. O2 2liters applied. R2 wants to be sent to the hospital, very anxious. Nursing note dated 10/31/23 at 5:47 a.m., (R2's) family and Physician informed of R2's transfer via ambulance to (name of) Hospital. Surveyor conducted a review of the hospital paperwork for R2's emergency room visit on 10/31/23. ED (emergency department) triage notes that per EMS (emergency medical services), (R2) coming from facility with complaints of shortness of breath this morning. Staff reports (R2) was found on 84 % room air with labored breathing, audible wheezing. Placed on 2 liters of oxygen and given duoneb. The HPI (history of present illness) states that (R2) was presenting with shortness of breath, and this started yesterday with a productive cough. (R2) was discharged on [DATE], back to the facility, with diagnosis of Pneumonia and fluid overload. (R2) received new medication orders for antibiotics and steroid. On 1/3/24 at 2:30 p.m., Surveyor interviewed Director of Nursing (DON)- B and asked if there was any evidence that R2's physician was notified of his change of condition on 10/27/23 when he presented with complaints of cold symptoms, productive cough with thick white secretions and lung sounds coarse with expiratory wheezing. DON- B stated she would have to review the record and get back to Surveyor. Surveyor also asked if the physician had been notified on 10/28/23 that R2 was having swallowing difficulties and refused his medications twice that day and the medication refusal on 10/29/23. DON- B stated she would review this concern. Surveyor attempted to interview the nurse who wrote the nursing note for 10/27/23 regarding the change in R2's condition. This person is no longer employed with the facility and could not be contacted. Entries made about the medication refusals were written by agency staff and no further contact was made with these nursing personnel. On 1/4/24 at 8:35 a.m., DON- B stated to Surveyor that she believed the Nurse Practitioner was made aware of the concerns about R2 but did not document anything in the medical record. DON- B stated that an interview conducted with the Nurse Practitioner would be able to verify this. DON- B stated that the Physician should have been made aware of the medication refusals and could not provide additional information that the facility attempted to notify the Physician. Surveyor asked Regional Director of Clinical Operations-C, 3 separate times to speak with the Nurse Practitioner to verify she was made aware of R2's change of condition on 10/27/23. As of the time of exit on 1/8/24, Surveyor was unable to speak with the Nurse Practitioner and the facility was not able to provide any additional evidence that the Physician or Nurse Practitioner was made aware of R2's change of condition and medication refusals. R2 could have been diagnosed and treated for the Pneumonia earlier than 10/31/23 when he requested to be sent to the hospital for evaluation. On 1/17/24 the facility submitted additional information regarding R2 and the change of condition that started on 10/27/23 with R2 having a cough and eventually leading to difficulty swallowing, medication refusal and a diagnosis of pneumonia. The facility indicated in their summary of the information that both the attending physician (JJ) and nurse practitioner (KK) were aware of R2's change in condition. Review of submitted documents indicate R2's physician was only notified of the situation on 10/31/23 as the nurses note indicates the physician and family were notified of the transfer to the hospital. There is no indication Physician-JJ was consulted with as R2 developed a change in condition. Addition review of information by the facility indicates Nurse Practitioner-KK was involved in seeing/assessing R2 on 11/1/23 and 11/3/23, Surveyor notes this is after the change of condition that led to R2 being diagnosed with antibiotics and steroids for pneumonia. 46517 2.) R6 was admitted to the facility on [DATE] with diagnoses including acute cystitis with hematuria; generalized weakness and deconditioning; acute kidney injury and Lewy Body Dementia with mood disturbances. R6 discharged from the facility on 11/19/23. R6's Minimum Data Set assessment dated [DATE] documented R6 wished to discharge to the community and there was no active discharge planning at the time of the assessment. R6 did not have a discharge care plan. Surveyor noted in R6's Electronic Medical Record (EMR), R6 tested positive for Covid on 11/13/23. R6 had a care plan titled, tested Positive for Covid, dated 11/14/23, and had interventions including, Hand sanitizer before and after leaving the resident's room and let your nurse know if resident shows any signs of symptoms [sic]. Surveyor noted this care plan did not mention how often assessments or vital signs should be done. Surveyor noted the last recorded vital signs in R6's Electronic Medical Record (EMR) were on 11/15/23. These vital signs were within defined limits with no abnormal values. There were no other vital signs recorded in R6's EMR from 11/15/23 to 11/19/23, when R6 discharged from the facility. Contrary to the Wisconsin Nurse Practice Act, there was no systemic and continual collection and analysis of data by an RN concerning the condition of R6 after R6 tested positive for COVID. R6 was seen by the Nurse Practitioner on 11/14, 11/15, and 11/16/23 who noted that R6 was not in acute distress. No vital signs or lung assessments were documented as having been done. Surveyor noted on 11/19/23, on dayshift, a nurse documented, No vaginal bleeding this shift. Patient's family states (they) have a cough. Writer did not observe cough upon assessment. Pulse Oximetry within normal limits on room air. Surveyor did not locate a comprehensive assessment nor vital signs on this date. The next progress note in R6's EMR was on 11/20/23 night shift when a nurse documented, out of building. Surveyor reviewed R6's EMR and could not locate documentation related to the events surrounding R6 leaving the facility. There was no documentation as to what happened to R6 and there was no discharge summary. R6 did not return to the facility after 11/19/23. Surveyor attempted to interview the nurses who worked on am shift, pm shift and night shift on 11/19/23; however, those nurses no longer worked at the facility. On 12/28/23 at 10:48 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Regional Director of Clinical Operations (RDCO)-C. Surveyor asked for any information surrounding R6's discharge such as where R6 went to, why R6 left the facility and whether there was any discharge summary/planning. Surveyor received a hospital discharge summary for R6 with a date of service of 12/01/23. This hospital discharge summary documented R6 presented to the hospital for evaluation of lethargy and confusion; was diagnosed with Covid and a Urinary Tract Infection (UTI); was started on antibiotics; gabapentin was decreased, and encephalopathy has improved. The hospital also documented family is hoping to take R6 home. Surveyor did not receive any facility documentation regarding R6's transfer to the hospital. On 11/06/23 at 1:08 pm Surveyor interviewed Assistant Director of Nursing (ADON)-AA. ADON-AA remembered R6 and informed Surveyor R6 had Covid and so did R6's roommate. ADON-AA stated for some reason R6 had to go to the hospital, but ADON-AA could not remember why. ADON-AA informed Surveyor R6's family was not happy that R6 had Covid and once R6 was in the hospital R6 did not want to come back. ADON-AA informed Surveyor he was uncertain if R6 had a change in condition and he did not have documentation relating to R6's discharge. Per ADON-AA the nurses should assess a patient if there was a reported change in condition and a patient who is Covid positive should have vital signs taken twice a shift. ADON-AA stated the nursing assistants would alert the nurse if a resident had a change in condition. Per ADON-AA, the nurse should update the doctor if a family member wanted a resident to be sent out and that should be documented. Surveyor relayed the concern of a lack of documentation surrounding R6's discharge and a lack of vital signs/assessments form 11/15/23 to discharge on 11/19/23. Surveyor asked for any additional information. On 12/28/23 at 1:40 PM, Surveyor interviewed Director of Nursing (DON)-B and Regional Nurse (RN)-D. DON-B informed Surveyor R6 went the hospital with something related to Covid or respiratory. DON-B reviewed her change of shift report from the weekend R6 went to the hospital and informed Surveyor R6's family took R6 to the hospital. Surveyor asked DON-B if she knew why R6's family wanted to take R6 to the hospital. DON-B informed Surveyor R6 was in isolation for Covid until 11/24/23 and DON-B stated she did not remember R6 have any symptoms of Covid. Surveyor asked if the nursing staff should document when a family takes a resident to the hospital. DON-B stated yes the nurses should document if a family takes a resident out to the hospital. Surveyor relayed the concern of a lack of documentation surrounding the events leading up to R6 going to the hospital, a lack of a discharge summary and a lack of vital signs/assessments from 11/15/23 to 11/19/23. DON-B stated she would look into it. On 12/28/23 at 2:30 PM during the end of the day meeting with NHA-A, DON-B, RDCO-C and RN-D, Surveyor relayed the concern of a lack of documentation surrounding R6's discharge and a lack of vital signs/assessments from 11/15/23-11/19/23. Surveyor asked for any additional information. No additional information was provided prior to exit from the facility. On 1/17/24 the facility submitted additional information to review that included notes from Nurse Practitioner (NP)-KK regarding R2's covid diagnosis. The notes dated 11/14/23, 11/15/23 and 11/16/23 indicate R6 tested positive for covid on 11/13/23 and R6 was not started on anti-virals due to mild symptoms. NP-KK's notes indicate the facility was to provide cough medicine as needed and to monitor R6. The notes indicate R6 denies bowel or bladder concerns however, it is also noted ROS (review of systems) is limited due to level of dementia. There is no information provided by the facility to show what R6's status was assessed as being on 11/19/23 when R6 was transferred by the family to the hospital and admitted with covid and a urinary tract infection.

Based on interview, observation and record review, the facility did not ensure 1 (R15) of 5 residents reviewed for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing. R15 was admitted to the facility with a stage 3 pressure injury to their sacrum. Admission orders included to assess R15 using a Braden Scale to assess for risk for developing pressure injuries. This was indicated as completed on the treatment administration records but there was not consistent indication this was completed. The facility assessments of R15's pressure injury did not include all details to show actual percentages of the wound bed tissue to help monitor for improvement or deterioration. Additionally the measurements taken by RN-E were different from the measurements of Wound MD-K's measurements of the same areas. R15 was observed during the survey to be lying on a mattress that provided increased pressure to R15 as it was at a higher weight setting than what R15 weighed. R15's sacral wound deteriorated but there were no revisions to the interventions for R15. R15 also developed bilateral pressure injuries to the front of the ear. R15 initially developed an area to the left front ear that was not addressed in R15's plan of care to prevent deterioration or further development of pressure injuries. R15 then developed a pressure injury to the right front ear that was staged as a stage 2 pressure injury despite the assessment indicating the presence of slough. Findings include: Surveyor reviewed facility's Skin Management Guidelines with an effective date of 11/28/17. Documented was: Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identity and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers, to implement preventative measures, and to provide appropriate treatment modalities for wounds according to industry standards of care. Responsible Party. Nursing, Therapy, Dietary Guideline Procedure: I. Prevention of Pressure Ulcers - All residents admitted to the facility will be evaluated for actual and potential skin integrity issues. - The Admission Evaluation will be completed upon admission. - The skin and body check section should be completed within the first 2 hours. - The Pressure Injury Notice will be completed and provided for the resident and / or Resident Representative providing notice of predicting factors and baseline care plan interventions to support prevention, treatment and healing. A complete evaluation is essential for an effective skin prevention and treatment program. A comprehensive individual evaluation guides the: - Identification of residents at risk and factors predicting the risk for breakdown - Identification of the presence of skin impairment - Provides an ability for the facility to develop and implement a care plan that reflects each resident's identified needs - Identify interventions to stabilize, reduce or remove underlying risk factors - Evaluate the effectiveness of interventions - Modify the interventions as appropriate A standardized pressure ulcer risk evaluation, The Braden Scale should be: - Completed weekly for the first 4 weeks post admission - Quarterly - With a change in condition (i.e., pressure ulcer development, change in mobility, continence, status, nutrition, etc.). An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors. Interventions for prevention, removing and reducing predicting factors and treatment for skin may include: - Pressure redistribution surface for bed and seating surfaces: - Specified through clinical evaluation and determination - Adaptive equipment and seating to support and encourage correct anatomical alignment - Elevating heels: - For residents that cannot turn and reposition themselves - For residents that have diminished sensory perceptions of the lower extremities that may affect and independent ability to turn, reposition and off load pressure - Offloading devices may vary, may include pillows and should be selected based on resident comfort and positioning needs. - Incontinence management - Specified through clinical evaluation and determination - Therapy as indicated after screening and / or evaluation - Dietary referral and interventions as determined for hydration and nutritional support - Inspection of skin daily with cares and weekly by a licensed nurse - Other as determined through evaluation for individualized care needs - Medication review - Specified turning and repositioning - Positioning - Exercise program and /or active and passive range of motion - Skin care - Pressure, friction, shear reduction Example of Care planning for Pressure Ulcer Prevention with Treatment Intervention Guidelines or Skin Risk Evaluation Interventions in Protocols & Interventions section . II. Treatment of Pressure Ulcers and Lower Extremity Ulcers (arterial, venous, neuropathy/diabetic, or mixed) If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 1. Review the wound formulary for guidance 2. Consult with the Physician/NP and Resident Representative . 7. Initiate Braden Scale and Initiate Investigation process if new onset 8. Evaluate interventions per risk factors identified and re-evaluate and modify the plan of care based on root cause analysis for new skin alterations. For intervention tips, see Pressure Ulcer Prevention & Treatment Interventions Guidelines or Skin Risk Assessment Interventions Suggestions in Protocols & Interventions section 9. Update the Care Plan for Skin Integrity and nursing assistant care cards with skin concern, appropriate risk factors, turning intervals and interventions as appropriate. 10. Initiate the Wound Initial Documentation Observation in PCC which will include: type of wound, location, date, stage (pressure ulcers only) or indicate partial of full-thickness (arterial, venous, neuropathy/diabetic ulcers), length, width and depth; wound base description, wound edge description and if present: drainage, odor, undermining, tunneling, and/or pain. The Weekly Wound Documentation Observation in PCC should only have ONE WOUND per observation. See Weekly Wound Documentation Progress Sheet & Wound Documentation Guidelines for instructions. 11. When a pressure ulcer is present, daily wound monitoring should include: - An evaluation of the ulcer, if no drainage is present - An evaluation of the status of the dressing, if present - The status of the area surrounding the ulcer (that can be observed without removing the dressing) - The presence of the possible complications, such as signs of infections - Whether pain, if present, is being adequately controlled Document on any changes or concerns in the nurse's notes and re-evaluate prior steps 1-9 as appropriate. 12. Consult with a Physician/NP, Family and Supervisor/Designee if the ulcer(s) has not shown progress in two weeks 13. Consult with the Physician/NP if the wound is deteriorating or increases in size. Reevaluate plan of care as appropriate R15 was admitted to the facility on [DATE] with diagnoses that included Nontraumatic Intracerebral Hemorrhage, Subdural Hemorrhage, Subarachnoid Hemorrhage, Compression of Brain, Epilepsy, moderate protein calorie malnutrition, and Cerebral Edema. R15 was admitted receiving hospice services. Surveyor reviewed the Admission Minimum Data Set (MDS) with an assessment reference date of 12/13/23 for R15. Documented under Section C, Cognition was a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. Documented under Skin Conditions was Risk of Pressure Ulcer/Injuries was 1. Yes. Documented under Current number of Unhealed Pressure Ulcers at each stage: Number of Stage 3 Pressure Ulcers that were present upon admit/reentry: 1. Care Plans were put in place for R15 for Actual Skin Impairment on 12/6/23 and 12/7/23. Documented was: Focus: The resident has actual impairment to skin integrity sacrum r/t [related to] stage 3, impaired mobility. Goal: The resident's (sic) will have no complications r/t documented skin impairment through the review date. Interventions: - Evaluate and treat per physician orders. - Evaluate resident for [signs and symptoms (S/SX)] of possible infections. - PAIN: Evaluate residents for changes in pain level and if appropriate request a scheduled pain medication from physician. - The resident needs pressure relieving/low air loss mattress to protect the skin while IN BED. - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Care Plans were put in place for R15 for Potential Skin Integrity on 12/6/23 and 12/7/23. Documented was: Focus: The resident has potential for impairment to skin integrity r/t impaired mobility. Goal: The resident will remain free of new skin impairment through the review date. Interventions: - Apply barrier cream per facility protocol to help protect skin from excess moisture. Surveyor reviewed R15's Braden Scale for Predicting Pressure Sore Risk with an assessment date of 12/6/23. Documented was a score of 6.0 which meant Very High Risk for pressure injuries. Surveyor reviewed R15's Braden Scale for Predicting Pressure Sore Risk with an assessment date of 12/7/23. Documented was a score of 6.0 which meant Very High Risk for pressure injuries. Surveyor reviewed R15's Admission Skin & Wound Evaluation with a date of 12/7/23. Documented was: Type: Pressure Stage: Stage 3: Full-thickness skin loss Location: Sacrum Acquired: Present on Admission Wound Measurements: Length: 2.7 cm Width: 1.9 cm Depth: Not Applicable Notes: New admit with Stage 3 pressure site to left sacrum area, cleansed [with (w/)] normal saline, patted dry, Santyl applied and covered w/ border foam dressing. On right side of sacrum/upper Buttocks - noted newly healed area of well epithelialized pink tissue. No s/sx of infection or new breakdown. Zinc oxide applied to area. Surveyor reviewed R15's MD orders. Documented was: Start Date: 12/7/23 - End Date: 1/4/24. Braden Observation (to be completed in [Electronic Medical Record (EMR)]) one time a day every 7 day(s) for 4 Weeks. Start Date: 12/8/23 - End Date: None Skin Checks Weekly - complete Skin Evaluation in [EMR] on admission and weekly on assigned day in the morning every Fri. Start Date: 12/8/23 - End Date: None Mattress: Air mattress for wound care. Check function every shift, current 125 lbs. every shift for wound care impaired mobility. Start Date: 12/7/23 - End Date: 12/20/23. Wound care - sacrum - cleanse w/normal saline, pat dry. apply Santyl ointment to site and cover with border foam dressing every day and [as needed (prn)]. Surveyor reviewed R15's Skin Observation assessment with a date of 12/8/23. Documented was: Skin Observation 1. Does the Resident have any NEW Skin Issues Observed? b. No 3a. Skin Turgor a. Good Elasticity 3b. Skin Color a. Normal for ethnic group 3c. Skin temperature a. Warm (normal) 3d. Skin moisture a. Normal 3e. Skin Condition a. Normal 4. Other Observations Treatment in Place to coccyx Surveyor reviewed Wound MD-K's assessment of R15's sacral wound with an assessment date of 12/13/23. Documented was: Measurements Length: 1.04 cm Width: 1.04 cm Depth: 0.10 cm Etiology Pressure Ulcer - Stage 3 Margin Detail - Attached edges Wound Assessment Granulation 51-75% Slough 1-25% Drain Amount Moderate Drain Description Serous Odor Normal Odor Periwound Macerated Depth (cm) 0.10 Surveyor reviewed facility's Wound Evaluation with an assessment date of 12/13/23. Documented was: Pressure - Stage 3 Body Location: Sacrum Dimensions: Length: 1.96 cm Width: 1.22 cm Progress: Stable Notes: saw Wound MD wound measures 1.0 x 1.0 x 0.1cm Etiology Pressure Ulcer - Stage 3 Margin Detail Attached edges. Wounded Assessment Granulation 51-75% Slough 1-25% Drain Amount Moderate Drain Description Serous Odor Normal Odor Periwound Macerated derma [NAME] foam Surveyor noted that the facility's assessment measurements did not match Wound MD-K's measurements. Surveyor reviewed R15's Skin Observation assessment with a date of 12/14/23. Documented was: Skin Observation 1. Does the Resident have any NEW Skin Issues Observed? b. No 3a. Skin Turgor a. Good Elasticity 3b. Skin Color a. Normal for ethnic group 3c. Skin temperature a. Warm (normal) 3d. Skin moisture a. Normal 3e. Skin Condition a. Normal 4. Other Observations Treatment in Place to coccyx Surveyor reviewed the Treatment Administration Record (TAR) for R15 for December 2023. On 12/14/23 the Braden assessment is marked as completed but there is no Braden assessment in R15's EMR [electronic medical record] for 12/14/23. Surveyor reviewed Wound MD-K's assessment of R15's sacral wound with an assessment date of 12/20/23. Documented was: Measurements Length: 1.64 cm Width: 2.14 cm Depth: 0.30 cm Etiology Pressure Ulcer - Unstageable Margin Detail Attached edges. Wounded Assessment Granulation 1-25% Slough 51-75% Drain Amount Small Drain Description Serous Odor Normal Odor Periwound Excoriated Depth (cm) 0.30 Surveyor reviewed facility's Wound Evaluation with an assessment date of 12/20/23. Documented was: Pressure - Stage 3 Body Location: Sacrum Dimensions: Length: 2.31 cm Width: 1.45 cm Progress: Deteriorating Notes: saw Wound MD wound measures 1.6 x 2.1 x 0.3cm Etiology Pressure Ulcer - Unstageable Margin Detail Attached edges. Wounded Assessment Granulation 1-25% Slough 51-75% Drain Amount Small Drain Description Serous Odor Normal Odor Periwound Excoriated Continue Santyl Surveyor noted that the facility's assessment measurements did not match Wound MD-K's measurements, the facility did not measure the depth of the wound and indicated the pressure injury was both a stage 3 and unstageable in the documentation. Surveyor noted the wound is assessed as deteriorated and no added interventions were added to the care plan. Surveyor also noted this is the second week the assessments refer to the periwound as being macerated with no assessment of care plan to address possible factor causing increased moisture to the skin. Surveyor reviewed R15's MD orders. Documented was: Start Date: 12/20/23 - End Date: 1/3/24. Wound care - sacrum - cleanse w/normal saline, pat dry. apply Santyl ointment to site and cover with border foam dressing every day and prn. Surveyor reviewed R15's TAR for December 2023. On 12/21/23 the Braden assessment is marked as completed but there is no Braden assessment in R15's EMR for 12/21/23. The Skin Check Weekly form for 12/22/23 is Blank noting it was not completed. Surveyor reviewed the facility's Wound Evaluation with an assessment date of 12/21/23 noting a new wound for R15. Documented was: Open Lesion Body Location: Front Left Ear Dimensions: Length: 0.94 cm Width: 0.68 cm Wound Bed % Granulation 100% Evidence of infection warmth Other bleeding Exudate light serosanguineous no odor Surrounding tissue scarring Periwound temperature warm Additional care checked includes heel suspension/protection device, incontinence management, mattress with pump. Progress: New Notes: layer of skin removed while cleansing, small fluid blister on ear lobe Notification Practitioner Notified. Surveyor noted a treatment was not received until the next day. Surveyor reviewed MD orders for R15. Documented was: Start Date: 12/22/23 - End Date: 12/27/23. wound care to left ear, clean with saline, cover with band aid loosely, change daily and PRN. Surveyor noted there were no interventions in place to prevent R15's ears from breaking down. After the blister formed and opened the care plan was not updated and no new interventions were added to prevent further breakdown. Surveyor reviewed the facility's Wound Evaluation with an assessment date of 12/26/23. Documented was: Pressure - Stage 3 Body Location: Sacrum Dimensions: Length: 3.99 cm Width: 2.35 cm Progress: Deteriorating Notes: Increased amount of slough Surveyor noted the wound deteriorated and there is no indication R15's interventions were assessed for effectiveness to determine if interventions were needed to be added to the care plan. Surveyor noted there were no changes to treatment. Surveyor reviewed facility's Wound Evaluation with an assessment date of 12/27/23. Documented was: Open Lesion Body Location: Front Left Ear Dimensions: Length: 0.9 cm Width: 0.41 cm Progress Improving Surveyor noted there was no description of the wound bed or any other comprehensive assessment of the wound aside from measurements. Surveyor reviewed the facility's Wound Evaluation with an assessment date of 12/27/23 noting a new wound for R15. Documented was: Pressure - Stage 2 Body Location: Front Right Ear In house acquired Dimensions: Length: 1.2 cm Width: 0.6 cm Wound Bed slough % Slough 50% Other scab Exudate light serous Surrounding skin fragile: skin that is at risk for breakdown. Treatment indicates normal saline, autolytic debridement and band aid. Progress: New Surveyor noted when R15 developed the area to the left front ear, no interventions were established in the plan of care to address R15's risk for developing pressure injuries to their ear. The assessment of R15's right ear is noted to be a stage 2 despite the presence of slough. Surveyor noted this area is not correctly staged. R15's Comprehensive Care Plan for Actual Skin Impairment was updated on 12/27/23. Documented was: Focus: The resident has actual impairment to skin integrity sacrum r/t stage 3, impaired mobility, stage 2 right and left ear. Interventions: - The resident needs pressure relieving/reducing heel boots to protect the skin. pressure relieving padding (rolled) towels to protect the skin of bilateral ears. Surveyor noted the Care Plan referred to the left ear as a Stage 2 and not an open lesion. Surveyor also noted heel boots were added to the plan of care despite R15's risk for pressure injuries since admission. 12/27/23 is the first care plan that included an off-loading intervention for R15's ears - after R15 developed facility acquired pressure injuries to both ears with one being assessed to have slough. R15's Care Plan for Actual Skin Impairment was updated on 12/28/23. Documented was: Focus: The resident has potential for impairment to skin integrity r/t impaired mobility, incontinence, and alterative nutritional status. Interventions: -Air Mattress per MD orders -Dependent with turning and repositioning every 2-3 hours -Dietary Consult as needed Surveyor reviewed MD orders for R15. Documented was: Start Date: 12/27/23 - End Date: None wound care to left ear and right ear, clean with saline, cover with band aid loosely, change daily and PRN. Surveyor reviewed the TAR for R15 for December 2023. On 12/28/23 the Braden assessment is marked as completed but there is no Braden assessment in R15's EMR for 12/28/23. The Skin Check Weekly is marked as completed but there is no Skin Check Weekly assessment in R15's EMR for 12/29/23. Surveyor reviewed the facility's Wound Evaluation with an assessment date of 1/2/24. Documented was: Pressure - Stage 3 Body Location: Sacrum Dimensions: Length: 3.7 cm Width: 3.3 cm Deepest Point 1 cm Wound bed slough % of slough 40% of wound filled Other pink or red Exudate moderate serous Periwound macerated: wet, white, waterlogged tissue. Max Undermining 0.5 cm Undermining 0.5 cm from 3 to 5 o'clock Progress: Deteriorating Notes: As per above. Undermining 3 to 5 o'clock Surveyor noted the wound deteriorated including undermining and a depth of 1 cm. There were no added interventions to the care plan. Surveyor reviewed R15's Skin & Wound Evaluation with a date of 1/3/24. Documented was: Type: Pressure Stage: Stage 2: Partial-thickness skin loss with exposed dermis Location: Front Right Ear Acquired: In-House Acquired Wound Measurements: Length: 0.9 cm Width: 0.3 cm Depth: Not Applicable Surveyor reviewed R15's Skin & Wound Evaluation with a date of 1/3/24. Documented was: Type: Open Lesion Location: Front Left Ear Acquired: In-House Acquired Wound Measurements: Length: 0.9 cm Width: 0.3 cm Depth: Not Applicable On 1/2/24 at 8:53 AM and 12:45 PM, 1/3/24 at 9:05 AM and 1:05 PM and 1/4/24 at 10:57 AM Surveyor observed R15's air mattress set to 160 lbs. Surveyor noted MD orders stated mattress should be set to 125 lbs. Surveyor reviewed the TAR for R15. Documented on 1/1/24 all 3 shifts, 1/2/24 all 3 shifts, 1/3/23 AM and PM shifts and 1/4/24 AM shift the TAR was marked off as completed for check function every shift, current 125 lbs. Surveyor reviewed R15's weight with an assessment date of 12/6/23. Documented was 122.2 lb. Surveyor reviewed the Operations Manual for R15's air mattress. Documented under Operating Instructions was Determine the patient's weight and set the control knob to that weight setting on the control unit. On 1/4/24 at 10:57 AM Surveyor observed wound care for R15 performed by Registered Nurse (RN)-E. Surveyor noted the sacral wound was about the size of a quarter with depth. The wound bed was covered with 20% granulation, 80% slough and there were noted scattered spots of black necrotic tissue. Surveyor asked about the air mattress settings. RN-E stated the bed gets set according to R15's weight. Surveyor asked how much R15 weighs. RN-E stated he will have to check. Surveyor noted the bed has been set to 160 lbs. Surveyor asked who is responsible for checking to make sure the bed is functioning and set to the correct settings. RN-E stated it is everyone's responsibility. On 1/4/24 at 11:40 AM RN-E told Surveyor that R15 weighs about 130 lbs., so we set the bed to 125 lbs. On 1/8/24 at 10:21 AM Surveyor interviewed Wound MD-K by phone. Surveyor asked about R15's sacral wound. Wound MD-K stated it was superficial when he first assessed it when she was admitted . Wound MD-K stated he was told she wasn't getting up and to put offloading protocol in place. Wound MD-K stated then the wound turned unstageable. Surveyor asked if he was aware that R15 now has bilateral pressure injuries to her ears. Wound MD-K stated he was not aware. Surveyor asked if he was aware that the sacral wound was now at a depth of 1 cm and tunneling. Wound MD-K stated he was not aware. Wound MD-K stated he did not assess the wound because he was on vacation the week of 12/24/23 and 12/31/23. Surveyor noted the observations of depth, slough and some spots of necrosis on 1/8/24. Wound MD-K stated the wound may be infected and lab work may be needed. Wound MD-K stated he will be in to assess the wound this week. On 1/8/24 at 11:37 AM Surveyor reinterviewed RN-E. Surveyor noted the conversation with Wound MD-K. RN-E stated he had spoken to him after Surveyor did and they will discuss the possible lab work after Wound MD-K assesses the wound tomorrow. Surveyor asked why the wound measurements in RN-E's charting is different than Wound MD-K's assessment. RN-E stated when he takes the picture the measurements get uploaded, so they do not always match. Surveyor asked how staff or anyone else know what the actual measurements are. RN-E stated they use Wound MD-K's measurements and assessment. Surveyor asked on 12/20/23 when the wound deteriorated why there was no update to the care plan. RN-E was unsure. Surveyor asked if he was in charge of updating the wound care plan. RN-E stated yes. Surveyor asked if he added any interventions. RN-E stated he did not see anything according to the dates. Surveyor asked about the 12/26/23 assessment and 1/3/24 assessments. Surveyor noted Wound MD-K did not assess the wounds. RN-E stated Wound MD-E was on vacation. Surveyor asked what measurements are used then for assessment. RN-E stated they use his measurements then. Surveyor noted facility documentation still assessed the wound as a stage 3 while Wound MD-K has it as an unstageable. RN-E stated that was his fault, he forgot to change it. Surveyor noted the wound continued to deteriorate on 12/26/23 with no change in treatment and no update to the care plan and again on 1/3/24 including increased depth, tunneling and no update to the care plan. RN-E stated it looks that way. Surveyor asked if he knew how R15 got the ear wounds. RN-E stated he was not sure but R15 is dependent on staff for turning and repositioning. Surveyor asked if staff were not turning and repositioning R15. RN-E stated he could not speak to that. Surveyor asked if RN-E was putting the etiology of both ear wounds as pressure. RN-E stated yes. On 1/8/24 at 12:36 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked about the Braden assessments and Skin sheets in R15's EMR. Surveyor noted the TAR indicates Braden's and Skin Sheets were marked as completed or blank and there was nothing completed in R15's EMR. DON-B stated there should be a weekly Braden for 4 weeks and a weekly Skin Assessment Sheet. Surveyor shared the observations of the air mattress at 160 lbs. and the MD order for the setting to be 125 lbs. DON-B stated the bed should have been set at 125 lbs. Surveyor asked about R15's wounds and if they deteriorate what should happen. DON-B stated, update the MD, update the care plan and add new interventions. Surveyor noted the issues with no updates to the care plan. DON-B stated they will be doing education and updating the plan of care right away. On 1/17/24 the facility submitted additional information for Surveyor to review regarding R15's deteriorating sacral pressure injury and facility acquired bilateral ear pressure injuries. Included in the information was an Unavoidable Pressure Injury form with a date of 1/13/23. The form indicates R15 is on hospice services but whether R15 is at end of life is not indicated as either yes or no. R15 has a history of healed skin problems. The document asks if the resident has two or more of the following diagnosis . under other is written CVA, unresponsive and immobile. The document asks if the resident receives one or more of the following treatment and malnutrition/dehydration and whether secondary to poor appetite or another disease process. Both sections are blank. Clinical signs and symptoms of malnutrition/dehydration under other indicates tube feeding, dysphagia, moderate protein malnutrition. The section for noncompliant behavior is blank as well as what R15's Braden scale is. Surveyor noted this was signed by wound physician-K on 1/17/24.

Based on observation, record review and interviews, the facility did not ensure they provided proper pain management for 1 (R16) out of 3 residents reviewed for pain management. The facility did not ensure that they developed and implemented a plan of care, based on a comprehensive assessment, to assist in managing R16's pain during daily wound treatments and movement during cares. Staff was aware R16 experienced pain with movement but the plan of care had not been updated to reflect possible interventions to reduce or eliminate pain during treatments and cares and while moving R16. The plan of care did not indicate what is the level of pain that R16 can tolerate, what provides relief for the pain and if there is any non-pharmacological intervention to help with pain relief. Findings include: Review of policy: Pain Management: effective date 11/28/2017. (Villa Healthcare) Purpose: It is the facility practices to observe residents for pain upon admission, quarterly, with significant change in condition that may cause an onset or increase pain and any time it is suspected a resident is in pain. Residents are observed for pain regularly during daily care and interactions. To ensure adequate and individualized pain management interventions are identified and implemented to meet the acceptable comfort range. General Guidelines (includes) : Follow the medication administration guidelines when administering pain medications. Residents may be reluctant to report pain due to belief that [NAME] is a normal part of the aging process or because of reluctance to bother staff members. Pain in our residents will be evaluated and/ or observed as needed and: quarterly and annually with the MDS assessment process. Care Plan: The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or potential for pain. They will adopt an interdisciplinary care plan after reviewing characteristics and causes for the resident's pain. R16 was originally admitted to the facility on [DATE] has diagnoses that include Dementia, Anxiety, other abnormalities of gait and mobility, osteoarthritis, age-related osteoporosis, and muscle weakness. The most recent, quarterly MDS (minimum data set), dated 11/13/2023, indicates that R16 has occasional pain, at a level 5 over the last 5 days of the assessment period and is receiving both scheduled and as needed pain medication. R16 has a BIMs (brief interview for mental status) score of 10 which indicates moderately impaired cognition. R16 is at risk for pressure injury development and currently has an unhealed area. R16 has adequate hearing and can make self-understood and can understand others. Surveyor conducted a review of R16's most recent plan of care and noted that R16 has an actual impairment to skin integrity including the right heel, left calf stage 3 which is due to limited mobility. This plan of care was initiated on 8/9/2023. Interventions include Pain- evaluate resident for changes in pain level and if appropriate request a scheduled pain medication from physician. This was initiated on 8/9/2023. The most recent plan of care also states that (R16) has potential for pain due to PVD (Peripheral Vascular Disease), arthritis and osteoporosis. This was initiated on 5/15/2019. Interventions included to anticipate (R16's) need for pain relief and respond immediately to any complaint of pain. Monitor/ record/ report to Nurse any signs/ symptoms of non-verbal pain: changes in breathing; vocalizations (grunting, moans, yelling out, silence); eyes (wide open/ narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing). It was noted that the plan of care regarding pain had not been updated with any additional interventions since 5/15/2019. A Nurse Practitioner note dated 11/6/23 indicates: HPI (history of present illness): .Seen today for monthly follow up. Member currently resting comfortably in her wheelchair upon exam. States her chronic pain has been controlled at rest - increases with movement. Gabapentin was just recently increased to 200 mg po (by mouth) q (every) am - continues to be on 300 mg PO nightly. Currently being followed by wound MD/RN for ongoing right heel pressure injury . Review of systems: Pain Assessment: Pain assessment completed: verbal. Verbal Pain Scale: 6. Description of pain: Sharp. What eases the pain: Rest. Pain notes: left anterior knee pain with movement. Focused A&P (assessment & plan) details indicate: Chronic pain syndrome. Chronic pain - stable. Chronic pain caused by osteoarthritis and immobility. Pain has been controlled with gabapentin and Tylenol. Intermittent knee pain with movement. Continue PRN (as needed) pain mediation. Vicodin d/c'd (discontinued) 12/7/20. Goals: Member will state pain symptoms are at a manageable level for them by 12/31/24. Contingency plan: consider non-pharm and trial of low oxycodone .Surveyor noted the recommendation for non-pharm measures and possible trial of low dose oxycodone was not addressed further on R16's plan of care. On 12/4/2023, R16 was evaluated by the Nurse Practitioner for a monthly follow-up. The progress note indicates that R16 is noted to have increasing pain to the right heel with daily wound cares. Wound has overall declined. New order for Norco 5-325 milligrams every 8 hours as needed for moderate/ severe pain. Nursing staff updated to try and give pain medication 30 minutes prior to wound care. R16 currently resting comfortably in bed and denies any other complaints at this time. Pain Assessment: pain assessment completed: verbal pain scale - 5. Description of pain: my knee just hurts all the time. What eases the pain: rest. Pain notes: chronic bilateral knee pain left is greater than right. Focused A&P (assessment & plan) details indicate: Chronic pain syndrome. Plan: chronic/stable. Chronic pain caused by osteoarthritis and immobility. Pain has been controlled with gabapentin and Tylenol. Intermittent knee pain with movement. Continue PRN pain medication. Contingency plan: consider non-pharm and trial of low oxycodone .Surveyor noted the recommendation for non-pharm measures and possible trial of low dose oxycodone was not addressed further on R16's plan of care. Surveyor conducted further review of R16's medical record and noted that the last Pain evaluation that the facility conducted was a quarterly assessment dated [DATE] and indicates R16 has no pain. A review of R16's current physician orders noted the following medications for pain management: *Lidocaine External Patch 4% apply to bilateral knees topically as needed for pain each day, as needed. - ordered 7/24/23 *Norco Oral tablet 5-325 milligrams (Hydrocodone- Acetaminophen) give 1 tablet by mouth every 8 hours as needed for moderate/ severe pain. *Norco Oral tablet 5- 325 milligrams (Hydrocodone- Acetaminophen) give 1 tablet by mouth one time a day for moderate/ severe pain prior to wound care treatment. Order date 12/12/2023. *Tylenol Extra Strength tablet 500 milligrams- give 500 milligrams by mouth 2 times a day for pain. *Acetaminophen tablet 325 milligrams- give 2 tablets by mouth every 6 hours as need for pain scale 1-5. Document level of pain on a 1-10 scale. Not to exceed 3000 milligrams in 24 hours. Review of R16's December Treatment Administration Record (TAR) for December 2023 indicates as an order dated 2/9/18, evaluate pain every shift - every shift for pain evaluation. Review of the entries on the TAR indicate 0 as the pain level for most days/shifts with R16 have a pain level of 5 on day shift on 12/6/23 and a level of 10 on day shift on 12/17/23. Night shift indicates a level of pain of 5 on 12/31/23. Surveyor noted there is no documentation to show what time R16's pain was assessed, what the circumstances were when the pain was assessed, and no indication of frequency noted by other staff throughout a shift to truly evaluate the effectiveness of R16's pain management. R16 also had physician orders for the treatment of the pressure injury to the right heel and left calf and left plantar foot. These treatments were to be completed 1 time daily and as needed. On 1/3/24 at 8:10 a.m., Surveyor made an observation of Wound Registered Nurse (RN)- E preparing to complete R16's wound treatments to the left calf and right heel. RN- E stated that R16 has been pre-medicated as he enters R16's room to find R16 awake and lying in her bed. RN- E pulls back the blanket that was covering R16's lower extremities and at this time it was observed that R16 had a patch to her left knee and was dated 12/30. Surveyor asked RN- E what the patch was and RN- E stated that is a Lidocaine patch and that they really don't help R16. RN- E verified the patch was dated 12/30. RN- E gathers the treatment supplies and removes an old bandage that is to the left calf. RN- E cleanses the area. At this time, R16 begins to make facial grimacing. RN- E then lifts R16's left leg into the air to place phone under the calf to take a picture of the wound. R16 yells out in pain stating Oh, oh, oh. R16 is verbally voicing pain as her leg is raised and then becomes tearful. RN- E states to R16, I can stop and R16 does not respond. RN- E prepares the new dressing and raises R16's leg again to apply the Santyl to the calf wound. R16 yells out in pain again and becomes more tearful. RN- E than states to R16, I ask you everyday regarding your pain and I tell you we can stop or just get through it and get it over with. R16 responds, tearfully, get through it. RN- E again states I always ask you if you want to just get through the treatment and get it over with. RN- E completes the treatment to the left calf and then places R16's left foot on a pillow to elevate it. R16 screams out in pain, and yells my knee, my knee. RN- E asks R16 what he should do and R16 responds, I don't know. During this observation there was another facility staff member in the room (name unknown). When R16 began crying and expressing her pain, the staff member went to the right side of R16 and held R16's hand, assuring R16 everything would be alright. RN- E then begins to start the treatment to the right heel. RN- E starts to remove the pressure relieving boot and R16 yells loudly in pain and says my knee, my knee, it hurts. RN- E asks R16 where the pain is and R16 states the whole knee. RN- E asks R16 again, do you want me to stop? I always ask you this or keep going and get it over with. As R16 is very tearful she whispers, get it over with. Surveyor exited the room at 8:30 a.m. as R16 was visibly very upset and very tearful and Surveyor wanted to provide additional space for RN- E. Surveyor reviewed the Medication Administration Record (MAR) for January 2024. The MAR has the medication Norco Oral tablet 5- 325 milligrams give 1 tablet by mouth one time a day for Moderate/ Severe pain prior to wound care treatment. The time for administration is 5:00 a.m. The electronic medical record (EMR) note dated 1/3/24 at 4:19 a.m. documents that R16 received the Norco Oral Tablet. This was administered by RN-Y who worked the 3rd shift (10:30 p.m. to 6:30 a.m.). On 1/3/24 at 2:15 p.m., Surveyor interviewed Regional Director of Clinical Operations (RDCO)- C regarding R16's most current, comprehensive pain assessment. RDCO- C verified that the most recent comprehensive assessment is dated February 2023. At the daily exit on 1/3/2024 at 2:30 p.m., Surveyor shared the details of the observation of R16 receiving her treatments by RN- E. Surveyor shared that R16 was yelling out in pain, was tearful and was asked if the treatment should stop or just keep going and get it over with. Surveyor expressed concern that R16 was administered the pain medication at 4:19 a.m. on 1/3/24 and the treatment did not begin until 8:10 a.m. (According to the National Library of Medicine-, last updated November 17, 2023, after a single oral ingestion of Hydrocodone, it reaches maximum serum concentration within 1 hour.) Surveyor reviewed the comprehensive wound evaluations, dated 1/3/2024, that were completed by Wound RN- E. The assessment information for R16's left medial calf- middle states this area was first observed 8 days ago. The Pain section of the assessment documents that R16 is cognitively impaired. Negative vocalization- troubled. Facial Expression- grimacing. Body Language- tense. Consolability- voice or touch. Pain Score 7. Notes of pain: premedicated, pain in knee when lifting leg, stated to keep going, get it done. Another staff member was talking with R16. The comprehensive wound evaluation for R16's pressure ulcer to the right heel, dated 1/3/24 states that R16 has had this area for 5 months and the area is improving. The pain assessment documents that the negative vocalization- troubled. Facial expression- grimacing. Body language- tense. Consolability- voice or touch. Pain Score- 6. Notes on pain. Premedicated at dressing change, pain in knee when lift (sic). Nursing note dated 1/3/24 at 4:29 p.m. indicates; This nurse notified the Nurse Practitioner of (R16) pain increasing with wound care, new orders given for X-ray to bilateral knees, schedule Norco daily and keep as needed, schedule Lidocaine patch. Pain assessment completed per Assistant Director of Nursing. Nursing note dated 1/3/24 at 6:24 pm by Director of Nursing (DON)-B indicates .indicators of pain: non-verbal sounds. Indicators of pain: facial expressions. Pain issue: #001: New. Location: Right knee. Pain Score: 3. Resident position changed. Resident has pain only with movement of lower extremities. currently no pain at rest. A vitals and pain only evaluation dated 1/3/24 at 6:24 pm indicates for pain: Indicators of pain or possible pain in the last 5 days: BLANK Should pain assessment interview be conducted? Attempt to conduct interview with all resident. No is indicated Ask resident: Have you had pain or hurting at any time in the last five days? BLANK Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? BLANK Ask resident: Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? BLANK Ask resident: Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? BLANK Ask resident: Over the past 5 days, how often have you limited your day to day activities (excluding rehabilitation therapy session) due to pain? BLANK Pain intensity: Ask resident: Please rate your worst pain over the last 5 days on a scale of 1-10, with 0 being no pain and 10 being the worst pain imaginable. Show pain scale. BLANK Numeric rating scale: BLANK Verbal descriptor scale: Ask resident: Please rate the intensity of your worst pain over the last 5 days. (Show resident verbal scale): BLANK Indicators of pain: non-verbal sounds, facial expressions. Pain Issue: New Issue Pain location: right knee - most recent pain level: mild Non-medication interventions: change in position. Pain note: resident has pain only with movement of lower extremities, currently no pain at rest. MDS responses: non-verbal sounds, facial expressions. Not checked includes: vocal complaints of pain and protective body movements or postures. Surveyor noted R16 was not directly spoken to regarding her pain despite observations of R16 being able to clearly state she is in pain and where it is located and why. Surveyor noted the assessment does not include an assessment of any other pain R16 may have including assessment of her left knee. Surveyor also noted this is not a new onset of pain as DON-B's assessment would indicate as review of R16's medical record indicates R16 has had pain for a period of time. On 1/4/24 at 10:45 a.m., Surveyor was making an observation outside R16's room when Surveyor could hear R16 yelling oh, oh, oh. Certified Nursing Assistant (CNA)- N then came out of room with a bag of soiled linens. Surveyor asked CNA- N if R16 was having pain and CNA- N stated yes, she was tearful and usually when you move R16 is when she has the pain. CNA- N then retrieved the Hoyer lift and the assistance of another CNA to transfer R16. CNA- N gets R16 situated in the sling and hooks the sling to the Hoyer lift. As the Hoyer lift begins to move R16 from the bed, R16 begins yelling, very loudly oh, Oh god and begins to cry. As the staff continue to raise R16 in the Hoyer lift they tell R16 to bear with them, it's almost over, just a few more minutes. R16 continues to yell and is tearful. CNA- N is able to maneuver R16 in the Hoyer and lowers R16 to her wheelchair. CNA-N states to R16 it's over, the hard part is over. R16 is asked about her pain, and she responds yes, it's my knee. CNA- N then tells Surveyor and R16 she will alert the nurse about R16's pain. On 1/4/24 at 11:58 a.m., Surveyor returned to R16's room to interview her about her pain. R16 stated that the pain is very bad when she is being moved. R16 stated she is no longer in pain, only when they move my knees. Surveyor asks R16 how this makes her feel. R16 responded it makes me upset when I hurt and that she doesn't mean to holler at the staff. On 1/4/24 at 12:05 p.m., Surveyor interviewed Med Tech- Z to ask if she was made aware of R16's earlier pain during the transfer. Med Tech- Z stated that yes, the aide had told her and when she went in by R16, R16 said she was no longer in pain. Med Tech- Z stated that she is aware that movement is what causes R16 the pain and that sometimes staff will ask if she wants pain medication before she receives cares and sometimes, they ask her after cares. On 1/4/24 at 1:00 p.m., Surveyor conducted a review of R16's plan of care for pain. It was noted that the plan of care had not been updated to reflect possible interventions to reduce or eliminate pain during treatments and cares and while moving R16. The plan of care did not indicate what is the level of pain that R16 can tolerate, what provides relief for the pain and if there is any non-pharmacological intervention to help with pain relief. As of the date of 1/7/24, the facility was unable to provide evidence that they had comprehensively assessed R16's pain level during treatments and cares when she is being moved. The facility staff continued to treat and provide cares to R16 while she vocally expressed, she was in pain, showed facial grimacing and was very tearful. The facility was unable to provide additional information as to why R16 was premedicated almost 4 hours before her treatment on 1/3/24, resulting in severe pain while RN- E continued the treatment to her wounds. The facility was also unable to provide additional information as to why the facility staff did not stop providing treatment or cares to R16 when she was expressing severe pain, alert the nurse for additional pain management interventions, and then return once R16's pain was under control. On 1/17/24 the facility submitted additional documentation for Surveyor to review regarding R16's pain. In the information, the facility contends that even though the comprehensive pain assessment is missing for R16, R16's pain was evaluated every shift, daily. The facility indicated physicians are hesitant to provide pain medications and R16 learned to live with this pain and accepts it the way it is. The facility also indicated there is no way to premedicate R16 for her pain as you do not know when you will need to move R16. Surveyor noted there were recommendations noted in R16's nurse practitioner assessments that have not been addressed by the facility to determine if it would provide further pain control to R16. Additionally, Surveyor noted R16 was premedicated as ordered however, it was not effectively implemented during observations of R1's wound care as it was administered on a previous shift and was past peak effectiveness by time wound care was completed.

Based on observation, record review and interviews, the facility did not ensure 4 (R66, R88, R69, R43) of 5 residents reviewed for accidents received care and services to prevent accidents. * On 3/24/23, R66 fell out of bed and suffered a fractured right hip. R66's care plan intervention dated 2/11/23 indicated her bed should be in the low position and at the time of the fall her bed was not in the low position. A thorough investigations as to why her bed was not in the low position was not conducted. Interviews were not conducted with staff or the resident after the fall to see why her bed was not in the low position at the time of the fall. In addition the post fall report indicated it was possible R66 was playing with the bed controller and no intervention was provided to prevent this in the future and no evidence was provided this was a problem before the fall on 3/24/23. During 3 days of the survey R66 was observed in bed and her mat which was suppose to be next to her bed as per 3/24/23 care planned intervention, was observed behind her headboard. In addition R66 was observed to have a rail on her bed with no safety device assessment for its use completed. This example regarding R66 rises to a scope and severity level of G (harm/isolated). * R88 had two unwitnessed falls on 3/22/23 and 4/4/23. The facility did not conduct a root cause analysis after these two falls. * R69's smoking care plan was not updated after having 2 occasions where her coat was observed to be smoldering despite having a smoking assessment indicating she was to be supervised and not have any smoking materials with her. * R43 did not have a smoking safety assessment completed in regards to determining the type of supervision R43's requires in regards to safe smoking. Findings include: 1. On 4/24/23 R66's medical record was reviewed. R66 was admitted on [DATE] with diagnosis that included Encephalopathy. R66's 2/22/23 Quarterly MDS (Minimum Data Set) assessment indicates a brief interview for mental status score of 7 (severely impaired) and extensive 1 assist with bed mobility. On 4/24/23 Surveyor reviewed R66's falls care plan dated 12/22/22 which indicated: bed in lowest position (2/11/23), fall mat and scoop mattress (3/24/23). R66's full care plan was also reviewed and did not indicate R66 played with her bed controller. R66's care plan also did not include the use of a bed rail. Review of R66's fall report dated 2/11/23 at 8:30 PM indicated: R66 fell while trying to get into her wheelchair from her bed. No injuries to R66 were observed. The intervention after the fall was to have R66's bed in the lowest position. Review of R66's fall report dated 3/24/23 at 7:36 PM indicated: When nurse walked in the room, R66 was lying on her right side screaming and crying. The report indicates the bed was at the high level implying as if she had been playing with the bed controller. R66 stated she fell and hurt her hip. The report indicated on 4/1/23 a scoop mattress was added to R66's bed and a fall mat placed next to her bed. Review of R66's hospital documentation from 3/24/23 was reviewed and indicated R66 suffered a right hip fracture that required surgical intervention from a fall. R66 returned from the hospital on 4/1/23. On 4/23/23 at 09:09 AM R66 was observed lying in bed. R66's fall mat was observed folded up behind the head of her bed. A quarter bed rail was observed on the left side of her bed. On 04/24/23 at 12:08 PM R66 was observed lying in bed. R66's fall mat was observed folded up behind the head of her bed. A quarter bed rail was observed on the left side of her bed. On 04/25/23 09:05 AM R66 was observed sitting up on the side of her bed. R66's fall mat was observed folded up behind the head of her bed. A quarter bed rail was observed on the left side of her bed. On 4/25/23 at 10:30 AM Director of Nurses (DON)-B was interviewed and indicated no information could be found as to why they had concluded R66 has been playing with her bed controller on 3/24/23. DON-B indicated she had no staff interviews or an interview with R66 to determine this. DON-B indicated she didn't investigate further because R66 playing with a remote was not the cause of the fall. The Surveyor asked DON-G if that could be the cause of R66's right hip fracture and she said yes. DON-B indicated nothing was done or added to R66's care plan about her playing with the bed remote when she returned from the hospital. DON-B was then informed that the Surveyor has witnessed 3 days of R66 not having her fall mat in place and it was folded and placed behind her bed all 3 days of observation. DON-B indicated the fall mat should be in place next to R66's bed. DON-B indicated she did not know if bed rail assessments were required for use and did not know when R66's bed rail was placed. On 4/26/23 at 9:30 AM DON-B was interviewed and indicated the facility completed a safety assessment for R66's bed rail on 4/25/23 and it should have been completed before it was used as was not. On 4/25/23 the facility's policy titled Falls Evaluation Safety Guidelines dated 11/26/2017 was reviewed and read: Post fall action: Root cause analysis, determine causal factors of the fall. A through investigation into the cause of R66's fall was not completed after her 3/24/23 fall which resulted in a right hip fracture. Interviews were not conducted with staff or the resident after the fall to see why her bed was not in the low position at the time of the fall. In addition the post fall report indicated it was possible R66 was playing with the bed controller and no intervention was provided to prevent this in the future and no evidence was provided this was a problem before the fall on 3/24/23. On 4/25/23 the facility's policy titled Bed Rail Device Guidelines dated 11/28/2017 was reviewed and read: Bed entrapment occurs when a resident is caught between the mattress and bed rail or within the bed rail itself. It is the practice of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. The facility will ensure individual resident bed rail evaluations are preformed on a regular basis. Evaluate the residents risk for entrapment from bed rails prior to installation. Residents care plan will include use of bed rails as evaluated. The above findings were shared with the Administrator and DON on 4/25/23 at 3:00 PM at the daily exit conference. Additional information was requested if available. None was provided. 42037 2. R88 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease. R88's Quarterly MDS (Minimum Data Set) assessment dated [DATE] shows a BIMS (Brief Interview for Mental Status) Score of 7, indicating R88 is not capable of daily decision making due to cognitive status. R88 requires extensive assistance of 2 staff members for transfers. Surveyor identified R88 had sustained unwitnessed falls on 3/22/23 and 4/4/23. Surveyor did not locate any root cause investigation/analysis of these 2 falls nor any collection of staff statements conducted by the facility to assist in determining a root cause analysis for R88's falls on 3/22/23 and 4/4/23. On 4/24/23, Surveyor shared with DON-B, they could not locate a through investigation related to R88's unwitnessed falls on 3/22/23 and 4/4/23 including a root cause analysis or staff statements. 16584 Surveyor reviewed the facility policy Smoking Guideline, effective date 11/28/17. The Smoking Guideline indicates: Purpose: Residents who want to smoke are evaluated and assessed for smoking safety. Each facility establishes its own smoking policy that addresses how, when and where to allow smoking. Responsible Party: Clinical Procedure: (includes) 1.) The social worker or designee will complete the smoking evaluation form with input from the interdisciplinary team. 2.) The evaluation is to be used at the time of admission, annually, with quarterly review and with changes in condition. 6.) Interventions for safe smoking, such as a smoking apron, will be included in the resident individualized smoking care plan. 7.) Any resident with restrictions will have direct supervision during smoking unless contraindicated within the facility smoking policy. Surveyor reviewed an addtional facility policy Smoking Guideline revised on 9/24/20 which states, Residents who want to smoke are evaluated and assessed for smoking safety. Each resident will be informed prior to, or upon admission, residents shall be informed about any limitations in smoking including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Procedure: 1. Nursing or designee will complete the smoking evaluation form with input for the interdisciplinary team. 2. The evaluation is to be used at the time of admission, annually, with quarterly review and with changes in condition. 4. Residents/ resident representatives will be informed prior to and upon admission of smoking policy, including any restrictions. 5. Residents/ resident representatives will be informed of the need to comply with the smoking policy, as well as any precautionary measures as determined necessary following evaluation. 6. Interventions for safe smoking, such as a smoking apron, will be included in resident the resident [sic] individualized smoking care plan. 7. Any resident with restrictions will have direct supervision during smoking unless contraindicated within the facility smoking policy. 3. R69 was originally admitted to the facility on [DATE] . The most recent quarterly Minimum Data Set (MDS) dated [DATE] indicates that R69 has a BIMS (brief interview for mental health) score of 14 indicating cognitively intact. On 10/30/2022 6:06p.m., Smoking Risk Obs Note Text: Reason for evaluation is: Patient (R69) placing lit cigarettes in pockets of her clothing. Visualized by staff, reported to day RN. Resident (R69) is a smoker. Resident is their own responsible party. Responsible Party is in agreement that the resident be allowed to smoke. The resident is NOT interested in smoking cessation. R69 uses cigarettes. Resident carries matches or lighter. R69 smokes 5 or greater times a day. R69 likes to smoke in the morning. R69 likes to smoke in the afternoon. R69 likes to smoke in the evening. R69 has known history of or current demonstration of unsafe smoking. R69 begs or steals smoking materials from others. R69 is unable to extinguish smoking material properly. R69 smokes cigarette butts from ash trays. R69 is unable to extinguish smoking material properly. R69 is safe to smoke with supervision. R69 is not safe to keep any/all smoking materials. All materials stored by staff. Cigarettes, cigarette material, cigars, pipe, etc. stored by staff. R69 does not require any adaptive equipment or assistance. Review of Facility Safe Smoking Policy, identification of where resident's materials will be stored, identification of designated smoking areas and disposal units, and review of smoking policy violations and risks vs. benefits was NOT discussed with R69 and/or Representative. Patient (R69) became defensive and uncooperative when approached about unsafe smoking noted 10/30 days. Refusal of body check to visualize skin for possible burn(s). Clothing noted to have burnt pocket x 1. A Smoking Risk Evaluation dated 11/13/22 documents; Reason for evaluation is Change in status. R69 is a smoker. R69 is their own responsible party. Responsible Party is in agreement that R69 be allowed to smoke. The [R69] is NOT interested in smoking cessation. R69 uses cigarettes. R69 carries matches or lighter. R69 smokes 5 or greater times a day. R69 likes to smoke in the morning. R69 likes to smoke in the afternoon. R69 likes to smoke in the evening. R69 likes to smoke at night. R69 has known history of or current demonstration of unsafe smoking. R69 is careless with smoking materials. R69 smokes cigarette butts from ash trays. R69 begs or steals smoking materials from others. R69 is unable to extinguish smoking material properly. Resident is careless with smoking materials. R69 smokes cigarette butts from ash trays. R69 begs or steals smoking materials from others. R69 is unable to extinguish smoking material properly. R69 is safe to smoke with supervision. R69 is not safe to keep any/all smoking materials. All materials stored by staff. Lighter/matches stored by staff. Cigarettes, cigarette material, cigars, pipe, etc. stored by staff. R69 requires: To make sure res cigarettes is all the way out before she puts them away in her pocket. Review of Facility Safe Smoking Policy, identification of where resident's materials will be stored, identification of designated smoking areas and disposal units, and review of smoking policy violations and risks vs. benefits was discussed with R69 and/or Representative. Facility Smoking Safe Smoking Policy reviewed with Resident. On 11/13/2022 at 10:24 a.m.; Nurse to Physician/NP/PA Notification (SBAR) Situation: Res coat jacket pocket was smoking from a lit cigarette in her cigarette box. Background: Type 2DM, muscle weakness, dementia, anxiety and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Assessment: CNA noted res coat jacket pocket was smoking from a lit cigarette in her cigarette box. R69 alert and responsive, no injury noted to res. Response: Dr. aware DON (Director of Nursing) aware R69 is her own responsible party. Request: R69 needs supervision with smoking or needs to be checked once done from smoking. Surveyor conducted a review of R69's plan of care and noted that R69 is non-compliant with smoking in the designated smoking areas. Date Initiated: 09/20/2021. Interventions included: o R69 sustain no injuries related to unsafe smoking practices by next review. Date Initiated: 09/20/2021 o Encourage oral hygiene daily and between meals. Date Initiated: 09/20/2021 o Encourage resident to utilize smoking materials and return post smoking session. Date Initiated: 09/20/2021 o Instruct R69 about smoking risks and hazards and about smoking cessation aids that are available. Date Initiated: 09/20/2021 o Instruct R69 about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 09/20/2021 o R69 is a safe smoker can smoke SUPERVISED. Date Initiated: 09/20/2021 Further review of the plan of care did not show that the facility addressed the concerns about R69 needing to be checked, once done smoking, that she has not placed a lit cigarette back into her cigarette box or pocket. On 4/25/23 at 3:00 p.m., Surveyor interviewed Administrator- A regarding R69 having 2 incidents where she entered the building, after smoking, and the smoking materials were not extinguished. Surveyor asked why, after the first incident on 10/30/22, the facility did not add additional interventions to the safe smoking plan of care to make sure R69 was safe to return into the building. Surveyor also asked Administrator- A if they had investigated to be certain that R69 was being supervised, while smoking on 11/13/23. No additional information was provided as of the time of exit on 4/26/23. 38253 4. R43 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia, chronic kidney disease, cerebral infarction, major depressive disorder, weakness, chronic obstructive pulmonary disease, hemiplegia and hemiparesis of the left side, epilepsy, . and other abnormalities of gait and mobility. R43's quarterly minimum data set (MDS) dated [DATE] indicated R43 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R43 needing supervision with bed mobility, transferring, dressing, hygiene, and bathing and independent with walking, eating, and toilet use. R43 had impairments to left upper and lower extremities, used a cane when ambulating, and was continent of bowel and urine. The facility assessed R43 fall risk on admission to be 11 indicating R43 was a high risk for falls. On 4/23/2023 at 1:45 PM Surveyor asked nursing where R43 was. Nursing replied that R43 was outside smoking. On 4/23/2023 during record review Surveyor noted on R43's admission MDS dated [DATE] the facility assessed R43's MDS section J1300 Current Tobacco use was checked 0. No. There was not an assessment for smoking done for R43. On 4/24/2023 at 9:00 AM Surveyor asked R43 how often R43 smokes. R43 stated R43 smokes 3-4 cigarettes a day, in the morning, noon, evening, and night. Surveyor asked R43 who holds onto R43's cigarettes and lighter. R43 replied R43 holds onto the cigarettes and lighter and no one ever asked about R43's smoking. R43 stated R43 has been a smoker for a long time and was a smoker when entered the facility. On 4/23/2023 at 2:58 PM Surveyor informed Director of Nursing (DON)-B and Nursing Home Administrator-A of Surveyors concern that R43 did not have an assessment done to assess if R43 was safe to smoke with or without supervision. No additional information was provided at this time.

Based on observation, interview, and record review, the facility did not ensure 2 (R10, R14) of 11 residents reviewed received treatment and services to prevent the development of pressure injuries and promote healing for facility acquired pressure injuries. R10 developed multiple pressure injuries including a stage 3 and an unstageable pressure injury that were facility acquired. R10 was at risk for pressure injuries. R10's Minimum Data Set (MDS) assessments indicated R10 was able to complete some cares with assist of one staff when she in fact required extensive staff assistance and was described by the facility as essentially bed bound throughout her admission in the facility. R10 was entered into hospice care on 9/1/22 with a significant change MDS dated [DATE] indicating R10 has 3 stage 2 pressure injuries, 1 stage 3 pressure injury and 1 unstageable pressure injury all are facility acquired. R14 was observed during survey on 12/19/22 with a dressing that was loose/falling off on a stage 4 pressure injury. The dressing/treatment was to be completed every 3 days or as needed. On 12/19/22 the dressing was dated 12/13/22 indicating it was last changed 6 days before the observation. At the time of the observation, R14 was noted to have 10 exudate and be in pain during cares in the area where the wound was located. Findings include: The Interim Director of Nursing (DON-B) provided the following policy on 12/19/22. The facility policy titled, Villa Healthcare - Skin Management Guideline dated 11/28/17 was reviewed and indicated, When a pressure ulcer is present, daily wound monitoring should include: An evaluation of the ulcer, if no drainage present. An evaluation of the status of the dressing, if present 1.) According to records reviewed by Surveyor, R10 was admitted on [DATE] from an acute care hospital after a fall that resulted in a closed fracture of the resident's proximal end of the right fibula and an unspecified fracture morphology and closed fracture of the resident's distal end of the left fibula. Additional diagnoses included dementia, and difficulty walking. The admission Minimum Data Set (MDS) dated [DATE] indicates R10 has a brief interview of mental status score (BIMS) of a 3 indicating severe cognitive impairment. The MDS indicates R10 has little pleasure in doing things and no behavior of rejecting cares. R10 requires limited assist of 2 staff for bed mobility, and extensive assist of 2 plus staff for transfers, personal hygiene including bathing, she is not steady and has lower extremity impairments on both sides and is at risk for pressure injuries with no areas at the time of the assessment. The most recent Braden Scale score dated 06/22/22 was 18, indicated R10 was at mild risk for skin breakdown. The resident passed away at the facility on 09/24/22, after three days receiving hospice care. The resident's Care Plan dated 05/25/22 included three focus areas: * Focus: The resident has potential for pressure injury r/t [related to] decreased mobility and urinary incontinence. Date Initiated: 06/11/2022. Interventions included: * Administer treatments as ordered and monitor for effectiveness. Date Initiated: 06/11/2022 * Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 06/11/2022 * Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 06/11/2022 * Instruct/assist to shift weight in W/C [wheel chair] q [every]15 minutes. Date Initiated: 06/11/2022 * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 06/11/2022 * Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date Initiated: 06/11/2022 * Apply barrier cream per facility protocol to help protect skin from excess moisture. Date Initiated: 05/27/2022 * Monitor skin when providing cares, notify nurse of any changes in skin appearance Date Initiated: 05/25/2022 R10's Quarterly MDS dated [DATE] indicates R10's BIMS as 3 indicating severe cognitive impairment. This MDS indicates R10 requires extensive assist of 1 staff for bed mobility, personal hygiene, toileting and bathing. R10 is at risk for pressure injuries and has no pressure injuries or venous wounds at this time. Review of R10's physician/treatment orders include: 05/25/22 at 4:42 p.m.: May apply barrier cream to peri area for skin protection every shift. D/C on 06/21/22 at 2:17 p.m. Surveyor noted the application of barrier cream was not initialed as completed on the day shift on 05/27/22, 05/31/22, 06/10/22, 06/11/22, 06/15/22 and evening shift on 05/27/22 and 06/15/22. 05/25/22: Skin Checks Weekly - complete Skin Evaluation in PCC [Point Click Care] on admission and weekly on assigned day Every evening shift every Wed [Wednesday]. Surveyor noted weekly skin checks were not initialed as completed on 06/01/22, 07/20/22, 07/27/22, 08/03/22, and 08/10/22. Coccyx area: An 8/15/22 skin and wound evaluation indicated R10 was noted to have Moisture Associated Skin Damage (MASD) identified as Incontinence Associate Dermatitis on the coccyx. The document indicates it is in house acquired present since the exact date of 8/15/22. The evaluation indicates the wound bed is epithelial, 90% of wound bed covered, no signs or symptoms (s/s) of infection, there is no exudate or odor, periwound indicates edges are attached and flush with the wound bed or as a sloping edge, surrounding tissue is denuded. The evaluation does not include any measurements of the area or details regarding treatment or care plan changes recommended. Notes indicate: few scattered areas of irregular partial thickness skin loss throughout sacralooccygeal region from suspected IAD (incontinence associated dermatitis). Review of physician order/treatment records indicate on 08/17/22: Dermaseptin barrier cream (house-stock) to buttocks three times daily and as needed after incontinence three times a day. This order was discontinued on 09/01/22. Barrier cream was not initialed as completed at 7:00 a.m. on 8/19/22, 08/20/22, and 08/24/22; at 11:00 a.m. on 08/19/22, 08/20/22, 08/23/22, and 08/24/22; and at 5:00 p.m. on 08/18/22 and 08/25/22. Coccyx The 8/22/22 Skin and Wound Evaluation indicates R10 now has a pressure injury to the coccyx that is unstageable. The evaluation does not indicate why the area is unstageable. The evaluation indicates there is no exudate or odor. The periwound has edges that are attached. The details regarding treatments/dressings are blank. The evaluation does not include details on the measurement of the wound or who completed the evaluation. R10's Care Plan dated 8/22/22 includes a Focus indicating: *The resident has actual impairment to skin integrity to sacrum r/t (related to) limited mobility. Sacral unstageable pressure injury 8/22/22. Date Initiated: 08/23/2022. Interventions included: * PAIN: Evaluate residents for changes in pain level and if appropriate request a scheduled pain medication from physician. Date Initiated: 08/23/2022 * Apply barrier cream per facility protocol to help protect skin from excess moisture. Date Initiated: 08/23/2022 * Ensure that heels are elevated while resident is lying in bed Date Initiated: 08/23/2022 * The resident needs low pressure mattress and heel wedge to protect the skin while IN BED [emphasis not added]. Date Initiated: 08/23/2022 * The resident needs wheelchair cushion to protect the skin while up IN CHAIR [emphasis not added]. Date Initiated: 08/23/2022 * Use a draw sheet or lifting device to move resident. Date Initiated: 08/23/2022 * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 08/23/2022. * SKIN [emphasis not added]: Provide skin care with each incontinent episode Date Initiated: 05/26/2022 * Clean peri-area with each incontinence episode. Date Initiated: 05/25/2022 An 08/26/22: Skin/Wound Note indicates: .Sacral unstageable pressure injury remains stable with 100% eschar, beginning to soften therefore will continue with barrier cream. Remainder of head-to-toe skin assessment completed with no new findings other than described above. Repositioned onto right side, body positioner used, heels elevated, LP [low pressure] mattress functioning[.] The 8/29/22 Skin and Wound Evaluation indicates R10 has a pressure injury on the coccyx, starting 8/15/22. 3.7 x 3.8x na (not applicable) 100% slough, no s/s infection, no exudate, edges are attached, surrounding skin is denuded, no induration or edema. Pain is rated as an 8. Progress is marked as stable. Notes indicate unstageable pressure injury that is beginning to soften to slough, remains adherent. Some extension of the wound into the right buttock. The 8/29/22 Skin and Wound Evaluation indicates R10 has a pressure injury on the coccyx, starting 8/15/22. 3.7 x 3.8x na (not applicable) 100% slough, no s/s infection, no exudate, edges attached, surrounding skin is denuded, no induration or edema. Pain is rated as an 8. Progress is marked as stable. Notes indicate unstageable pressure injury that is beginning to soften to slough, remains adherent. Some extension of the wound into the right buttock. An 8/31/22 skin & wound evaluation indicates R10 has a pressure injury on their coccyx that is facility acquired and unstageable - start date 8/15/22. Area is 3.4 cm, 4.2 x 1.9 x nay, 100% slough. Notes indicate unstageable pressure injury with softening of eschar now covered with yellow slough. No signs of infection, resident very thin with significant bony prominences. An 9/7/22 skin & wound evaluation indicates R10 has a pressure injury on their coccyx that is facility acquired and unstageable - start date 8/15/22. Area is 1.7 cm - 1.9 x 1.6 x na - 100% slough. Notes indicate wound measures smaller, the portion of the wound that extended onto the right buttock has epithelized. Adherent slough persists to wound bed. An 9/14/22 skin & wound evaluation indicates R10 has a pressure injury on their coccyx that is facility acquired and unstageable - start date 8/15/22. Area 1.9 cm - 2.2 x 1.2 x na 100% slough. Notes indicate stable wound, remains covered with 100% slough, no significant change. An 9/21/22 skin & wound evaluation indicates R10 has a pressure injury on their coccyx that is facility acquired and unstageable - start date 8/15/22. Area .9 cm - 1.5 x 0.8 - 100% slough. Notes indicate stable unstageable pressure injury remains slough covered. Right Buttock An 8/29/22 skin & wound evaluation indicates R10 has an open lesion on their right buttock that is facility acquired on 8/29/22. 4.3 x 1.8 x na - there is description of the wound bed. Notes state: `new open area adjacent to unstageable pressure injury. Appears to be friction shear with 100% pink dermal tissue. Surveyor noted this is referenced in the skin evaluations for the coccyx. Despite indicating they are caused by friction/shear the facility identified this as an open lesion. An 8/31/22 skin & wound evaluation indicates R10 has an open lesion on their right buttock that is facility acquired on 8/29/22. 4.5 x 12.0 x na - there is description of the wound bed. Notes state: Wound noted 2 days prior, suspected friction/shear however will continue to monitor as wound evolves. Small circular area of non-viable dark tissue suggestion (sic) wound may be full thickness. Surveyor noted there is no indication this area was considered to be a pressure injury despite noting it was caused by friction/shear. There are no additional facility evaluations of this area after this date. Left Thigh An 8/22/22 skin & wound evaluation indicates R10 has a facility acquired deep tissue pressure injury on the left front thigh, the start date indicates 8/22/22. 2.6 x 2.3 x na, no exudate or odor, surrounding tissue is intact. Notes indicate: New DTPI (deep tissue pressure injury) to medial left leg above the knee. Some amount of fluid noted superior to wound edge. The document does not indicate there were notifications regarding this area. An 08/26/22: Skin/Wound Note indicates: Routine wound follow up completed, noted the deep tissue pressure injuries located to the left and right medial thigh have ruptured revealing 100% pink dermal tissue. Now stage 2 pressure injury. Treatment plan modified . Remainder of head-to-toe skin assessment completed with no new findings other than described above. Repositioned onto right side, body positioner used, heels elevated, LP [low pressure] mattress functioning[.] Review of physician order/treatment records indicate on 08/26/22: wound care to the left and right medial thigh; cleanse area with wound cleanser or saline, pat dry, cut piece of oil emulsion to fit wound, apply, cover with a bordered foam dressing. Complete wound care and change dressing Tuesday, Thursday, Saturday.one time a day every Tue [Tuesday], Thu [Thursday], Sat [Saturday]. This order was discontinued on 09/01/22. An 8/29/22 skin & wound evaluation indicates R10 has a left front thigh facility acquired open lesion (Surveyor noted this is a change from the previous week where it was identified as a deep tissue injury). The start date indicates 8/29/22. 2.6 x 2.3 x na, no exudate or odor, surrounding tissue is intact. Notes indicate: New 100% dermal open area to thigh, just few cm from initial DTPI that evolved to stage 2 pressure injury. Total of 3 area to medial thigh, 2 left, 1 on the right. Area was open to air therefore unable to quantify amount and consistency of drainage. An 8/30/22 skin & wound evaluation indicates R10 has a left thigh (front) pressure injury that is a stage 2, facility acquired with a start date of 8/22/22. No measurements are indicated. Notes indicate: DTPI that evolved to stage 2 pressure injury with 100% pink dermal tissue. An 8/31/22 skin & wound evaluation indicates R10 has a left thigh (front) pressure injury that is a stage 2, facility acquired with a start date of 8/22/22. Measurements indicate 2.1 x 1.6 x na. Note indicates: Resident self-removes dressings therefore unable to quantify amount and consistency of drainage. Surveyor noted the care plan was not revised to address R10 removing this dressing or documentation to indicate an assessment/discussion was had with R10 regarding the removal of dressings. There is also a second skin & wound evaluation dated 8/31/22 indicating R10 has a stage 2 pressure injury to left front thigh - start date is 8/29/22 - this form indicates measurements of 4.0 x 2.1 x na. The notes indicate: Stage 2 pressure injury to thigh, dressing removed by resident. A 9/7/22 skin & wound evaluation indicates R10 has a left thigh (front) pressure injury that is a stage 2, facility acquired with a start date of 8/22/22. Measurements indicate 0 x 0 x na. Epithelial percentage is 100%. Note indicates fully epithelialized. There is also a second skin & wound evaluation date 9/7/22 that indicates R10 has a left thigh (front) pressure injury that is a stage 2, facility acquired with a start date of 8/29/22. Measurements indicate 0 x 0 x na. Epithelial percentage is 100%. Note indicates fully epithelialized. Right Thigh Review of skin & wound evaluations for the right thigh include: 8/22/22 pressure injury that is facility acquired deep tissue pressure injury - start date 8/22/22. This evaluation indicates the area is located at the right medial thigh2.1 x 1.7 x na. Notes indicate: New DTPI to medial thigh just above the knee, area with deep maroon pigmentation, warmth, remains intact. +1 LE (lower extremity) edema. 8/29/22 right thigh medial pressure injury - facility acquired now identified as a stage 2 dated 8/22/22. 4.2 x 2.8 x na. Wound bed tissue is not identified. Notes indicate: No change in wound characteristics since DTPI evolved to stage 2 pressure injury. Site open to air therefore unable to quantify amount and type of drainage. 8/31/22 right medial thigh facility acquired pressure injury. 1.4 x 1.4 x na. Wound bed tissue type is not identified. Notes indicate: Resident removes dressings therefore open to air and unable to quantify amount and consistency of drainage. Treatment plan modified. Surveyor noted the care plan was not revised to address R10 removing dressings. On 9/7/22 the skin & wound evaluation indicates the area measures 0 x 0 with epithelialization. Notes indicate: Fully epithelialized wound to right knee. Right knee Further review of the facility skin & wound evaluations indicates R10 on 9/7/22 was identified to have an open lesion to the right knee - 2 x 1.7. This area had light purulent exudate, the wound bed tissue type is not identified. The notes on this evaluation indicate: new wound to anterior right knee. Suspect pressure as etiology due to appearance of wound is similar to prior DTPI that evolved into a stage 2. Surveyor noted this evaluation does not include all the details to be a comprehensive evaluation. The skin & wound evaluation dated 9/14/22 continues to identify this area as an open lesion despite being identified in the previous evaluation as having pressure as the cause. No measurements are indicated. The notes just indicate fully epithelialized wounds to the knee. Left Buttock On 9/7/22 the skin & wound evaluation indicates a facility acquired pressure injury was noted to the left buttock. This area is identified as unstageable. 3.6 x 2.2 x na with 90% slough. The remaining 10% of the wound tissue type is not identified. This is identified as a deteriorating wound. Notes indicate: Originally suspected friction/shear injury however as the wound progresses appears full thickness likely from pressure. Surveyor noted R10 was identified as developing other areas from friction and shear however this is not addressed on R10 plans of care. The 9/14/22 evaluation of this area indicates it is not a facility acquired stage 3 with 100% eschar. 3.9 x 1.8 x na. The notes indicate: Left buttocks wound showing new epithelial tissue to wound edges resulting in a decrease of surface area. The 9/21/22 evaluation continues to identify this area as a stage 3 facility acquired pressure injury. 2.9 x 1 x na. Wound bed is identified as 20 % granulation, 70% slough 10% eschar. Light exudate of serosanguineous is noted, surrounding tissue is check as having scarring. Notes indicate: Wound continues to decrease in size with new epithelium seen to wound edge. Wound bed was 100% slough last week, now 20 gran, 10 eschar, 70 slough. Wound Physician Evaluations The 08/31/22 Specialty Physician Initial Wound Evaluation and Management Note: CHIEF COMPLAINT This patient has multiple wounds. At the request of the referring provider, Dr. [MD-WW], a thorough wound care assessment and evaluation was performed today. She has a stage 3 pressure wound of the left, medial knee for at least 7 days duration. There is light serous exudate (Site 1) STAGE 3 PRESSURE WOUND OF THE LEFT, MEDIAL KNEE FULL THICKNESS .Wound Size (L [length] x W [width] x D [depth]): 4.2 x 3.0 x 0.1 cm [centimeters,] Surface Area: 12.60 cm^2[,] Exudate: Light Serous[,] Granulation tissue: 100 % .Tegaderm apply once daily for 30 days (Site 2) NON - PRESSURE WOUND OF THE LEFT, LATERAL THIGH FULL THICKNESS [,] Etiology (quality) Trauma/Injury .Wound Size (L x W x D): 2.2 x 2.3 x 0.1 cm[,] Surface Area: 5.06 cm^2[,] Exudate: Light Serous[,] Granulation tissue: 100 % .Tegaderm apply once daily for 30 days (Site 3) NON - PRESSURE WOUND OF THE RIGHT THIGH FULL THICKNESS[,] Etiology (quality) Trauma/Injury .Wound Size (L x W x D): 2.0 x 2.0 x 0.1 cm[,] Surface Area: 4.00 cm^2[,] Exudate: None[,] Granulation tissue: 100 % .Tegaderm apply once daily for 30 days Surveyor noted the facility referred to these areas as pressure and the wound physician is referring to them as non-pressure from trauma/injury. There is no explanation or indication of what the trauma/injury was that caused these areas. Surveyor noted the facility continued to refer to these areas as pressure injuries. (Site 4) STAGE 3 PRESSURE WOUND SACRUM FULL THICKNESS .Wound Size (L x W x D): 4.0 x 3.2 x 0.3 cm[,] Surface Area: 12.80 cm^2[,] Exudate: Moderate Serous[,] Slough: 20 %[,] Granulation tissue: 80 % .Leptospermum honey apply once daily for 30 days; Alginate calcium w/silver apply once daily for 30 days .Gauze island w/ bdr [border] apply once daily for 30 days .Recommendations[:] Turn side to side and front to back in bed every 1-2 hours if able; Reposition per facility protocol[,] REASON FOR NO DEBRIDEMENT [emphasis not added][:] Unable to obtain consent from patient or surrogate and unable to contact primary physician at this time (Site 5) STAGE 3 PRESSURE WOUND OF THE LEFT BUTTOCK FULL THICKNESS .Wound Size (L x W x D): 5.5 x 2.1 x 0.2 cm[,] Surface Area: 11.55 cm^2[,] Exudate: Light Serous[,] Granulation tissue: 100 % .Tegaderm apply once daily for 30 days[.] PREALBUMIN RECOMMENDED ON 8/31/2022 The 08/31/22 Specialty Physician Initial Wound Evaluation and Management Note included a wound care assessment summary and treatment plan for each wound. (SITE 1) STAGE 3 PRESSURE WOUND OF THE LEFT, MEDIAL KNEE .DRESSING TREATMENT PLAN .Add Tegaderm Once Daily 30[,] Discontinue Gauze .My goal for this wound is palliation as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. (SITE 2) NON - PRESSURE WOUND OF THE LEFT, LATERAL THIGH .DRESSING TREATMENT PLAN .Add Tegaderm Once Daily 30 .My goal for this wound is palliation as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. (SITE 3) NON - PRESSURE WOUND OF THE RIGHT THIGH .DRESSING TREATMENT PLAN .Add Tegaderm Once Daily 30 .My goal for this wound is palliation as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. (SITE 4) STAGE 3 PRESSURE WOUND SACRUM .DRESSING TREATMENT PLAN .Add Leptospermum Honey Once Daily 30[,] Alginate Calcium w/silver Once Daily 30 .Add Gauze Island w/ bdr Once Daily 30[,] RECOMMENDATIONS[:] Turn side to side and front to back in bed every 1-2 hours if able; Reposition per facility protocol .My goal for this wound is palliation as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 63 days. This estimate is made with an 80% degree of certainty. (SITE 5) STAGE 3 PRESSURE WOUND OF THE LEFT BUTTOCK .DRESSING TREATMENT PLAN .Add Tegaderm Once Daily 30 .My goal for this wound is palliation as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Surveyor noted R10's care plan was not updated to include the specific care plan/repositioning recommendations for R10 made by the wound physician. The 08/31/22 Specialty Physician Initial Wound Evaluation and Management Note included a summary for coordination of R10's care: History and information from the patient's chart reviewed: recommended Prealbumin on 8/31/2022. Data and history pertinent to this patient's care were obtained via nursing staff, patient, family member. This patient's care was discussed with another health care provider assigned nurse during this visit. Plan to discuss patient's abnormal BMI [body mass index] with current dietitian. If the patient does not currently have a dietitian following, recommend dietary consultation for abnormal BMI (see value above). The clinical documentation for this consultation was made available to the referring physician, Dr. [MD-WW]. This documentation has also been made available for access to the appropriate personnel and placement in the medical record. FOLLOW-UP: Evaluation by wound care specialist within 7 Day(s) with further intervention as indicated. An 08/31/22 Nutrition/Dietary Note indicates: Res [resident] cont [continues] w/wounds [with wounds]. Res is on a pureed diet with nutritional juice BID [twice daily] to provide additional kcal [kilocalories] and pro [protein] to help meet needs. Eating an average of ~ [approximately] 25-50% of meals. Will rec [recommend] increasing nutritional juice to TID [three times daily]. No sig [significant] wt [weight] changes. Will cont to monitor weight, intakes, labs, and wound healing. Review of physician orders/treatment orders dated 09/01/22 indicate: wound care to the left and right medial thigh (2 areas to left, 1 on right); cleanse area with wound cleanser or saline, pat dry, cover with transparent film dressing. Complete wound care and change dressing Monday, Wednesday, Friday one time a day every Mon [Monday], Wed, Fri [Friday]. This order was discontinued on 09/07/22. Also, on 09/01/22: wound care to sacrum; cleanse wound with normal saline or wound cleanser, pat dry, apply Medihoney gel followed by silver calcium alginate dressing, then bordered gauze. Complete wound care and change dressing daily one time a day. 09/01/22: wound wound [sic] care to the left buttock; cleanse area with wound cleanser or saline, pat dry, cover with transparent film dressing. Complete wound care and change dressing Monday, Wednesday Friday. one time a day every Mon, Wed, Fri. On 9/1/22 a significant change MDS was completed as R10 started hospice services. The MDS indicates A BIM score of 3 indicating R10 has severe cognitive impairment. This MDS indicates R10 has physical behaviors, but no rejection of care is indicated. The level of assist needed by R10 remains unchanged from the 7/20/22 MDS. The MDS indicates R10 is at risk for pressure injuries and has 3 stage 2 pressure injuries, 1 stage 3 pressure injury and 1 unstageable pressure injury. There is no indication R10's care plan was revised with this MDS. On 09/02/22: wound wound [sic] care to the right buttock; cleanse area with wound cleanser or saline, pat dry, cover with transparent film dressing. Complete wound care and change dressing Monday, Wednesday, Friday. one time a day every Mon, Wed, Fri. This order was discontinued on 09/06/22. Wound care was not initialed as completed on 09/02/22. The record indicates also on 09/02/22 at 7:54 a.m.: wound care to the sacrum; apply Zinc Oxide paste to wound twice daily and as needed after incontinence. Do not scrub off old zinc paste from skin. two times a day. This order was discontinued on 09/06/22. Wound care was not initialed as completed at 0700 (7:00 a.m.) on 09/05/22 and 09/06/22 and at 1700 (5:00 p.m.) on 09/02/22 and 09/04/22. 09/06/22: wound care to the sacrum and right buttock; apply Zinc Oxide paste to wound twice daily and as needed after incontinence. Do not scrub off old zinc paste from skin. two times a day for for [sic] wound management. This order was discontinued on 09/26/22. Wound care was not initialed as completed at 0700 (7:00 a.m.) from 09/10/22 through 09/14/22, 09/16/22, and from 09/19/22 through 09/21/22. Wound care was not initialed as completed at 1700 (5:00 p.m.) on 09/07/22, from 09/14/22 through 09/16/22, 09/19/22, 09/22/22, and 09/23/22. 09/07/22: wound care to the right knee; cleanse area with wound cleanser or saline, pat dry, cover with transparent film dressing Complete wound care and change dressing Monday, Wednesday, Friday. one time a day every Mon, Wed, Fri. This order was discontinued on 09/12/22. Wound care was not initialed as completed on 09/07/22. 09/07/22: Wound care to left medial thigh (2) and right medial thigh previous wounds; apply skin prep daily one time a day. A 09/12/22 Skin/Wound Note indicates: Head to toe skin evaluation completed during routine wound care. Pressure injuries to left and right thigh, knee have fully epithelized. Stage 3 pressure injury to the right buttock and unstageable sacral wound remain stable. No new wounds or pressure injuries present at this time. Surveyor noted the facility staff continued to refer to thigh wounds as pressure injuries despite the wound physician's evaluation. During interview on 12/28/22 at 12:46 p.m. with the Wound Services Director (RN-Q), RN-Q indicated, The resident has wounds on her butt, heel, thighs, and knee. Pressure ulcers were acquired here [at the facility]; 08/29 left buttock was Stage 2, on 08/15/22, coccyx wound began as MASD [moisture associated skin damage] at first due to incontinence and evolved into an unstageable wound by 08/22/22; within a week; the resident also developed a right knee wound on 09/07/22; a left thigh wound on 08/29/22, a right medial thigh wound on 08/22/22, and a left thigh wound on 08/22/22. All thigh wounds resolved prior to death. The resident was placed on hospice on 09/11/22. I [RN-Q] have 24 to 48 hours to evaluate wound after being notified; the resident was on a low air loss mattress on 08/26/22. I don't think there is a provider order for it. I've worked here since April 2022; I assess wounds weekly, and measurements are done at that time; coccyx wound deteriorated a week later but was slowly improving; the left buttock more partial thickness and was starting to get a little better. The Surveyor asked if she thought the wounds were unavoidable and RN-Q stated, I don't know, she was extremely cachectic and resistive to care. The Surveyor questioned the likelihood of the wounds being unavoidable if the wounds were able to be healed or were healing; RN-Q stated, Partial thickness wounds tend to heal quicker. It's hard to say, I've seen it go both ways. DON-B provided an Investigation Report on 12/28/22 after the daily debrief meeting at approx. 4:45 p.m. that showed an investigation was conducted for R10 to determine whether the resident's pressure ulcers were unavoidable. The document included the resident's hospice start date of 09/01/22. The document included when each of the five wounds developed and listed risk factors including: nutritional risk factors included an Albumin of 2.4g/dL (grams per deciliter), a weight loss of 2.9% in August (likely higher actual weight loss related to presence of edema), a house supplement was ordered upon admission with additional nutritious juice supplements added on 07/19/22 and increased on 08/31/22, the resident had chronic urinary and bowel incontinence and swelling noted to the resident's bilateral lower extremities in August, the resident's plan of care addressed her impaired circulation (no dopplers completed during stay), and R10's had a history of refusing care. The investigation did not include the review of Treatment Administration Records to determine if orders to prevent skin breakdown were followed and whether the care plan interventions were followed to prevent skin breakdown (i.e., incontinence care, repositioning, and wound care). During the exit meeting on 12/29/22, the Clinical Service Director (CSD-AA) did not have questions regarding the information shared by the Surveyor regarding the pressure ulcers and lack of investigation into whether the pressure ulcers were avoidable. On 1/5/23 the facility provided information that included the facility's rationale for why R10's pressure injuries are unavoidable based upon behaviors and co-morbidities. The facility summary states: These wounds were unavoidable based upon the resident's diagnosis, change in condition and entrance into hospice are (sic) shortly after wounds developed in August. 4 of 6 wounds healed before the resident's expiration on 9/24/22. The remaining 2 wounds were improving significantly. Therefore, the s/s (scope/severity) at a harm level is not indicated. The only deficient practice was related to care plan error describing (R10) as mobile when in fact she was bedbound her entire stay at the facility. This may

Based on observation, interview, and record review, the facility did not provide an environment free of accidents and hazards by leaving medicated lotions, and personal care products within reach and unsupervised for 3 (R20, R21, R22) of 3 residents reviewed in the secured 500 unit. Findings include: On 12/20/22 at 9:02 a.m., Surveyor observed an eight (8) fluid ounce tube of Dermasil(R) dry skin treatment on the top shelf of a bookcase in the TV room with no staff present. R20 and R21 were in the TV room, and at 9:03 a.m., R22 independently wheeled into the TV room and transferred themselves from the wheelchair to a stationary padded chair. R22 was able to state their name. On 12/20/22 at 9:08 a.m., Licensed Practical Nurse (LPN-J) said, that lotion [holding the tube of Dermasil(R)] is not supposed to be there [indicating the unsupervised bookcase in the TV room]. R20 was admitted on [DATE] with diagnoses including type 2 diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, dysarthria (difficulty with speech and language) and anarthria (lack of speech or language), and muscle weakness. A physician's note dated 09/14/22 showed that R20 had a diagnosis of vascular dementia. R20's last annual Minimum Data Set (MDS) dated [DATE] documented the resident's Brief Interview of Mental Status (BIMS) score was 7, suggesting a severe cognitive impairment. Physical functioning for transfer as needing extensive one-person physical assistance, with no limitation in range of motion. R20's MDS indicates they use a walker or wheelchair. Review of R20's Care Plan initiated 12/02/21 included the following: R20 has a communication problem related to cerebrovascular accident (CVA). The goal, initiated on 12/02/21 with a target date of 03/3/23 stated: R20 will be able to make basic needs known on a daily basis through next review date. Interventions initiated on 12/02/21 included: Anticipate and meet needs and to discuss with resident/family concerns or feelings regarding communication difficulty. Initiated 12/02/21. Review of a second Care Plan note initiated on 12/15/22 stated: (R20) has impaired cognitive function/dementia or impaired thought processes related to BIMS score seven (7). That goal initiated 12/15/22 with a target date of 03/03/23 stated: The resident will be able to communicate basic needs on a daily basis through next review date. Interventions initiated on 12/15/22 included: Encourage daily rest periods initiated on 12/15/22. Cues reorient and supervise as needed (12/15/22), monitor/document/report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status (12/15/22). Use task segmentation to support short term memory deficits. Break tasks into one step at a time (12/15/22). R21 was admitted on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. R21's most recent quarterly MDS dated [DATE] identified a BIMS score was 15 suggesting intact cognition [the BIMS of 15 did not reflect the diagnosis of dementia]. Physical functioning was coded for transfers as extensive assistance, two-person assistance needed. Locomotion on unit was coded as supervision of one person assist. With limitation on one side of upper extremities and one side of lower extremities. R21's Care Plan initiated 05/18/20 with a target date of 02/27/23 included: The resident has an actual [facility did not insert word here] for ADL self-care performance deficit related to [facility did not insert word here to define deficit] initiated 05/18/2020. The goal initiated on 05/18/20 stated: The resident will maintain current level of function in (SPECIFY) [facility did not insert word here to specify level of function] through the review date. Interventions initiated on 05/18/20 included: Ambulation: Non-ambulatory: independent with wheelchair mobility- Initiated 5/20/2020. Transfers: hands on assist of one (extensive) initiated 5/20/2020. Transfers: Resident requires supervision initiated 05/23/2020. R22 last annual MDS dated [DATE] was coded for BIMS score of 9, suggesting the resident had a moderate cognitive impairment. Physical functioning was coded for mobility locomotion on unit as extensive one (1) person assist, transfer-extensive one-person assist, Surface to surface transfers was not steady-only able to stabilize with staff assistance. Functional limitation in range of motion was impaired on one side of upper extremity and one side of lower extremity. R22's Care Plan initiated on 10/27/21 included: Focus: The resident has actual activities of daily living (ADL) self-care performance deficit; unsteady gait and muscle weakness. Interventions initiated on 10/27/21 included: Transfers: resident requires physical assistance. Focus: the resident has limited physical mobility related to muscle weakness and gait and mobility abnormality. Goals initiated on 10/27/21 with a target date of 02/20/23 included: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions include the following uses cane initiated 10/27/21 provide supportive care, assistance with mobility as needed, and document assistance as needed- initiated 10/27/21.[R22] has impaired cognitive function/dementia or impaired thought processes r/t dementia initiated 11/04/21. On 12/21/22 at 12:18 p.m., a room adjacent to the Spa had an open door. In the room on top of the counter were three (3) 7.5 ounces bottles of Derma Vera Skin and Hair Cleanser, two (2) 1.5-ounce tubes of Dawn Mist fluoride toothpaste, multiple packs of orange sticks, a pair of nail clippers, two (2) bottles of Osmolite 1.2 calorie 1000 milliliters, and a wooden handled plunger. In the same room a cabinet under the sink had seven (7) additional bottles of Skin and Hair cleanser. In a drawer there was 20 bottles of Dawn Mist toothpaste and three (3) tubes of petroleum jelly. On 12/21/22 at 12:28 p.m., Licensed Practical Nurse (LPN)-J stated that door should not be left open. It's not locked or anything. LPN-J closed door [the door did not have a locking mechanism] and walked away from the room. The items identified in the room were still in the same locations. The secured 500 unit had 30 residents with access to the space and items. On 12/21/22 at 12:35 p.m., the Interim Director of Nursing (DON-B) was brought to the room and stated, those things should not be open and within reach of residents who wander because it is a risk for accidents. She gathered the listed items but left the Osmolite in the room.

Based on observation, interview, and record review, the facility did not ensure 1 (R15) of 1 resident reviewed who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. R15 has diagnoses including depression and anxiety. Based on interview and record review, the facility did not have an interdisciplinary approach to care for the resident, specifically related to the resident's distressed behaviors including having conflicts with others and calling 911. R15 continues to exhibit a depressed mood as observed during an interview with facial grimacing and tears in his eyes when describing how the facility called the police on his mother, who was upset with the lack of cares provided. R15 was observed lying in bed with his blanket covering his head. R15 is noted to repeatedly call 911 with verbalizations of not being cared for. R15 expresses repeated care concerns of not being cleaned up in 4 days, not being showered, not getting out of bed. R15 repeatedly states, I want out of here .they know I want out of here. Surveyor noted Geropsychiatric follow-up and interdisciplinary team discussions did not include information about R15's plan of care. The facility did not assist R15 to attain the resident's highest practicable mental and psychosocial well-being while living in the facility. Findings include: According to records reviewed by Surveyor, R15 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), anxiety, depression, neurogenic bladder, and history of pulmonary embolism. The most recent quarterly Minimum Data Set (MDS) dated [DATE] identified R15 with a Brief Interview for Mental Status (BIMS) score of 15 which suggested the resident's cognition was intact; the resident had no behavioral symptoms and did not reject care. The MDS indicated that the resident required assistance of one for bed mobility, which happened once or twice during the assessment period and required two or more staff persons for transfers, which happened once or twice during the assessment period; and was dependent upon one staff person for bathing. R15 required the use of an indwelling urinary catheter for a neurogenic bladder; bowel continence was not rated. The annual MDS dated [DATE] was essentially unchanged except R15 required extensive assistance for bed mobility from one staff person, required extensive assistance from two or more staff for transfers, and was always incontinent of bowel; bathing did not occur during the assessment period. R15's Initial Psychiatric Evaluation note dated 04/11/22 was completed by a Nurse Practitioner and documented chief complaint - nervousness, yelling, poor coping .irritability at times, verbal outbursts at times .Rapport: uncooperative, Facial expression: slightly angered. The note further indicated R15 stated, I have my own psychiatrist .would likely benefit from Buspar. No further recommendations were made. A Geropsychiatric Follow-Up note dated 07/26/22 was reviewed and indicated Major depressive disorder, anxiety, ADHD [attention deficit hyperactivity disorder]. Hospital 7/2 - 7/7 - sepsis (UTI [urinary tract infection]), Calling 911 to repeat [R15] isn't being cared for. False accusations persist. Inpatient with having needs met .Depressed, irritability, verbal outbursts frequently .Patient states has own psychiatrist and saw her last month! Not on record here! Patient refuses any med [medication] adjustments, especially to decrease Adderall which is likely increasing anxiety. Follow up 3 months. The note further indicated R15 stated, I hate it here. I don't want to change my meds. The note had no additional recommendations for facility staff to find strategies to assist R15 with effective coping skills etc. No further Geropsychiatric notes were provided indicating there was a follow up three months after 07/26/22. The Care Plan dated 09/28/22 identified problems as follows: The resident has a behavior problem of mocking other people with a goal that stated, Resident will show a decrease in negative behaviors by next review date. The approaches to reach the goal included, Provide a calm and safe environment to allow resident to express feelings as needed. Provide resident with area for decreased stimulation as needed for negative behaviors. The resident uses antidepressant medication [medication not specified] r/t [related to] Depression with a goal that stated, The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The approaches to reach the goal included, Administer ANTIDEPRESSANT [emphasis not added] medications as ordered by physician .Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy The Hospital Physician History and Physical note dated 12/03/22 indicated R15 was hospitalized for altered mental status, elevated temperature, influenza A, and urinary tract infection. A discharge note dated 12/07/22 indicated R15 was prescribed Bupropion 300 milligrams (mg) daily for major depressive disorder. Based upon a review of R15's medication orders, R15 was ordered Bupropion 300 milligrams extended release daily for depression. Physician Orders were reviewed and included the following: 12/07/22 - Bupropion XL [extended release], 300 milligrams (mg), give one tablet by mouth one time a day for depression. 12/08/22 - Methylphenidate 20 mg, give one tablet by mouth, three times a day for ADHD [attention deficit hyperactivity disorder]. 12/08/22 - Oxycodone 15 mg, give one tablet by mouth every 6 hours as needed for pain. R15's Nursing Progress Notes were reviewed from August to December 2022 to determine if there had been notes regarding R15's behavior symptoms. According to a note, On 08/28/22 at 9:57 a.m. - [R15] hit agency CNA [Certified Nursing Assistant] for trying to turn off [R15's] call light and address [R15's] need. 2nd time CNA responded .DON [Director of Nursing] involved. At 10:02 a.m. - Resident called ambulance to be sent out bc [because] med [medication] pass taking too long and [R15] wanted pain med right now. The Nursing Progress Note indicated that at 2:23 a.m. on 08/28/22 R15 had received Oxycodone 15 mg [milligrams] for pain in an unknown location and unknown intensity. R15 was due at approximately 9:23 a.m. for Oxycodone but chose to contact 911 to be transferred to the hospital for pain medication. On 12/21/22 the facility provided copies of Behavior Management Interdisciplinary Team Notes following the Surveyor's request to provide any notes regarding R15's behavior management plan with the interdisciplinary team. Notes were reviewed and included: 04/26/22 - Methylphenidate TID [three times a day] 10 milligrams [mg] - ADHD [attention deficit and hyperactivity disorder] start date 04/14/22. Bupropion QD [daily] 300 mg depression 04/01/22. BIM [Brief Interview for Mental Status] score 14 [indicated R15 had no cognitive impairment] 04/06/22. PHQ9 [Personal Health Questionnaire 9] score 7 [indicated mild depression] on 04/06/22. Extremely anxious, calls 911 nearly daily. The note had no further recommendations or revisions to R15's plan of care. July [no specific date] - Methylphenidate 20 mg TID, ADHD 07/07/22; bupropion QD 300 mg, anxiety 07/08/22. Decrease Adderall. The note had no further revisions to the plan of care. October [no specific date] - Methylphenidate 20 mg TID, ADHD 10/04/22; bupropion 300 mg QD, depression 09/16/22; Lamotrigine 25 mg QAM [every morning] depression 10/05/22. The note had no further revisions to the plan of care. On 12/19/22 at 9:55 a.m., R15 was observed lying in bed in a private bedroom and agreed to be interviewed. R15 explained, I want to get out of here .My medications are late sometimes. They don't have enough help here. My mom came in on Sunday [12/18/22] and lost it! She is a nurse and had to clean me up. I really stunk bad. I wasn't cleaned up in 4 days. My mom yelled at the staff and they called the police on her! I can't believe they called the police on my mom! She was doing their job, cleaning me up. My mom took pictures of me when I was a mess. During the time R15 described the event, he exhibited facial grimacing, had tears in his eyes, and repeated the same phrase more than three times, I can't believe they called the police on my mom! When asked if he had voiced his care concerns to the Director of Nursing, Social Worker, or Administrator, he responded They know I want out of here. I have complained, no one does anything! I have MS, I can't clean myself up. I haven't had a shower in weeks .They are too busy to get me up .they don't get me up for therapy. A manual standard wheelchair was observed in R15's room and when asked how R15 would transfer to the wheelchair to get out of bed and go to therapy or get to a shower, R15 responded, I can't sit in that wheelchair. They [nursing staff] don't get me up .I can't sit up straight by myself. When asked if R15 had been transferred to another supportive reclining chair, R15 responded, I only have that wheelchair, as R15 pointed to the manual wheelchair in the room. On 12/19/22 at 1:20 p.m., a Certified Nursing Assistant (CNA-S) was interviewed regarding R15's activities of daily living and CNA-S indicated, [R15] gets up with therapy after lunch .they get him up and we transfer [R15] back to bed. When CNA-S entered R15's room on 12/19/22 at approximately 1:25 p.m. R15 was lying flat in bed and had blankets covering the resident's head and face. R15 was interviewed by the Surveyor while CNA-S was present; the Surveyor then observed hygiene care and an indwelling urinary catheter was observed. When R15 was asked if therapy had come to provide treatment, R15 stated Not yet. CNA-S did not offer to get the resident out of bed prior to leaving the room. After CNA-S left the room at approximately 1:40 p.m., R15 indicated R15's mother wanted to tell the Surveyor what she observed on 12/18/22. R15 called R15's mother and her husband and she indicated [R15] was lying in stool, it was hard, it was on the sheets, the odor was so strong. [R15] told me there were not enough staff and [R15] doesn't get showers, doesn't get out of bed. I never see [R15] out of bed. On 12/19/22 at 3:45 p.m. an Occupational Therapist (OT-U) and a Physical Therapist (PT-BB) who were familiar with R15 were interviewed and each acknowledged that R15 was evaluated for therapy services and had a plan in place. When each were asked if staff caring for R15 were permitted and trained to get R15 out of bed, PT-BB indicated, Staff have to use a Hoyer lift [mechanical device] to get [R15] up to a high-back wheelchair or Broda [reclining chair]. When asked if staff were getting R15 up when therapy services interact with R15, each acknowledged R15 primarily remained in bed and PT-BB stated, I don't know why they don't get him up. On 12/20/22 at 9:00 a.m. R15 was not in bed and when staff were asked where R15 was, an Agency Registered Nurse (RN-NN) indicated, [R15] called the ambulance and left around 7:00 a.m. When asked what was wrong, RN-NN stated, I never saw [R15]; he was gone. I heard [R15] complained of the [urinary] catheter burning. When asked if R15 would refuse physical or occupational therapy or getting out of bed with staff assistance RN-NN stated, Yes. [R15] gets therapy .I've been here before and therapy works with [R15]. Staff try to get [R15] up, but [R15] refuses. On 12/20/22 at 10:00 a.m. the Interim Director of Nursing (DON-B) was interviewed and asked if the facility had conducted a comprehensive interdisciplinary meeting with R15 to discuss concerns regarding care to meet R15's needs and avoid conflict with staff. DON-B indicated being aware of R15's concerns and indicated R15 was difficult for staff to work with at times stating, [R15] is a very angry [person]. Has a chronic, debilitating disease. Wants to get out of here. Group home won't take him. Won't work with our Behavioral Health Nurse Practitioner, uses profanities, kicks staff out of room. When asked if DON-B had communicated with the Medical Director for guidance to care for R15's behavioral health needs, DON-B stated, He's aware [R15] does this On 12/20/22 at 2:30 p.m. the Social Services Director (SW-M) was interviewed to discuss R15 and whether the interdisciplinary team had conducted a comprehensive review to meet R15's psychosocial needs. SW-M indicated [R15] has been in and out of the hospital, not very nice to the staff, kicks staff out of room. [R15's] behaviors are escalating .mean to staff, swears at them, gives them the finger. When asked if the Facility Consultant Psychiatric Nurse Practitioner had offered staff and R15 any assistance to meet R15's needs in the most effective way possible and ultimately avoid further conflict, SW-M responded, We could Set up another meeting to talk with [R15] and invite the Psychiatric Nurse Practitioner. The SW-M indicated We don't know what else to do. On 12/21/22 at approximately 12:10 p.m. OT-U was interviewed and asked when R15's high-back wheelchair would have been ordered, since it was not observed in R15's room, shower/spa room, or storage room. OT-U provided a Physical Therapy Encounter Note dated 09/22/22 that indicated, Pt. [patient] in bed, stated [R15] wasn't changed at all yesterday, wants to get into the chair but needs to get changed .PT coordinated with CNAs to get patient changed and into chair. CNAs changed pt. then got pt. into chair .PT educated pt. on sitting with high back w/c [wheelchair] in most tolerable upright position Additional Physical Therapy notes were reviewed and indicated, 12/08/22 - Initial evaluation. 12/12/22 - refused therapy, upset re: Ocrevus [plasmapheresis services] appointment, upset not being dressed. 12/13 - mom visited and upset with care. 12/16/22 - participated and motivated. 12/16/22 - work on balance and trunk control. On 12/21/22 at 3:20 p.m. R15 was observed lying in bed with blankets over top of R15's head. R15 was interviewed and asked why [R15] had gone to the hospital on 12/20/22 at approximately 7:00 a.m. R15 responded, I had burning with the catheter. When asked if the Facility Nurse had evaluated R15's catheter, R15 acknowledged the Nurse had examined the catheter and urinary drainage bag. R15 indicated he did not want to wait for the Doctor .wanted it looked at right away. When asked when R15 last had a shower, R15 opened the cellphone and stated, It was 11/03/22 when I had a shower .They always give an excuse 'We're short [short staffed].' My shower day is Thursday. R15 indicated physical therapy was just in and worked on bedside strengthening. I sat on the edge of the bed. R15 was further interviewed and indicated, My Outpatient Psychiatrist sees me by telehealth every week. R15 was asked how R15's Outpatient Psychiatrist and Facility Nurse Practitioner communicated and shared information to help R15 most effectively. R15 responded, You'd be depressed too if you were here. I have my Psychiatrist to help me. What would the Nurse Practitioner do for me here? On 12/27/22 at 9:25 a.m. the Facility Resident Assessment Coordinator (RAC-DD) who is a Licensed Practical Nurse and Resident Assessment Coordinator (RAC-EE) who is a Registered Nurse were interviewed. Each acknowledged that R15 had diagnoses of depression and anxiety and was taking a daily antidepressant, bupropion, and had not refused taking bupropion. RAC-DD further indicated that we talk about [R15] at our morning meetings. RAC-DD and RAC-EE were asked if an interdisciplinary team meeting had occurred regarding care issues that included conflicts with other residents, conflicts with staff, calling 911 for pain medication, or complaints of urinary catheter burning and RAC-DD responded, No. We talk about him in the morning and further acknowledged no additional team meetings had occurred to review R15's plan of care to treat symptoms of distressed behavior. At approximately 1:44 p.m., DON-B stated that the facility did not document quarterly interdisciplinary team meeting notes to capture discussions regarding R15's care needs and concerns. On 12/27/22 at approximately 11:12 a.m. the Consultant Psychiatric Nurse Practitioner (PNP-KK) was telephonically interviewed regarding R15's behavioral health needs PNP-KK acknowledged R15 had diagnoses of depression and anxiety but did not believe R15 had an attention deficient disorder despite R15's personal Psychiatrist's order for Adderall medication; PNP-KK had no access to R15's Psychiatrist notes since R15 would not sign over permission for us to review. PNP-KK added, The Adderall will increase [R15's] anxiety .not recommended for [someone with a diagnosis of] MS [multiple sclerosis] .[R15] won't let me make changes in medications .refuses to talk to me, refuses to play ball. When asked if any recommendations had been made to the interdisciplinary team to assist R15 in managing the resident's anxiety and depression, PNP-KK indicated, No changes since our last behavior meeting [October 2022]. On 12/27/22 at approximately 4:00 p.m. DON-B, the Nursing Home Administrator (NHA-A), and the Director of Clinical Services (DCS-AA) were interviewed at the daily debriefing meeting and no new information was provided to assist R15 to attain the resident's highest practicable mental and psychosocial well-being while living in the facility.

Based on observation, interview and record review, the facility did not ensure that residents were free from physical abuse for 2 (R14 and R12) of five residents reviewed for abuse. * R14 self-reported to facility staff on 3/26/22 that she was struck in the chin by her roommate R13. *R12 was reported to have been pulled out of her bed on three occasions (4/6/22, 5/8/22 and 5/22/22) by R13, who insisted this was her bed and her apartment. This continued abuse resulted in actual harm to R12 of bruising and pain which resulted in a need for evaluation in the emergency room . Using the reasonable person concept, it is likely this caused chronic or recurrent fear/anxiety from the lack of security of feeling safe in one's own room. Findings Include: The facility policy, entitled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, effective date 11/28/17, states in part: .It is the policy of the Facility that each resident will be free from Abuse. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection .The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention . The policy covers the seven components of Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting and Response. R13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Comprehensive MDS (Minimum Data Set) Assessment, dated 1/22/22, indicates R13's speech is clear and R13 able to make herself understood. R13's BIMS assessment indicates a score of 6 out of 15 which is severely impaired for daily decision making. 1. R13's roommate was R14. R14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's most recent MDS Comprehensive Assessment was completed on 8/20/21. R14's speech is clear, and she is able to make herself understood. R14's BIMS assessment indicates a score of 14 out of 15 which indicates that she is cognitively intact. R14 requires partial to moderate assistance for mobility. Surveyor reviewed R14's NN (Nursing Notes) dated 3/26/22. NN states, Resident is reported to have bruise on chin. Writer observed that bruise was present on right side of chin at 0730. Resident reports roommate struck her. Bruise measures 4cm x 2.25cm. R13 was the identified roommate at the time of the incident. According to R14's NN dated 3/26/22, DON-B instructed staff to move R14 to a safer situation and resident was moved to a different room. Resident informed of room change and is feeling less nervous about going back to her room with the room change. On 5/24/22 at 9:06AM Surveyor interviewed R14 and asked if she felt scared in the facility. R14 stated that she was, a little bit scared at first when it happened, however now she isn't afraid anymore. 2. Another resident on R13's floor was R12. R12 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's most recent MDS (Minimum Data Set) Comprehensive Assessment was completed on 10/28/21. R12's speech clarity is scored at a 1; unclear speech - slurred or mumbled words and her ability to make self understood is scored at a 3; rarely/never understood. R12's BIMS (Brief Interview for Mental Status) assessment indicated a 0 that resident is rarely/never understood. Staff assessment for Mental Status Section C1000. Cognitive Skills for Daily Decision Making is scored at a 2 (moderately impaired - decisions poor; cues/supervision required. R12's MDS indicates R12 needing substantial/maximal assistance for mobility. According to R12's NN (Nursing Notes) dated 4/6/22, R12 was found lying on the floor at 9:04AM. Another resident (R13) was sitting in R12's bed. R13 appeared aggressive and was shouting that this was her bed and her apartment. Resident on floor (R12) said that the other resident (R13) pulled her out of the bed onto the floor because she thought it was her bed. Resident was checked for injuries, pain, body and neuro checks were completed. Surveyor reviewed R13's Physician Note dated 4/9/22. Note states that patient's altered behavior over the last few weeks and possibly much longer recently assumed to be due to [CONDITION(S)]. However, patient's treatment with antibiotics did not seem to change the behavior. Order an ammonia level and other test that may explain reversible causes of altered mental status and behavior. Aggressive behavior on the other hand may also deserve treatment with neuroleptic. Review of R13 Physician Note dated 4/18/22. Blood work and exam did not explain escalating behavior. Staff is at risk as well as the patient. Starting [MEDICATION(S)] orally with follow-up all platelet count and ammonia level. Physician's note on 4/20/22 states demented patient with behavioral problems who is failing [MEDICATION(S)]. We will try low dose [MEDICATION(S)] in the evening with follow-up of electrolytes and electrocardiogram (EKG). R13 was started on [MEDICATION(S)] 250mg 1 tablet 2 times per day for dementia with physical and verbal aggression on 4/18/22. [MEDICATION(S)] 25mg at bedtime for agitation was added on 4/20/22. 3. Continued review of R12's NN state that on 5/8/22 at 4:46AM R12 was found lying on the floor. Another resident (R13) was sitting on her bed. Resident unable to explain how she got on the floor. Small bump on the middle of forehead. Review of the record indicates that neuro checks were completed 5/8/22 at 21:23PM, 5/9/22 at 6:37AM, 5/10/22 at 5:31AM and 5/10/22 at 20:02PM. All were negative for abnormal findings. 4. Continued review of R12's NN state that on 5/22/22 at 11:00AM R12 was found on floor next to bed and another resident (R13) was walking out of her room. Small 1cm hematoma noted to front of forehead right side, lumbar area is excoriated, no bleeding or drainage noted, left side has a large bump to area, was slightly purplish. Sent to [name] hospital. Return to facility 5/22/22 at 11:25PM. Per R12's NN, on 5/23/22 at 21:01 an order was placed to apply a cold compress to right wrist for 20-30 minutes two times every shift for acute pain for 2 days until finished. R12 refused ice pack. On 5/23/22 at 23:24PM R12 refused to take her medication for pain and R12 did not complain of pain. On 5/24/22 at 6:02AM R12 continues to complain of right arm pain. R12 refused Tylenol. On 5/24/22 at 7:28AM results of x-ray ordered are negative for fracture or dislocation. On 5/24/22 at 8:30AM Facility provided Surveyor a printed word document that outlines interventions they implemented for R13 since 4/6/22. This document indicates that on 5/22/22 R13 is 1:1 while outside of room. On 5/24/22 at 11:45AM Surveyor interviewed DON-B regarding expectation from staff implementing a 1:1. She stated that the expectation currently is that when R13 is up and walking around then staff assigned is walking with her. Staff should be within arm's reach if not closer she R13 attempt any aggressive behavior. Observations and interviews on 5/23/22 and 5/24/22 revealed that 1:1 supervision was not being provided, and staff was unaware that 1:1 supervision needed to be provided. Cross-reference F689. On 5/25/22 at 2:30PM Nursing Home Administrator (NHA-A) and DON-B were informed of the above findings. Additional information was requested if available. No additional information was provided. Abuse occurred because R13 intended her actions regardless of whether R13 was aware of the potential consequeces. Neither R12 nor R14 experienced serious physical harm; however, both experienced psychosocial harm. R14 stated she was scared at first. R13 is not able to verbalize her feelings after being pulled from bed three times. Using the reasonable person concept since R12 is unable to verbalize how she feels, a reasonable person would feel scared and experience chronic or recurrent fear/anxiety when targeted and repeatedly pulled from bed. One's sense of security is compromised when one cannot feel safe in one's own room because another person repeatedly enters your living space and pulls you from bed. Security is the second-most basic level of need according to Maslow's hierarchy of needs. If not met, one cannot reach his/her highest practicable level of well-being.

Based on observations, interviews and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 2 (R4 and R8) residents reviewed for pressure injuries. R4's sacral pressure injury was not comprehensively assessed to include staging of the pressure injury, characteristics of the wound and measurements of the wound. R8 was observed to have the wrong dressing on wound, no air mattress and the treatment was not completed as ordered. Findings include: The facility policy titled: Skin Protection Guideline dated 7/7/21, documents (in part) . . Purpose: To provide evidenced based practice standards for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluation Our facility applies a process to identify residents with or at risk for developing a pressure injury: Upon admission/readmission Transfer out/in With significant changes in condition Routinely through the MDS (Minimum Data Set) process The process includes evaluating: Specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI (Pressure ulcer/Pressure injury). Implementing, monitoring and modifying interventions to stabilize, reduce or remove underlying risk factors. If a PU/PI is present, provide treatment to heal and prevent the development of additional PU/PI's. The first step in the prevention of PU/PI's is the identification of the resident at risk. A pressure ulcer/injury can occur whenever pressure has impaired circulation to the tissue. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. An admission evaluation helps identify residents at risk and residents with existing PU/PI's. Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. Interventions Selection of an individualized support surface for bed and seating to enhance pressure re-distribution. Elevating heels (offloading all pressure) for residents that cannot turn and reposition themselves. Specified turning and repositioning. Monitoring of Skin Integrity weekly by a licensed nurse. Regardless of terminal status or disease trajectory ongoing interdisciplinary measures should be evaluated and implemented to attempt to maintain skin integrity, protect skin and treat skin. Quick Reference Guide for Topical Wound Management: Wound assessment and special considerations: Note wound location and dimensions. Assess periwound skin for changes in temperature or firmness. 1.) R4 admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility admission Nursing Evaluation dated 2/10/22 documented: Does the resident have skin integrity issues? Yes Skin impairments: Document impairment site. Under description document initial wound measurements and general evaluation. 49) Right heel dark/red/black pressure area 50) Left heel dark red/black pressure area 53) Sacrum open area Comments: Wound team to assess. Surveyor noted there was no documentation of a comprehensive assessment to include staging of the wounds (including the sacrum pressure injury), description of the wound characteristics or measurements of the wound. Review of R4's hospital record on 2/10/22 documented: Coccyx wound stage 3 with slough. A Facility Progress note dated 2/10/22 documented: Sacral/coccyx wound present and cleansed with saline and wet to dry placed. Wound team to assess all areas noted. Surveyor noted there was no documentation in the progress notes of a comprehensive assessment to include staging of the wound, characteristics of the wound or measurements. R4's Care Plan Focus, date initiated 2/11/22 documented: The resident has actual impairment to skin integrity (SPECIFY location) r/t (related to). Surveyor noted no location or related to was documented. Interventions included: Evaluate and treat per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Evaluate resident for S/SX (signs/symptoms) of possible infections. Review of R4's February 2022 Treatment Administration Record (TAR) documented: Coccyx wound cleanse with saline and place a wet to dry and cover with a border dressing Q (every) daily one time a day for wound healing/comfort wound team to assess. Signed as completed on 2/11/22. Santyl ointment 250 unit/gm (gram) ([MEDICATION(S)]) Apply to coccyx topically one time a day for wound care - order date 2/11/22. Signed as completed 2/12, 2/13, 2/14 and 2/16/22. There was no signature as completed for 2/15/22. R4's Admission MDS with an Assessment Reference Date of 2/13/22 documented: Bed mobility - Extensive assistance, 2 person physical assist. Skin conditions: Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar present on admission. The CAA (Care Area Assessment) worksheet documented: Existing pressure ulcer/injury. Assess location, size, stage, presence and type of drainage, presence of odors, condition of surrounding skin. Note if eschar or slough is present. Needs a special mattress or seat cushion to reduce or relieve pressure. Requires regular schedule of turning. A Facility Progress note dated 2/15/22 documented: Writer in to complete weekly wound assessment with wound MD (Medical Doctor). Patient refuses assessment, states: I'm resting now he can see me next week. Writer explained the risks vs (versus) benefits, including worsening wounds and death. Resident vocalizes understanding. Patient is own responsible party. Surveyor noted this was the only documentation regarding the sacral pressure injury since R4 was admitted to the facility 5 days prior. Treatment to the sacral pressure injury was signed out as having been completed, however there was no documentation in R4's medical record of any assessment of the wound to include staging of the wound, characteristics or size/measurements of the wound. Facility progress notes dated 2/17/22 at 4:53 PM documented: Received orders post [CONDITION(S)] for resident to be sent to (hospital) ED (emergency department) for eval (evaluation) & tx (treatment) if ind. (indicated) / Hgb (hemoglobin) 6.5/transfusion PRBC's (packed red blood cells) per (doctor) neph (nephrologist). Call placed to ambulance for transport. Review of the hospital ED report dated 2/17/22 documented (in part) . . ED course: [AGE] year old male presents to the emergency department for evaluation of abnormal lab. On exam, patient is febrile (with fever) at 104 degrees Fahrenheit taken orally. MD note 2/17/22 at 9:45 PM documented (in part) . Patient believes his fever is originating from his previous sacral ulcer which is worsening. States that he was not receiving optimal care at his rehabilitation facility. Large, malodorous sacral ulcer with serous discharge. 5 inches. Assessment/Plan: [CONDITION(S)]: Suspected source sacral ulcer. Patient with a previous sacral ulcer which has worsened in size, pain and now has discharge. WBC (white blood cell count) of 22.5 up from 13.6. Concern for sacral [CONDITION(S)] vs (versus) polymicrobial wound infection. Need to r/o (rule out) bacteremia. DX (diagnosis) for fever includes [CONDITION(S)] (urinary tract infection) given previous orchitis/epididymitis and still has a chronic indwelling foley. UA (urinalysis) shows small leukocyte esterase with WBC clumping. Consider MRI (magnetic resonance imaging) to r/o [CONDITION(S)] 2/2 (secondary to) sacral ulcer. Surveyor advised Director of Nursing (DON)-B of the inability to locate facility documentation of an assessment of R4's sacral pressure injury. Surveyor asked DON-B for any/all facility documentation related to R4's sacral pressure injury. No documentation was provided. On 5/24/22 at 3:10 PM Surveyor advised Director of Nursing (DON)-B of concern the facility did not comprehensively assess and measure R4's sacral pressure injury upon admission, nor at any time during the 8 days he resided in the facility. DON-B reported the expectation is The nurse should at least document an assessment, what the wound looks like and some rough measurements at least, until the wound care nurse can see. Surveyor further noted R4's care plan was not individualized to indicate a specialty mattress was implemented for the unstageable pressure injury and there was no schedule of turning indicated, despite the fact R4 admitted to the facility with pressure injuries. On 5/25/22 at 11:26 AM Director of Operations-L advised Surveyor the facility had documentation on 2/17/22 of R4's temperature 97.1. Director of Operations-L stated: I would think if the patient was going septic, they would show more signs, and the temperature would be higher. Surveyor reviewed facility documentation which indicated R4's temperature of 97.1 was taken at 9:41 AM and R4 was not sent to the emergency department until at least 5:00 PM. The facility did not complete a comprehensive assessment of R4's sacral pressure injury to include characteristics of the wound, staging and measurements upon admission or at any time during the 8 days R4 resided in the facility. Treatment to the sacral pressure injury was signed out as having been completed, however there was no documentation of an assessment of the pressure injury. R4's Care Plan was not individualized to include appropriate interventions for R4's pressure injuries. Director of Nursing-B was advised of the above concerns. No additional information was provided. 2.) R8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Quarterly 3/29/22 MDS (Minimum Data Set) indicated R8 was cognitively intact, required extensive assistance with 1 staff for bed mobility, and dependent on staff for toileting and bathing. R8's 5/17/22 Wound Physician notes indicated a Stage 4 sacral wound measuring 4.2 x 2 x 1.1 cm which was debrided. Wound Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care ordered: Iodosorb gel to wound bed covered by bordered foam. On 5/24/22, at 8:44 AM, Surveyor conducted an observation of R8's sacral wound care by WCRN-G (Wound Care Registered Nurse). WCRN-G stated she is not certified and has been working at the facility for 2 months. R8 was assisted to her side for care. Surveyor observed R8 had 2 soaked and draining 4 x 4 gauze dressings taped to her wound that were undated. R8 stated CNA (Certified Nurse Assistant) came in and put it on because the wound was open and draining. WCRN-G stated she did not change R8's dressing yesterday as R8 was in [CONDITION(S)] when wound rounds were being conducted. Surveyor observed white, mushy tissue surrounding the wound bed indicating maceration. WCRN-G cleansed the wound and it looked like 70 % granulation and 30% slough with no redness or irritation. WCRN-G stated epithelial tissue with no tunneling but there is undermining. WCRN-G used a Q-tip to place [MEDICATION(S)] medication cream around the outside of the wound which she stated was for irritation. WCRN-G stated no measurements to be done today as the new Wound Physician wound not come until Thursday and they do measurements with him. WCRN-G placed Iodosorb on the wound bed and covered with a border dressing. R8 did not have an air mattress. R8 had 2 wheelchair cushions including a donut hole provided by R8's sister and placed on top of a gel wheelchair cushion. On 5/24/22, at 9:14 AM, WCRN-G notified the Surveyor that she realized she forgot to date the dressing so she went back and did it. On 5/24/22, at 2:30 PM, Survey Team shared concerns regarding wound care at daily exit meeting. On 5/25/22, at 8:14 AM, Surveyor discussed with DON-B (Director of Nursing) that measurements were not done on 5/24/22 for R8's weekly measurements as the new Wound Physician was not due until 5/26/22. Surveyor also shared that R8 had an inappropriate wound dressing and [MEDICATION(S)] was utilized during R8's wound care without a Physician order. R8 also did not have an air mattress. DON-B stated she told the wound care nurses measurements were required weekly due to change in date of Wound Care Physician Rounds. DON-B stated she thought R8 had an air mattress. On 5/25/22, at 12:05 PM, Surveyor interviewed R8 who stated she once had an air mattress and it helped her but the facility took it away and she does not know why. On 5/25/22, Survey team conducted facility exit and no further information was provided regarding R8's wound care.

Based on observation, interview and record review the facility did not ensure residents received care and services consistent with professional standards of practice for 3 of 5 sampled residents (R4, R2 and R6). R4 admitted to the facility with a surgical wound of amputated toes on her right foot. The surgical site was not routinely assessed and monitored, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in decline of the wound (infection) resulting in hospitalization for further debridement of the surgical incision and intravenous antibiotics. The facility's failure to comprehensively assess and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Supervisor notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy via phone on 6/9/21 at 2:15 PM. The Immediate Jeopardy was removed on 6/9/21 when the facility implemented an action plan. The deficient practice continues at a scope/severity (s/s) of a D (potential for more than minimal harm/isolated) as the plan continues to be implemented and the additional example regarding R2 and R6. R2 slipped off the bed and was lowered to the ground by the Certified Nursing Assistant (CNA). R2 was not assessed by a Registered Nurse (RN) after the fall and was later found to have a fractured right leg. R6 developed 2 leg wounds from a cast rubbing, and 2 areas of excoriation from moisture that were not comprehensively assessed upon discovery. Findings include: The facility did not have a Policy and Procedure specific to surgical site assessment and monitoring. The facility Skin Management Guideline revised 11/28/17 documented (in part): Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate whose critical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures, and to provide appropriate treatment modalities for wound according to the industry standards of care. Procedure: 1. Prevention of Pressure Ulcers - All residents admitted to the facility will be evaluated for actual and potential skin integrity issues. - A complete evaluation is essential for an effective skin prevention and treatment program. A comprehensive individual evaluation guides the: - Identification of residents at risk and factors predicting the risk for breakdown. - Identification of the presence of skin impairment. - Provides an ability for the facility to develop and implement a care plan that reflects each resident's identified needs. - Evaluate the effectiveness of interventions. - Modify the interventions as appropriate. An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors. Interventions for prevention, removing and reducing predicting factors and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - Pressure redistribution surface for bed and seating surfaces: Specified through clinical evaluation and determination. - Adaptive equipment and seating to support and encourage correct anatomical alignment. - Elevating heels: For residents that cannot turn and repositions themselves. For residents that have diminished sensory perceptions of the lower extremities that may affect an independent ability to turn, reposition and offload pressure. Offloading devices may vary, may include pillows and should be selected based on resident comfort and positioning needs. - Inspection of skin daily with cares and weekly by a licensed nurse. - Skin care. - Pressure, friction, shear reduction. Monitoring of Skin Integrity: - Skin will be observed daily during cares by the nursing assistants. If any skin concerns are noted, they are to be reported to the licensed nurse. - The care plan for skin integrity is to be evaluated and revised based on the response, outcomes, and needs of the resident. Document on any changes or concerns in the nurses notes and re-evaluate as appropriate. On 6/2/21 at 11:40 am Director of Nursing (DON)-B stated the expectation for surgical wounds is for the nurses to monitor and document on surgical wounds daily and weekly monitoring by the wound care nurse. 1.) R4 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. R4's Admission Nursing Evaluation dated 3/19/21 documented: Skin integrity - the resident has actual impairment to skin integrity (specify location). Surveyor noted there was no site or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Care plan was reviewed: Focus area date initiated 3/19/21 documented: Amputation of right toes r/t (related to) wounds. Interventions Initiated 3/22/21 included: Check and document on wound daily for s/sx (signs/symptoms) of infection, drainage, bleeding, any breakdown of skin and impaired circulation ([CONDITION(S)] or pain). Monitor for bleeding. Document amount of bloody drainage on dressing and in drainage system. Reinforce dressing PRN (as needed). Focus area date initiated 3/19/21 documented: Actual impairment to skin integrity right foot r/t amp (amputation) site wound. Interventions Initiated 3/19/21 included: Evaluate and treat per physicians orders. Evaluate for s/sx of possible infections. Interventions initiated 3/22/21: Evaluate residents for changes in pain level and if appropriate request a scheduled pain medication from physician. Ensure that heels are elevated while resident is lying in bed. Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Hospital Discharge Summary dated 3/19/21 documented: Dressing/Wound Instructions - Wound care instructions: Bilateral heel stage 1 pressure injuries. Wash wound with warm soap and water daily and PRN. Use non-scented soap that is not antimicrobial. Apply Nutrashield to heels BID (twice daily) and PRN. Surveyor noted the wound care instructions to wash wound with warm soap and water daily were unclear if it meant the heel pressure injuries or surgical site. Surveyor noted the instructions were to wash wound with soap and water (stage 1 pressure injuries are not open skin/wounds), however the facility was not able to verify and the order was not clarified upon admission. R4's Treatment Administration Record (TAR) did not include any dressing or wound care to R4's incision site from 3/19/21 to 3/23/21. The TAR included skin prep bilateral heels BID (twice daily), of which Surveyor noted was not signed out as having been completed 7 of 16 shifts. Surveyor noted the facility 24 hour board (unsure of date or shift) documented 2 entries: #1 Right foot dressing change. Bleeding to incision line. Foot warm with some redness, sutures intact, no odor - MD (Medial Doctor) updated. #2 Dressing changed. Sutures intact, foot cool to touch, remains red/purple/whole. Surveyor located no documentation in the progress notes indicating when these observations were noted or the response from the doctor. Surveyor located no evidence the facility was consistently assessing or monitoring R4's surgical site daily. Review of facility progress notes documented random entries of the dressing CDI (Clean, Dry, Intact). Facility progress notes documented: 3/19/21 at 11:59 PM: Sutures intact, no bleeding or s/sx infection. 3/20/21 at 5:35 AM: Right foot dressing CDI. Resident states she bumped her right foot several times while in bed causing more pain to the surgical site. Scheduled Tylenol given, states Tylenol doesn't help much. Surveyor noted there was no assessment of the surgical site documented after R4 reported having bumped her foot several times causing more pain to the surgical site. 3/21/21 at 5:53 AM: Dressing clean, dry and intact to right 4th toe. Surveyor noted no assessment of the surgical incision documented. 3/21/21 a 4:28 PM: Dressing to recently amputated toes clean and dry. Surveyor noted no assessment of the surgical incision documented. 3/21/21 at 10:17 PM: Dressing CDI. Surveyor noted no assessment of the surgical incision documented. 3/22/21 at 7:26 AM: Dressing changed per resident request. Surveyor noted no assessment of surgical incision site documented. 3/22/21 at 4:18 PM: Dressing to recently amputated toes clean and dry. Patient is at [CONDITION(S)] today and to be evaluated by wound care RN (Registered Nurse) for further directions for wound care to right amputated toes. Surveyor noted no assessment of the surgical incision site documented. 3/22/21 at 7:55 PM: Pain - dressing changed to right foot. Bleeding noted to dressing - incision site bleeding. Sutures intact. Foot very warm to touch with some redness and some soft white spots noted. Incision site cleansed with normal saline, patted dry and 4x4's placed along incision line for padding. Kerlix wrapped around for protection. No odor present. Resident wears an ortho shoe with straps for walking which may be rubbing on foot. Vitals signs stable. MD updated and stated to have wound nurse take a look. Call placed to wound nurse and message left. 3/23/21 at 8:00 AM: Nurse Practitioner note: Right foot 5 digit amputation. History of Peripheral Artery Disease. Positive [CONDITION(S)] to 1st & 3rd toe. Sutures intact. Vascular changes with discoloration to entire right foot. Foot changes to purple/red in color in dependent position. Dressing changes to right foot every day. On 6/7/21 at 12:50 pm Surveyor's interview with Nurse Practitioner (NP)-L revealed she did not remember the resident and could not provide any more information of what her foot looked like, other than what was in her notes. On Surveyor interview with Medical Doctor (MD)-P revealed he was out of town and did not see R4 at any time while she resided in the facility, thus could not offer any information of what her foot looked like. Surveyor noted new treatment orders obtained on 3/23/21 entered on the TAR: Wash lightly drainage from right toes incision site with wound wash and monitor for any s/sx infection F/B (followed by) ABD (abdominal) pad and secure with Kerlix and tape every day shift. Surveyor noted this treatment was not signed out as completed on 3/24/21, 3/25/21 and 3/26/21. On 3/26/21 the AM shift nurse progress notes documented the resident not in facility due to [CONDITION(S)]. There was no evidence the treatment was completed upon return to the facility or on the next shift, and no assessment of the surgical incision was documented. The treatment was signed out as having been completed on 3/27/21 but there was no assessment of the surgical incision documented. This nurse no longer works for the facility, thus was unavailable for interview. Review of Daily skilled Nursing evaluation forms 3/23/21 - 3/25/21, section J Post Surgical Care was blank - no documentation. Surveyor noted there was no documentation or evidence of an assessment of R4's surgical incision after she was seen by NP-L on 3/23/21. On 3/28/21 at 11:50 AM progress notes documented: Resident complained of increased pain to right amputated toes surgical site. Upon inspection area noted with discoloration (Surveyor noted there was no description of the discoloration) and tender to touch at the surgical site. (MD-P) made aware of assessment and orders given to send resident to ER (emergency room ) for evaluation. Surveyor was unable to interview this nurse as she no longer works for the facility. On 6/2/21 at 11:40 am Surveyor interviewed R4 who reported she kept asking for the dressing to be changed and for someone to look at her foot and it was only changed once or twice upon her insistence. She reported (NP-L) did see it one day, but no-one looked at it again after that, until she insisted someone look at it on 3/28/21 or she was going to call 911. R4 reported when the dressing was removed, her toes (nubs) were black. She reported she went to the ER, was hospitalized and had to have more of my foot removed. Surveyor review of Hospital Records: Hospital ED (Emergency Department) provider notes dated 3/28/21 at 12:31 PM documented (in part): (R4) presents to the ED for evaluation and worsening pain and redness to her right foot surgical site. At her rehab center she states that the staff have not been consistently checking on her surgical wound. Initially they had applied a soft Vaseline cream to her incisions, wrapped it and put her foot in a sock, but it has been 4 days since anyone has evaluated or re-bandaged her wounds. I anticipate that she will require further care beyond the ED given concerns for infection. (Intravenous [MEDICATION(S)] and [MEDICATION(S)] were ordered.) Physician notes in the hospital record dated 3/28/21 at 2:07 PM documented (in part): Foot is erythematous. Distinct pocket of pus on medial plantar foot. Continue [MEDICATION(S)] and [MEDICATION(S)]. Further physician notes on 3/28/21 documented (in part): Diffuse [CONDITION(S)] of right foot involving distal half of dorsal and plantar aspect. Incision appears to be separating at the medical aspect and there is small amounts of dried blood around the area. There is also a fluctuant, pus filled 1-2 cm area at the plantar-medial aspect of the incision which is likely due to an abscess formation. Infected amputated right 1-5 toes, abscess? - most likely 2/2 (secondary to) inadequate hygiene of surgical site and inadequate dressing changes. Bacterial infection is favored. [CONDITION(S)] is also in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Inpatient Wound Care Progress note dated 3/29/21 documented (in part): Reports that dressing was not changed for almost a week prior to admission. She has been wearing a wedge shoe and walking with therapy. She is tearful today - her mother had amputations related to her DM (diabetes mellitus). Medical decision making: readmitted for right foot infection. Blistering from infection versus ischemia to medial and lateral portions of incision. Debridement Procedure: Attention directed to area of concern with notation showing concerns with purulence drainage along plantar medial flap margin with bulla. Ten blade utilized, making incision and scant family serous fluid evacuated, roughly 1 cc (cubic centimeter) with underlying dermal tissue noted to be otherwise intact. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . I do not appreciate any active signs of infection at this time with no plans for any immediate surgical intervention. Nephrology consult note dated 3/29/21 documented (in part): (R4) presented to the ED on 3/28 right foot amputation infection. She is teary, upset and frustrated with infection. She reports wound care and dressing changes were not being done at [NAME] (Subacute Rehabilitation Facility). Social Worker notes dated 3/29/21 documented (in part): Patient confirmed she was at (Facility) since 3/19/21 but stating she does not want to return there unless I have to. R4 admitted to the facility with a surgical wound to her right foot following amputation of all toes on her right foot. The facility did not consistently change the dressing and did not assess and monitor the surgical incision for signs and symptoms of infection on a daily basis. This failure resulted in R4 being hospitalized for further debridement of the surgical site and IV therapy leading to a situation of immediate jeopardy. The facility removed the immediate jeopardy on 6/9/21 when it implemented the following: ~ The facility reviewed the situation related to R4. ~ A facility policy and procedure was developed and reviewed by the Medical Director related to non-pressure related wound care. ~ All residents with wounds were assessed for appropriate treatment orders, a house wide skin sweep was completed to identify any new wounds and all treatment supplies were audited to ensure availability. ~ All licensed nursing staff were educated prior to assuming their next shift on the updated wound guideline, notice of change in condition, ensuring completion of treatments, daily wound charting, head to toe skin assessment and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~ The facility developed a system to audit skin assessments and treatment orders are obtained by physicians upon admission and as indicated. ~ Audits will be reviewed and presented at QAPI. The deficient practice at F684 continues at a scope and severity of a D (potential for harm/isolated) as the facility implements its action plan and as evidenced by the following examples. 2.) The Wisconsin Nurse Practice Act notes the following: N 6.03 Standards of Practice for Registered Nurses (1) GENERAL NURSING PROCEDURES An R.N. shall utilize the nursing process in the general execution of nursing procedures in the maintenance of health, the prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or directing and supervising nursing acts delegated to L.P.N's or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R2 is [AGE] years old and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 has impaired cognitive function; is totally dependent on 1 staff for turning and repositioning in bed; and requires a Hoyer Lift transfer with the assistance of 2 staff. FACILITY INVESTIGATION On 5/14/21, R2 sustained a fracture to her right leg and the facility's investigation provided the following information. On 5/14/21 at 7:34 am, R2 was seated at the edge of her bed as CNA - G was assisting R2 with dressing. R2 began to slide off of the bed and CNA - G lowered R2 to the floor. CNA - G told LPN - H and LPN - I what had occurred. Both LPN - H and LPN - I evaluated R2 and concurred that R2 had no injuries. R2 was able to move both legs and bend both knees without pain. No swelling was noted at the time. Neither LPN - H nor LPN - I contacted a RN to assess R2 after the fall. At approximately 3:30 PM that day R2 was seen by Nurse Practitioner (NP) - L. NP - L had been informed that R2 was refusing therapy due to pain in her right lower leg. NP - L noted that R2 had swelling and ecchymosis (bleeding beneath the skin) to her right lower leg. R2 was transferred to the hospital where she was diagnosed with a fractured right tibia (leg). INTERVIEW WITH DIRECTOR OF NURSING On 5/27/21 at 1:29 PM, Director of Nursing (DON) - B was interviewed. DON - B said that LPN - H and LPN - I reported to her that the incident was not a fall because R2 had been lowered to the floor. DON - B said that she re-educated both LPNs that a fall is defined as a change in plane. DON - B informed the LPNs that because R2 had fallen, an RN should have been notified to further assess R2. 3.) R6's medical record was reviewed by Surveyor. R6 has a plan of care for the potential of impaired skin integrity started on 4/16/21. This is due to incontinence and decreased mobility. The interventions include: elevate heels; apply barrier cream; encourage repositioning and pressure reduction in wheelchair. R6's Skin Observation form dated 4/25/21 indicates a large abrasion wound on the right knee and right lower leg. There is not a comprehensive assessment documented by a RN (Registered Nurse) that includes measurements and descriptions of the wounds. R6 has a Progress Note dated 4/25/21 that there are 2 abrasions on the right leg and right knee due to rubbing from a cast on the left leg. There were notifications to the physician and emergency contact regarding a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R6's progress note on 5/13/21 indicates new moisture open areas on the posterior bilateral thighs. The NP-L (Nurse Practitioner) was updated and a barrier cream treatment was ordered. There is not a comprehensive assessment documented of these new areas. R6 is their own person and encouraged to reposition more frequently. The progress note on 5/14/21 indicated the abrasions are healed. However there is no consistent comprehensive assessments by the RN between discovery on 4/25/21 through apparent healing on 5/14/21. R6 went out to the hospital on 5/27/21 and upon return to the facility on [DATE] a comprehensive skin assessment was conducted by a RN-U. R6's abrasions were no longer open and appeared healed. R6 has a pressure injury on the right lateral buttock and left ischium. On 6/8/21 at 8:14 AM Surveyor spoke with DON-B (Director of Nurses). DON-B indicated the previous staff that was doing wound care is no longer at the facility. DON-B was not made aware of these wounds not being comprehensively assessed. There is no comprehensive assessments for the onset of the right leg wounds and areas on the posterior thighs. . On 6/8/21 at 12:03 PM Surveyor spoke with NP-L. NP-L indicated the abrasion wounds were from the cast and did not observed the posterior thighs until hospital transfer on 5/27/21. The posterior thighs were not open wounds and appeared to be moisture associated excoriations. On 6/9/21 at 9:30 AM Surveyor observed R6's wound treatments with RN-U and there were no abrasions noted to the legs. R6's left ischium, and right lateral buttock, had developed into a pressure injury wound during their hospital stay. On 6/9/21 at 1:23 PM Surveyor spoke with RN-F who assessed R6's posterior thighs on 5/21/21 (after they were noted around 5/13/21). This was the first RN comprehensive assessment of the thighs. RN-F indicated they were moisture associated areas and they were using barrier cream. R6 was going to be seen by the facility wound physician the following week. However, R6 went out to the hospital for a different reason and was not seen by the wound physician. On 6/9/21 at 4:00 PM at the facility exit meeting with Administration the concerns with skin assessments was shared. There was no further information provided.

Based on observation, interview and record review the facility did not ensure residents received care and services consistent with professional standards of practice to prevent pressure injuries and did not ensure residents received necessary treatment and services to promote the healing of existing pressure injuries for 1 of 1 (R5) residents reviewed for pressure injuries. The facility assessed R5 to be at risk for pressure injuries and he developed a pressure injury to his right 3rd toe. The pressure injury was identified on 5/6/21 and the care plan was not revised with interventions. The pressure injury was not routinely assessed and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in decline of the wound (infection) requiring antibiotic intervention and subsequent amputation of his remaining toes. The facility failure to comprehensively assess and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Supervisor notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy phone on 6/7/21 at approximately 12:15 pm. The facility removed the immediate jeopardy on 6/7/21 when the facility implemented their action plan. The deficient practice continues at a scope and severity (s/s) of an E (potential for more than minimal harm/pattern) as the facility continues to implement its plan for wound care. Findings include: The facility Skin Management Guideline revised 11/28/17 documented (in part): Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate whose critical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures, and to provide appropriate treatment modalities for wound according to the industry standards of care. Procedure: 1. Prevention of Pressure Ulcers - All residents admitted to the facility will be evaluated for actual and potential skin integrity issues. - The Pressure Injury Notice will be completed and provided for the resident and/or Resident Representative providing notice of predicting factors and baseline careplan interventions to support prevention, treatment and healing. A complete evaluation is essential for an effective skin prevention and treatment program. A comprehensive individual evaluation guides the: - Identification of residents at risk and factors predicting the risk for breakdown. - Identification of the presence of skin impairment. - Provides an ability for the facility to develop and implement a care plan that reflects each resident's identified needs. - Evaluate the effectiveness of interventions. - Modify the interventions as appropriate. An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors. Interventions for prevention, removing and reducing predicting factors and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - Pressure redistribution surface for bed and seating surfaces: Specified through clinical evaluation and determination. - Adaptive equipment and seating to support and encourage correct anatomical alignment. - Elevating heels: For residents that cannot turn and repositions themselves. For residents that have diminished sensory perceptions of the lower extremities that may affect an independent ability to turn, reposition and offload pressure. Offloading devices may vary, may include pillows and should be selected based on resident comfort and positioning needs. - Inspection of skin daily with cares and weekly by a licensed nurse. - Skin care. - Pressure, friction, shear reduction. Monitoring of Skin Integrity: - Skin will be observed daily during cares by the nursing assistants. If any skin concerns are noted, they are to be reported to the licensed nurse. - The care plan for skin integrity is to be evaluated and revised based on the response, outcomes, and needs of the resident. II. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . - Evaluate interventions per risk factor identified and re-evaluate and modify the plan of care based on root cause analysis for new skin alterations. - Update the care plan for skin integrity and nursing assistant care cards with skin concern, appropriate risk factors, turning intervals and interventions as appropriate. - When a pressure ulcer is present, daily wound monitoring should include: - An evaluation of the ulcer, if no drainage is present. - An evaluation of the status of the dressing, if present. - The status of the area surrounding the ulcer (that can be observed without removing the dressing). - The presence of the possible complications, such as signs of infections. - Whether pain, if present, is being adequately controlled. Document on any changes or concerns in the nurses notes and re-evaluate as appropriate. R5 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 had amputation of his 2nd right toe in January, 2021; the wound became infected in March, 2021 resulting in hospitalization . R5's Care plan was reviewed: Focus area date initiated 4/30/21 documented: The resident has actual impairment to skin integrity related to (Specify location). Surveyor noted there was no site or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interventions included: Evaluate and treat per physician orders. Evaluate for s/sx (signs/symptoms) of possible infections. Focus area date initiated 4/30/21 documented: The resident has an amputation of 2nd right toe related to Diabetes Mellitus. Interventions: Encourage compliance with treatment program. Focus area date initiated 5/12/21 documented: The resident has [CONDITION(S)] related to Diabetes. Interventions: Educate the resident on the importance of proper foot care including, proper fitting shoes, wash and dry feet thoroughly, keep toenails cut, inspect feet daily, daily change of hosiery and socks. Elevate legs when sitting or sleeping. Encourage good nutrition and hydration. If resident has thick nails, corns, callouses, refer to podiatrist. Focus area date initiated 5/12/21 documented: The resident has Diabetes Mellitus. Interventions: Check all of body for breaks in skin and treat promptly as ordered by the doctor. Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of infection to any open areas: Redness, pain, heat, swelling or pus formation. R5's Admission Nursing Evaluation dated 4/30/21 documented: Skin integrity right toe(s) 1st and 2nd toe amputated. 5th digit small sore, covered with border dressing. There was no documentation indicating a wound was present on his right 3rd toe. The facility Skin Observation dated 5/3/21 documented: Skin observation right toe(s) open area 5th toe. There was no documentation indicating that a wound was present to his right 3rd toe. Progress note dated 5/6/21 documented: Wound nurse in to see resident. Top of right third slightly scabbed and reddened. No drainage or active bleeding. Resident stated That his shoes rub against the top of his foot. The facility Wound Assessment Details Report dated 5/6/21 documented: Wound: Right 3 toe. Type: Pressure. Classification: Ulcer. Source: Present on admission. Date identified: 4/30/21. Clinical stage: Unstageable. Size (cm) centimeters: 0.50 x 1.5 x unknown. Surveyor noted the wound report documented the pressure injury was present on admission, though there was no documentation of the wound prior to 5/6/21. Review of R5's hospital record prior to and at the time of admission does not indicate R5 had a wound on the right 3rd toe when he arrived at the facility. Surveyor noted R5's care plan was not revised after the pressure injury was identified on 5/6/21, including possible causative factor of his shoes rubbing. On 6/3/21 Surveyor interviewed Licensed Practical Nurse (LPN)-O who reported she was the facility wound nurse at the time. LPN-O initially stated she saw the wound on R5's right 3rd toe on 4/30/21. Surveyor noted R5 admitted to the facility in the evening, after 7:00 PM and asked LPN-O if she would have been working that late. LPN-O reported she does sometimes work late. Surveyor advised her there was no assessment, measurement or treatment implemented for the wound on 4/30/21. She reported she would have to check her records. LPN-O revised her statement and reported she was not working when R5 was admitted , so she did not see the wound on 4/30/21. She reported when she saw the wound on 5/6/21, she entered it as present on admission because the resident told her it was. Surveyor advised LPN-O there were no care plan revisions after the pressure injury was identified on 5/6/12 (and no development of a care plan on 4/30/21 if the wound really was present on admission). LPN-O reported she would have to check her notes. No additional information was provided. R5's Treatment Administration Record (TAR) documented a treatment put in place on 5/6/21: Wash right 3 toe with wound wash f/b (followed by) skin prep and a non-stick dry dressing and Kerlix and secure with tape. Every MWF (Monday, Wednesday, Friday). Surveyor review of the May, 2021 TAR indicated: Friday, 5/7/21 - treatment not signed out as completed. Monday, 5/10/21 - treatment signed out as hold - see NN (nurses notes). Surveyor review of nurse's notes revealed no documentation regarding the pressure injury or why the treatment was not completed. Wednesday, 5/12/21 - treatment not signed out as completed. Surveyor noted there was no documentation treatment was completed to R5's pressure injury on 5/7/21, 5/10/21 and 5/12/21 as ordered. There was no documentation or evidence the facility assessed or monitored the pressure injury after it was identified on 5/6/21 until the resident was seen by the Podiatrist on 5/13/21. R5's Progress Notes documented: 5/13/21 at 3:04 PM: Per (Doctor) Podiatrist, he thinks the wound to resident's 3rd toe of right foot has [CONDITION(S)]. He recommends another course of antibiotic. (Resident was previously on antibiotic for his amputation site infection.) 5/13/21 at 8:20 PM: Symptoms of infection reported to PMD (Primary Medical Doctor). Redness, warmth, tenderness on right 3rd toe. Afebrile. No change in activity or appetite. NOR (New Order Received) for cx (culture) of wound, X-ray of right foot and [MEDICATION(S)] 100 mg (milligrams) BID (twice daily) x 10 days and [MEDICATION(S)] (Double Strength) 1 tablet BID x 10 days for wound infection. 5/13/21 at 11:03 PM: D/t (Due To) allergy [MEDICATION(S)] changed to [MEDICATION(S)]. 5/14/21 at 2:12 PM: Resident seen by NP (Nurse Practitioner) this shift. New orders received for antibiotics x 2 for 10 days. DX (Diagnosis) [CONDITION(S)] of wound to 3rd toe of right foot. New treatment order obtained and applied as ordered. Wound bed covered in slough. Surrounding tissue reddened and slightly warm to the touch. Radiology report shows [CONDITION(S)]. Surveyor verified per TAR and progress notes - treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/21 R5 was seen by his primary Podiatrist and returned to the facility with orders to send to ER (emergency room ) for evaluation. R5 was admitted to the hospital and returned to the facility on [DATE] following amputation of the remaining toes on his right foot. The Hospital Discharge Summary dated 5/22/21 documented: The wound culture of right toe drainage obtained in ED (Emergency Department) grew [CONDITION(S)] ([CONDITION(S)]). Wound infection of right 3rd toe. Wound culture grew [CONDITION(S)] and patient was started on IV (intravenous) [MEDICATION(S)]. Wound care consulted, recommended right 3-5th toe amputation, as remaining 4-5th toes would provide no benefit and have the potential to become infected in the future. The facility identified R5 to be at risk for pressure injuries and a care plan was not developed to prevent pressure injuries. The facility identified a pressure injury to R5's right 3rd toe on 5/6/21. No revisions were made to the care plan. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence the facility comprehensively assessed and monitored the pressure injury daily, according to the facility policy and procedure. This failure led to R5 developing infection to his right 3rd toe which subsequently resulted in amputation of his 3rd toe and the remaining toes on his right foot. This created a situation of immediate jeopardy that was removed on 6/7/21 when the facility implemented the following plan: ~ The facility reviewed the situation related to R5. ~ All residents with wounds were assessed for appropriate treatment orders, a house wide skin sweep was completed to identify any new wounds and all treatment supplies were audited to ensure availability. ~ All licensed nursing staff were educated prior to assuming their next shift on the updated wound guideline, notice of change in condition, ensuring completion of treatments, daily wound charting, head to toe skin assessment and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~ The facility developed a system to audit skin assessments and treatment orders are obtained by physicians upon admission and as indicated. ~ Audits will be reviewed and presented as QAPI. The deficient practice at F684 continues at a scope and severity of an E (potential for harm/pattern) as the facility implements its action plan for residents at risk & with pressure injuries. .

Based on observation, interview and record review the facility failed to ensure 2 of 10 residents residing on the 200 unit were free from sexual abuse. This deficient practice had the potential to affect 10 out of 10 female residents on the 200 unit. On 9/17/20, R14 entered R13's room exposing his penis while approaching R13 saying sexually inappropriate comments. Staff did not immediately report this incident of abuse and did not immediately protect additional residents from potential further abuse that night. After facility staff developed interventions on 9/18/20, the facility failed to follow through with one on one (1:1) supervision for R14, failed to assess the effectiveness of interventions and failed to ensure frequent checks were done for R14. When interviewed, staff gave inconsistent responses as to what frequent checks meant. R14 continued to seek out female residents and make sexually inappropriate comments to staff showing willful intent, culminating in an incident on 1/1/21 when a staff person who just happened to be walking by saw R14 with his pants down and standing by the head of R22, a female resident with severe cognitive impairment. The facility's failure to take immediate action to ensure residents are safe from sexual abuse and its failure to ensure care-planned interventions were specific to the resident and followed created a finding of immediate jeopardy that began on 9/17/20. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the Immediate Jeopardy on 1/7/21 at 9:28 AM. The immediate jeopardy was removed on 1/7/21; however, the deficient practice continues at a scope/severity level of E (actual harm/pattern) as the facility continues to implement and monitor its removal plan. Findings include: Surveyor reviewed the facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property policy with an effective date of 9/11/20. Documented under DEFINITION OF ABUSE AND NEGLECT was: a. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . ii. Sexual abuse is non-consensual sexual contact of any type with a resident . F. PROTECTION: ABUSE POLICY REQUIREMENTS: It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). PROCEDURE: Immediately upon receiving a report of alleged abuse, the Administrator, and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of the utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed and resident protected . iii. If the alleged perpetrator is a facility resident, the staff member with immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instructions from administration, if possible. If the situation is an emergent danger to the other residents or staff, dial 911 for immediate assistance. iv. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. Notify resident physician. v. Social Services or designees should keep in frequent contact with the resident and/or resident representative. vi. If the resident could be at risk in the same environment, evaluate the situation and consider options including a room change or roommate change. vii. Notification of law enforcement and/or State Agency, Crisis Response, Poison Control, etc. as indicated. viii. A medical, evidentiary, or sexual assault exam should be completed as soon as possible, as appropriate. Surveyor reviewed R14's Hospital Physician Discharge Summary with a date of 8/31/20. Documented was 65 (year old) man .who presented with (altered mental status (AMS)) . was found by his fiancée slumped to the right in his chair during lunch and not eating his food. Fiancée reports patient was not speaking and appeared not there so she called 911. Documented under Hospital Course By Problem List was Dementia with behavioral disturbances. Behaviors include instances of aggression, combativeness, and verbal outbursts towards staff. Behaviors occurred prominently at night, likely representing sundowning. Patient is calm, cooperative and pleasant during the day. Psych was consulted who recommended [MEDICATION NAME] 250 mg (by mouth (PO)) daily for mood symptoms, increased to 500 mg on (8/28/20.) Patient's agitation and combativeness resolved by time of discharge. The resident's Healthcare Power of Attorney (POA) was activated during hospital stay due to incapacitation. R14 was admitted to facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident's admission paperwork noted R14 was taking 500mg [MEDICATION NAME] PO daily for mood stabilizer. Surveyor reviewed R14's MDS (Minimum Data Set) Assessment with an assessment reference date of 9/7/20 and 10/29/20. Documented under Cognition was a BIMS (brief interview mental status) score of 13 which indicated cognitively intact. Documented under Mood were Mood severity scores of 12 and 10 which indicated moderate depression. Surveyor reviewed R14's Care Area Assessment (CAA) for Mood State with an assessment reference date of 9/7/20. Documented under Analysis of Findings by Social Services Director (SSD)-L was (R14) refused psych services, if he stays long term the conversation will be revisited. Surveyor reviewed R14's Electronic Medical Record (EMR). No Behavior Monitoring, Mood Monitoring for [MEDICATION NAME] medication, Behavior Care Plan, Mood Care Plan was found for R14 from 8/31/20 to 9/17/20. Surveyor reviewed a Misconduct Incident Report submitted by the facility to the State Agency on 9/24/20 for an incident involving R14 and R13. Documented was On 9/18/2020 (SSD-L) spoke with (R13) who stated that on 9/17/20 . she saw (R14) in her room . R13's statement was I fell asleep at 8:00 PM, I woke up at 10:10 PM to a man in my room with his brief on his ankles and urine dripping on the floor. He was holding his penis walking towards me saying he wanted to give me pleasure. He said some vulgar things to me. I was trying to find my call light but it was dark so it took me a second. I put the call light on and he was still walking towards me, he said he wanted to eat my pussy and stick his dick inside me. I took the brake off the wheelchair and tried to push him away with it. I was able to sit up in the bed and shoo him out of the room. By the time the staff arrived he was in the hallway headed back towards his room. The facility investigation documented interventions put in place were (R14) was moved to another room and unit and placed on 1:1 supervision. Surveyor reviewed R13's Discharge MDS with an assessment reference date of 10/9/20. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. R13 was her own person. Surveyor reviewed witness statement from the Former Certified Nursing Assistant (CNA)-G, who entered the room shortly after R14 exited. This statement documented 1. Did you work 9/17/2020 on 2nd shift? Yes. 2. Did you see (R14) in the hallway with his brief around his ankles? If yes, what did you do? Yes, placed him back in his room, had updated (Licensed Practical Nurse (LPN)-I) of what happened. 3. Did (R13) report any interaction between her and (R14) at night prior to him being found in the hallway? If yes, who did you report this to? Yes, (R13) informed me of what R14 did which was come into her room with his brief around his ankles and say he wanted to eat her pussy and pleasure her. I updated LPN-I. CNA-G was no longer employed at the facility and was unable to be interviewed. Surveyor reviewed witness statement from LPN-I that stated 1. Did you work 9/17/2020 on 2nd shift? Yes. 2. Did you see (R14) in the hallway with his brief around his ankles? If yes, what did you do? No. 3. Did (R13) report any interaction between her and (R14) at night prior to him being found in the hallway? If yes, who did you report this to? No. 4. Please provide any other information you find relevant below. (CNA-G) came to the desk and stated that (R14) went into (R13's) room and said inappropriate things. It was told to myself and (LPN-H) night shift nurse. It was at the end of my shift so I left. LPN-I was interviewed by Surveyor on 1/5/20 at 3:06 PM. LPN-I had no recollection of the incident on 9/17/20 between R14 and R13. Surveyor reviewed witness statement from LPN-H that stated 1. Did you work 9/17/2020 on 2nd shift? Yes. 2. Did you see (R14) in the hallway with his brief around his ankles? If yes, what did you do? No. 3. Did (R13) report any interaction between her and (R14) at night prior to him being found in the hallway? If yes, who did you report this to? Yes, stated to me that (R14) had wandered across the hallway. She never told me that there was anything inappropriate occurred. 4. Please provide any other information you find relevant below. No information was given to me by (LPN-I.) I was working down the 100 unit at the time. (R13) was upset about him peeing in the room. On 9/18/20 at 3:30 PM SSD-L went to R13's room on an unrelated issue and R13 made a statement about the incident. SSD-L informed Assistant Nursing Home Administrator (ANHA)-C who started the investigation, called the police and sent in a self-report to the State Agency per report submitted to the State Agency 9/23/20. There is no documentation of immediate interventions put in place for R13 or R14 to protect the residents from 9/17/20 at the time of the incident to 9/18/20 when SSD-L was made aware of the incident by R13. Surveyor reviewed R14's Comprehensive Plan of Care with a start date of 9/18/20. Documented was Focus: (R14) has the potential to have inappropriate sexual behavior towards other residents and staff (related to (r/t)) his (diagnosis (dx)) of dementia. Goal: (R14) will have fewer episodes of inappropriate sexual behavior by review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. If reasonable, discuss (R14's) behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to him. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Provide a program of activities that is of interest and accommodates (R14's) status. Psychiatric/Psychogeriatric consult as indicated. Behavior monitoring was put in place on 9/18/20. Surveyor reviewed R14's MD orders. On 9/22/20 an order for [REDACTED]. On 1/6/21 at 11:58 AM, Surveyor interviewed SSD-L. Surveyor asked when she was made aware of the incident on 9/17/20 between R14 and R13. SSD-L stated on 9/18/20 when she went to R13's room to speak about her discharge. SSD-L stated R13 told her she told other staff members but they did not follow up. SSD-L stated she took R13's statement and gave the information to ANHA-C. Surveyor asked what interventions were put in place for R14 to prevent further sexual abuse to residents. SSD-L stated R14 was moved to another unit/room and put on 1:1 supervision. Surveyor asked how long a resident is on 1:1 supervision. SSD-L stated 3 days and then the resident was put on frequent checks. Surveyor asked what the timeframe was for frequent checks. SSD-L stated for me, whenever I think about it or every 20 to 30 minutes. For the floor nurses and CNAs it is every 2 hours. Surveyor asked about psych services. SSD-L stated the POA denied psych services on admission. Surveyor asked about the (9/22/20) MD order for ASAP psych consult. SSD-L stated she was unaware of this order. Surveyor asked if the POA was re-approached about psych services at any time between then and the time of the interview. SSD-L stated she never re-approached the POA about psych services but she should have. On 1/6/21 at 7:11 AM Surveyor interviewed ANHA-C and DON-B. Surveyor asked if Behavior Monitoring for R14 should have started prior to 9/18/20 for [MEDICATION NAME] and mood monitoring. ANHA-C stated yes, on admission due to the Hospital report. Surveyor asked when they were aware of the 9/17/20 incident. ANHA-C stated through my investigation I found out (CNA-G) told (LPN-I) about the incident that night but it was not reported to the Administration. CNA and Nursing schedules were reviewed with ANHA-C for the days after the incident. It was noted the 1:1 supervision was started on PM shift 9/18/20 and ended on day shift 9/19/20. ANHA-C had no explanation why the 1:1 was stopped and stated it should have been in place for at least 72 hours following the incident for R14 and then frequent checks initiated. DON-B stated 1:1 should have started Friday, 9/18/20 PM shift and continued over the weekend and reevaluated Monday. DON-B provided 15 minute behavior monitoring documentation from 9/25/20 through 10/5/20. There was no indication of frequent checks initiated until 9/25/20. There is no indication why they were initiated 9/25/20. Surveyor asked DON-B what frequent checks were. DON-B stated every 15 to 30 minutes. Surveyor reviewed the Progress Notes for R14. Documented on 11/17/20 at 10:02 PM was (R14) was wandering into other resident's rooms and in and out of his room every time resident escorted back to room would suggest having staff go to bed with him. Documented on 11/18/20 at 11:00 PM was (R14) wandering up and down hall, trying to go into female resident's rooms and asking staff to come lay with him in his bed once redirected to room. Resident is often wandering without his walker or wheelchair. Resident is a fall risk. Documented on 11/27/20 at 9:15 PM was (R14) tried to grope staff sexually, and get staff to lay in bed with him. There was no increased monitoring, update to care plan or added interventions after these 3 incidents. Surveyor reviewed Comprehensive Care Plan with an initiation date of 11/30/20. Documented under Interventions was Care in Pairs noting 2 staff members in the room when providing cares to R14. On 1/5/21 at 2:12 PM, Surveyor interviewed CNA-D and CNA-E. Surveyor asked about providing cares for R14. CNA-D and CNA-E both stated cares for R14 were an assist of 1 and both were unaware of the 11/20/20 care planned intervention regarding Cares in Pairs. Surveyor reviewed a Nurse Practitioner visit note from on 12/2/20. Documented under History of Present Illness was has behavioral issues including inappropriate sexual comments, aggression, and combativeness at times. This has improved with the use of [MEDICATION NAME]. Under Focused A&P's (Assessment and Plan) - During Today's Visit was Dementia secondary to [MEDICAL CONDITION] aggressive and sexual behaviors at times. Patient on [MEDICATION NAME]. Documented in Progress Notes on 12/13/20 at 10:46 PM was (R14) alert but confused, not asking for help with needs. Observed walking in the hall without direction or idea of destination. Was using his walker and his gait was slightly festinated with knees locked together. Patient redirected to his room and given cares. Was combative with (bedtime) medication pass and grabbed writers hand, twisting it strongly. Had aggressive facial expression and was difficult to redirect. Took meds after 1:1. There was no increased monitoring, update to care plan or added interventions after this incident. Documented in Progress Notes on 1/1/21 at 7:36 PM by LPN-K was (R14) was found in (R22's room) standing over (R22) with his pants down and private area out. R22 was identified and noted to have a BIMS of 5 which indicated severe cognitive impairment. Surveyor reviewed the facility's in-house Investigation related to the incident between R14 and R22. Documented was On 1/1/2021 it was reported to (LPN-K) that (R14) was found in (R22's) room with his pants down. (R22) was sleeping and her roommate was not in the room. (R14) had not contacted the resident at all. He was removed from the resident's room and placed on frequent checks. The following steps were taken: - (R14) was placed on frequent checks and when asked what happened (R14) was unable to (recall the event.) - (R14's) care plan was updated. - Family, care team and MD were updated of the event. - Statements collected from (CNA-F) who reported the event and (LPN-J) who documented it. - (R22) statement was received and she was unaware of anything that took place and was not concerned. - MD and family of (R22) were updated. - Skin check was performed on R22 with no new areas of concern. In conclusion (R14) will continue to be monitored for inappropriate sexual behaviors. (R22) has been placed on alert charting to monitor for changes in behavior. This incident was not reported to the State Agency as an allegation of abuse. Surveyor reviewed witness statement from CNA-F that stated 1/2/21: I was coming down hallway 200 and I saw (R14) in the dark with his pants halfway down hovering over (R22's) head while she was asleep. Then I asked him what he was doing. Then he said I was looking for you. Then I told him to come out of the room. Then he told me he was looking for someone named On 1/5/21 at 3:33 PM Surveyor interviewed CNA-F. Surveyor asked about the incident between R14 and R22 on 1/1/21. CNA-F stated she was walking down the hallway and noticed R22's room door open and saw a shadow. CNA-F stated she entered the room and saw R14 with his penis exposed and leaning over her (R22's) head. Surveyor asked what she did when she found R14. CNA-F stated she led R14 back to his room and put him in bed then went to inform LPN-J. Surveyor asked if she found R14 during a routine check. CNA-F stated no, she was just walking down the hall. Surveyor asked if R14 had displayed these behaviors prior to 1/1/21. CNA-F stated yes, R14 looks at CNAs and Nurses in sexual ways and asks them to come into bed with them. He wanders the halls and tries to enter other female residents' rooms. Surveyor reviewed witness statement from LPN-J that stated 1/2/21: (R14) was found by one of the CNAs in (R22's) room with his pants down. (R14) was escorted out of the room and into his own room. Writer went in and checked on (R22.) (R22) was asleep under her blankets and not disturbed. (Roommate of R22) was unaware of anyone else in the room previously. On 1/5/21 at 3:33 PM Surveyor interviewed LPN-J. Surveyor asked about the incident between R14 and R22 on 1/1/21. LPN-J stated CNA-F informed her what happened. Surveyor asked what LPN-J did with the information. LPN-J stated she was not sure what to do. LPN-J stated she discussed the incident with Registered Nurse (RN)-K and she passed the information on to the 1st shift Nurse since she did not think it was an urgent incident. Surveyor asked what was done for R14 to monitor him. LPN-J stated the staff made sure he stayed in his room overnight and he was checked on frequently. Surveyor asked what timeframe was meant for frequent checks for R14. LPN-J stated she checks every hour and the CNAs check in between then. Surveyor asked if R14 had displayed these behaviors prior to 1/1/21. LPN-J stated yes, he tries to grab female staff's butt and boobs and is often sexually inappropriate. On 1/5/21 at 4:15 PM Surveyor interviewed RN-K. Surveyor asked about the incident between R14 and R22 on 1/1/21. RN-K stated he was unaware of any incident. Surveyor asked if LPN-J had discussed the incident with him. RN-K stated no. Surveyor asked if R14 was on frequent checks for any sexually inappropriate behavior. RN-K stated not that I know of. Surveyor asked what time frame was meant for frequent checks. RN-J stated anywhere from an hour to 30 minutes to 15 minutes, it depends. Surveyor reviewed R14's Comprehensive Care Plan. Added to his Care Plan was 1/2/21: Resident is to be frequent checks to monitor for inappropriate sexual behavior. Documented on 1/2/21 at 2:02 PM in Progress Notes was Writer spoke with (R14) regarding event that occurred on 1/1/21 in the evening. Resident was unable to comprehend or respond to questions asked by writer due to speech and cognitive delay. Writer found with skin assessment no new areas of concern, resident family and MD updated regarding the events. Intervention put in place for resident at this time is for resident to have more frequent checks to be increased. On 1/6/21 at 11:58 AM, Surveyor interviewed SSD-L. Surveyor asked when she was made aware of the incident on 1/1/21 between R14 and R22. SSD-L stated on 1/5/21. Surveyor asked what was done to prevent R14 from further sexual abuse incidents with residents. SSD-L stated R14 was moved to the 600 unit and will be placed in a permanent room soon. Surveyor observed R14 was not moved to the 600 unit on 1/6/21 at 12:29 PM. R14 remained in same room across the hall from R22. On 1/6/21 at 7:11 AM Surveyor interviewed ANHA-C and DON-B. Surveyor asked when Administration was made aware of the incident between R14 and R22. ANHA-C stated 1/2/21 in the morning. ANHA-A stated she started an investigation and received witness statements. Surveyor asked what was done to immediately to protect both residents. ANHA-A stated R14 was kept in his room and staff checked on him more frequently when they became aware of the incident. Surveyor asked if this was an adequate intervention. ANHA-C stated no. Surveyor asked how this was a different intervention from the 9/17/20 incident. DON-B stated the monitoring was increased including frequent checks. Surveyor asked Don-B what timeframe frequent checks would be. DON-B stated 15 to 30 minutes. Surveyor noted the inconsistent statements from staff as to what frequent checks are. Surveyor asked if 1 hour would be adequate. DON-B stated no. Surveyor asked if there was a written policy or procedure that would define frequent checks. DON-B stated no. R13 was no longer at the facility and could not be interviewed by the surveyor. Surveyor noted R22 had a BIMS of 5 and was cognitively impaired and could not be interviewed. Because neither woman could express how these incidents made them feel, the survey team used the concept of the reasonable person. Surveyor noted a reasonable person (i.e., one who is without a cognitive impairment) would have a high likelihood to experience and feel extreme fear and anger when alone in her room with a male resident who has his pants down and, in the case of R13, making sexually inappropriate comments of his intent. Such a person could become psychosocially or emotionally traumatized. Additionally, the survey team noted that further advancements by R14 towards R22 did not occur because a CNA just happened to walk by the room and catch a glimpse of a shadow in the room. Facility failure to take immediate action to ensure residents were safe from sexual abuse on 9/17/20 and its failure to ensure care planned interventions were specific to the resident and followed, which resulted in a second incident of abuse on 1/1/21, created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 1/7/21 when the facility implemented the following: * R14 was moved to a secured male only dementia unit. * One to one monitoring provided to: 1-Identify patterns and observe life routines during the day, evening and night. 2-Identify triggers or life routine timing and contributing factors that may stimulate psychological impulses to initiate peer seeking. * R14's POA consented for Psych services. * Interdisciplinary team: Administrator, Director of Nursing, attending physician, Social Worker, Licensed Nurse and Nursing Assistant providing direct resident care on unit will: 1-Review the patterns and life routines observed. 2-Discuss triggers and contributing factors for psychological impulses. 3-Together with the Resident Representative review the Plan of Care and continued interventions for the Plan of Care. 4-Determine appropriate continued individualized interventions and requirement for continued monitoring frequency. *All female residents have the potential to be affected. Records have been reviewed of female residents to ensure: 1-No changes in mood or behavior, changes in sleep patterns or meal intakes. 2-Any resident with objective change reviews will have an evaluation conducted by Social Services and Nursing. Interviews with female residents on unit to confirm feelings of safety Female residents with an inability to interview: Record reviews to confirm: 1-No change in mood or behavior. 2-No change in sleep patterns. 3-No change in meal intakes. 4-No change in basic habits or routines of daily life. Record reviews have been completed: 1-Confirmed no additional residents with sexual exhibited behaviors. * In house residents with confusion and a history of wandering have been reviewed with care plans updated as needed. * Immediate Abuse education provided with direct care staff. Facility staff received education prior to working shifts on the facility's abuse policy. Educator has been trained by the Administrator and / or determined designee. Facility staff will not work until educated on Abuse Policy. 25% of staff were trained by 1/8/2021. Emphasis: 1-Resident to resident altercation. 2-Immediately separate residents. 3-Stay with the aggressor. 4-Provide 1:1. 5-Notify the nurse, consult with the physician and resident representative. 6-Interdisciplinary team completes an evaluation to determine continued individualized interventions and frequency for monitoring. 7-Goal of care to appropriately intervene to identify the root cause and integrate interventions to protect and prevent behavior from re-occurring. New employees: Orientation will include abuse policy training prior to working the floor. * Audits of 24-hour board/report were completed daily and compared to documentation in PCC (Point Click Care) to ensure compliance with education. Random daily staff audits will confirm staff understanding of education. Random daily resident audits will confirm feelings of safety inside the facility environment. * The results of these audits will be reviewed by the Quality Assurance Performance (QAPI) Committee for patterns, trends, and continued recommendations for process monitoring and improvement.

Based on interview and record review the facility did not ensure 1 (R1) of 2 residents reviewed received hydration and nutritional services consistent with the resident's needs. -R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was assessed on 9/10/20 to be at risk for dehydration due to limited mobility and recent infection. The facility did not ensure R1 had a plan of care in place with interventions to prevent dehydration. The facility did not have a system in place to ensure R1 was offered adequate fluid, offering a 16 oz glass of water every shift and fluids per resident preference/request at meals. The facility had no system in place to monitor how much fluid was consumed, tracking fluid along with meal intake with no way to differentiate if the fluids were consumed. In October R1 began requiring increased assistance with meals. The facility did not update R1's plan of care related to R1 requiring increased assistance with intake. On 10/25/20 R1 began having increased lethargy, with labs ordered. On 10/26/20 R1's sodium level came back at a critically high level. No new intervention was put into place until 10/27/20 when IV fluids were ordered. The facility had no system in place to determine how much IV fluids had been received when R1's IV infiltrated. R1 was hospitalized on [DATE]. Findings include: The facility Hydration Management policy and procedure, undated, states The elderly have a diminished sense of thirst and decreased kidney function. The amount of fluid needed to maintain health and prevent dehydration is specific to each resident and may fluctuate as a resident conditions fluctuate. Therefore, healthcare staff will ensure adequate fluid intake by: -Licensed staff observation of hydration status every shift during meals, medication passes and other staff/resident interactions -Keeping fluids accessible -Cuing to drink with meals and medications and assisting and/or cueing drinking as needed. R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Hydration Evaluation, with an effective date of 8/26/20, documents the resident scoring a 4 with points scored related to the resident being dependent on a device for mobility, being incontinent of urine, having 1-2 predisposing factors present, and related to medications received in the last 7 days. The assessment documents a Score of 14 or higher indicates resident is at RISK for dehydration and further assessment should be conducted to review residents fluid status. R1's Admission Minimum Data Set Assessment (MDS), with an assessment reference date of 9/2/20, documents R1 required extensive assistance of one person's physical assistance with eating (how residents eats and drinks.) The assessment documents R1's cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The assessment documents R1 had rejection of cares 1-3 days during the assessment reference period. R1's Care Are Assessment for Dehydration/Fluid Maintenance, signed as completed on 9/10/20, documents Resident is at risk for dehydration due to having limited mobility and recent infection. No S/S [signs/symptoms] of dehydration since admission. Fluids will be kept at bedside and offered with each contact. Labs done per MD order. Staff to observe for S/S of dehydration. Will proceed toc are plan [sic, to care plan] to prevent dehydration. The Care Area Assessment documents dehydration/fluid maintenance will be addressed in the plan with the overall objective being to avoid complications and minimize risks. Review of R1's care plan did not contain a focused area for dehydration and fluid maintenance and did not include an intervention to offer fluids with each contact. R1's plan of care includes a focus area for The resident has a nutrition problem r/t [related to] DM2 [diabetes mellitus type 2], increased nutrition needs AEB [as evidence by] multiple pressure ulcers initiated 9/16/20. Interventions initiated on 9/16/20 include CHO [carbohydrate] controlled diet, regular texture, thin liquids and Provide, serve diet as ordered. Monitor intake and record q [every] meal. R1's plan of care includes a focus area for The resident has actual/potential for an ADL [activities of daily living] self-care performance deficit r/t [related to] [CONDITION(S)] that includes an intervention of Dining: resident requires cueing initiated on 9/21/20. On 9/3/20 a Comprehensive Nutrition Assessment completed by RD (registered dietician)-T documents under Nutritional-Focused Physical Findings General appearance is: thin. Resident is not well nourished . The assessment documents under Nutritional Needs Fluids 1850. Oral route for fluids. The assessment documents Resident is a 68 y/o [year old] male admitted to rehab dx [diagnosis] [CONDITION(S)], Alzheimer's dx, dementia, pressure ulcer, DM2, depression, [CONDITION(S)] of intestine, ETOH [alcohol] abuse, alcoholic fatty liver. Resident receives a CHO controlled diet with regular texture, dependent on staff for feeding, consumes 75-100% of meals. The surveyor reviewed R1's documentation and noted no specific documentation related to the amount of fluids R1 consumed or is offered. On 1/6/21 at 12:29 pm the surveyor interviewed CNA (certified nursing assistant)-Q. The surveyor asked CNA-Q how she would know how much fluids to give to a resident. CNA-Q stated it would be in the resident Kardex. The surveyor reviewed R1's Kardex and noted it did not specify how much fluids to offer R1. On 1/6/21 at 12:35 pm the surveyor interviewed CNA-P. The surveyor asked how CNA-P knows how much fluids to give a resident. CNA-P stated it would be on the resident Kardex. CNA-P stated if it wasn't on the Kardex she would ask the nurse. On 1/6/21 at 12:38 pm the surveyor interviewed CNA-S. The surveyor asked how CNA-S knows how much fluids to give a resident. CNA-S stated twice a shift she passes water and residents get fluids at 8 and 12 with meals. CNA-S stated if the resident is not on a fluid restriction the amount of fluids given would just be per the resident's preference. On 1/6/21 at 12:27 pm the surveyor interviewed LPN (licensed practical nurse)-R. The surveyor asked how LPN-R knows how much fluids a resident has had. LPN-R stated if the resident is not on input and output monitoring it would just be included along with their amount eaten for meals. The surveyor noted there is no way to know how much of the percentage consumed was fluids or food intake. On 1/6/21 at 1:03 pm the surveyor interviewed RD-T. The surveyor asked RD-T how fluids are usually tracked. RD-T stated fluids aren't usually tracked, and that fluids are offered every shift with meals and waters are passed every shift. The surveyor asked how it is determined if resident's are getting offered enough fluids. RD-T stated the MD may order to encourage fluids, maybe a specific amount of may be more general such as encourage 2 liters a day or just encourage fluids. The surveyor asked how staff are expected to know the amount of fluids to offer. RD-T stated staff give a full cup of water every shift, and that she believed they are 16 oz glasses (approximately 473 mL). The surveyor asked if the 3 16oz glasses (a total of 1,419 cc's) would meet a 1800mL a day fluid goal. RD-T stated it would not, but resident's should be getting a couple cups with meals. The surveyor asked if there is any way to know how much fluid a resident is offered other than the 3 16 oz glasses. RD-T stated not unless the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The surveyor noted from 10/1/20-10/7/20, for the 21 meals during that time period, 17 meals are documented as being 76-100% eaten, 1 meal 51-75% eaten, 1 meal 26-50 eaten, and 2 meals with nothing documented. From 10/1/20-10/7/20 R1 is documented as being independent with how they ate, with the exception of on 10/5/20 for the 6pm meal being documented as requiring supervision (oversite, encouragement or cueing). The surveyor noted from 10/8/20-10/14/20, for the 21 meals during that time period, 9 meals are documented as being 76-100% eaten, 3 meals 51-75% eaten, 2 meals 26-50% eaten, 1 meal 0-25% eaten, and 6 meals with no documentation of the amount eaten. From 10/8/20-10/14/20 R1 is documented as being independent for how they eat and drink for 8 meals, supervision for 4 meals, limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) for 3 meals, and had 6 meals with nothing documented. The surveyor noted from 10/15/20-10/21/20, for the 21 meals during that time period 17 meals are documented as being 76-100 eaten, 1 meal 51-75% eaten, 2 meals 26-50% eaten, and 1 meal 0-25% eaten. From 10/15/20-10/21/20 R1 is documented as being independent for how they eat and drink for 9 meals, supervision for 1 meal, limited assistance for 1 meal, extensive assistance for 1 meal, and total dependence for 5 meals. The surveyor noted no change in R1's plan of care when R1 began requiring increased assistance with eating and drinking 10/15/20-10/21/20. On 10/22/20 R1 is documented as eating 76-100% of all 3 meals, requiring supervision for eating for 2 meals, and being independent with 1 meal. On 10/23/20 R1 is documented as eating 76-100% of breakfast, 26-50% of lunch, and 51-75% of dinner. R1 is documented as requiring total dependence on staff for breakfast and being independent with lunch and dinner. On 10/24/20 R1 is documented as eating 76-100% of breakfast, and 26-50% for lunch and dinner. R1 is documented as needing extensive assistance for breakfast and lunch and being independent with dinner. On 10/25/20 R1 is documented as eating 76-100% for breakfast, 26-50% for lunch, and has no documented intake for dinner. R1 is documented as the ADL not occurring for the assistance required with breakfast, is documented as requiring total dependence for lunch, and has no documentation for dinner. A Nurse to Physician/NP/PA Notification note on 10/25/20 at 4:08 pm documents Situation: lethargic Background: [CONDITION(S)], Alzheimer's, type diabetes [sic], [CONDITION(S)], [CONDITION(S)]. Assessment: t [temperature] 98.2 p [pulse] 70 r [respirations] 18 b/p [blood pressure] 101/70 spO2 [oxygen saturation] 98% at room air. Skin warm and dry, lungs clear, bowel sounds active x4, no [CONDITION(S)] noted. Response: [MD-O] updated new orders, cmp [complete metabolic panel], cbc [complete blood count], u/a [urine analysis] and chest e-ray [sic] . Progress notes on 10/25/20 at 11:00 pm document .Resident striking out to staff with feeding. Ate 50% of supper and 250cc of fluids . On 10/26/20 R1 is documented as refusing breakfast, eating 0-25% of lunch, and 26-50% of dinner. R1 is documented as needing total dependence (full staff performance) for eating breakfast and lunch and is documented as being independent with dinner. Progress notes on 10/26/20 at 12:05 am document attempted to straight cath resident no urine return will continue to push fluids and attempt again. Progress notes on 10/26/20 by NP (Nurse Practitioner)-N at 2:30 pm documents Provider assessment for acute onset lethargy and routing f/u [follow up] on Alzheimer's with behavioral disturbance .ASSESSMENT/PLAN a) Acute Lethargy: Per staff this is new for patient. He is baseline dementia with some aggressive behaviors. Acute onset of lethargy noted on 10/25. MD updated, orders received for CMP, CBC, U/A and chest x-ray. VSS [vital signs stable]. Currently VS [vital signs] remain stable. Will await test results. Continue close monitoring for acute changes. No new orders as orders already in place by MD. ** Noted progress note with elevated sodium level of 169. [CONDITION(S)] likely cause of acute lethargy. Per progress note MD notified of above, will defer to MD orders at this time. I will f/u [follow up] with patient in a.m. Chest x-ray negative for acute changes. Progress notes on 10/26/20 at 3:59 pm by LPN-M documents Lab Result: Critical Na [sodium] level of 169 call over from lab. [MD-O] office called with results. Currently no new order received. Other lab, UA, and chest xray pending. Progress notes on 10/26/20 at 5:43 pm document Lab Report: -Chest X-ray: No acute cardiopulmonary process. -CBC & Blood chemistry results received. All results call and fax to MD. Awaiting any f/u orders/instruction. On 1/6/21 at 3:20 pm the surveyor interviewed LPN-M. The surveyor asked LPN-M if he had spoke with a physician on 10/26/20. LPN-M stated he wanted to say he spoke with the doctor but may have been a nurse at the office and let them know, who would notify the doctor and call back if new orders received. LPN-M was unable to recall if he spoke with the physician. On 1/7/21 at 9:59 am the surveyor interviewed MD-O. MD-O stated he was notified of the critical level on 10/26/20 and ordered some fluids. MD-O stated he recalled some issue with either getting the line started or getting the fluids in, does not recall all the issues. MD-O stated R1 had serious dementia and was not able to eat and drink enough and was questioning if the resident needed a PEG tube or hospitalization , but wanted to get fluids in first. MD-O stated he also recalled speaking with NP-N as well. The surveyor reviewed R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/7/21 at 10:20 am the surveyor informed DON (Director of Nursing)-B of MD-O stating he was notified on 10/26/20 of the critical lab value and ordered fluids and not being able to find documentation of fluids starting until 10/27/20. On 1/7/21 at 10:35 am MD-O informed the surveyor he was unable to recall if it had been 10/26/20 or 10/27/20 when notified of the critical lab value, that it was blurry to him related to the timing. MD-O stated patient care comes first and wants to make sure resident's get the care they need. On 1/7/21 at 9:05 am the surveyor interviewed NP-N. NP-N informed the surveyor she thought the MD had been notified based on LPN-M's note. NP-N stated she (NP-N) may do her charting at the end of the day, but (NP-N) charts the time she physically saw the resident. NP-N stated she was probably thinking on 10/27/20 when they saw me why was nothing done. NP-N stated she discussed the resident with MD-O and the determination was made to start fluids after consultation. NP-N stated vital signs were stable for the resident so did not seem emergent, that just the sodium had been elevated and the potassium was normal. On 10/27/20 R1's care plan was updated to include a focus area for [R1] has [CONDITION(S)] r/t [related to] Poor intake. Interventions initiated on 10/27/20 include Hydration interventions per Physicians orders, Educate the resident/family/caregivers on importance of fluid intake, and IV fluids. The surveyor noted no new interventions had been put into place until 10/27/20, when the facility had first been notified of the critical sodium level on 10/26/20. Review of R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed R1's medical record including MAR (medication administration record) and noted there was no documentation of how much fluid R1 had received. On 10/27/20 R1 is documented as refusing breakfast and lunch, and having eaten 76-100% of dinner. R1 is documented as needing total dependence for all 3 meals. R1's plan of care was not updated to include that he required total dependence with meals. Progress notes on 10/27/20 at 4:47 am document Resident remains lethargic . Progress notes on 10/27/20 at 1:45 pm document .resident remains lethargic at times, continues to strike out at staff with cares. NP updated. Supplements taken, small bites of food take . Progress notes on 10/27/20 at 2:00 pm NP-N documents under assessment/plan; 1) Lethargy/[CONDITION(S)]: Likely r/t elevated labs. 22g PIV [peripheral IV] placed in right FA [forearm].45NS [normal saline] on drip chamber tubing at 100/hr. Total to be infused 3 liters. STAT CMP was ordered prior to this infusion starting so may not reflect accurate levels given the time of the draw. Staff will continue to monitor for acute changes . On 10/28/20 R1 is documented as having eaten 0-25% of breakfast and lunch, and 51-75% of supper. R1 is documented as needing total dependence for breakfast and lunch, and extensive assistance for dinner. Progress notes on 10/28/20 at 7:30 am by NP-N documents under assessment/plan; 1) [CONDITION(S)]: IV fluid infusions continue. IV infiltrated. New IV placement in lower right FA 24g. IV fluids restarted. [MD-O] informed of lapse in treatment. Awaiting D5W (Dextrose 5%in water) to switch fluids. When this arrive we can change the .45NS (Normal Saline) to D5W. 0845 [8:45 am] D5W fluids obtained. IV fluids switched over, continues at a rate of 100/hr . Progress notes on 10/29/20 at 7:20 am document .Writer in to assess IV, res arm/and on top of IV site, IV infiltrated and out, small amount of blood noted, gauze placed over site. SPO2-89% on room air, O2@3LPM via mask provided. SPO2 91-93% with O2. Response: [MD-O] aware. New orders: stat BMP, stat chest xray and covid test. Progress notes on 10/29/20 at 7:30 am by NP-N document .Pt's [patient's] wife .on this phone this morning when I arrived. I asses the patient and gave her an update. Given the new findings and ongoing decline patient will be sent out to Aurora [NAME] for evaluation and treatment. [MD-O] started [MEDICATION(S)] last evening for UTI. [MD-O] notified of the above assessment and pending transfer . On 1/7/21 at 9:05 am the surveyor interviewed NP-N. NP-N informed the surveyor the resident had not seemed to improve, and she questioned the amount of IV fluids the resident had actually received, as there was no way to determine based on the charting and the IV being off from it infiltrating so the decision was made to send the resident out. On 1/7/21 at 9:20 am the surveyor interviewed DON-B. The surveyor asked DON-B how the facility would track IV fluids administered. DON-B stated the facility usually signs out the order, would not put an independent amount. The surveyor informed DON-B of the concern of being unable to determine how much fluids R1 had received when his IV infiltrated and he was no longer receiving IV fluids per the order. The surveyor asked how the facility ensures residents are offered adequate fluids. DON-B stated residents are offered water and fluid with meals. The surveyor informed DON-B of staff informing the surveyor resident's receive fluid at meals per the preference and not being able to identify a system to ensure residents are at least offered an adequate amount of fluids to meet their needs. The surveyor informed DON-B of the concern of R1's plan of care not being updated when he began requiring increased assistance with meals.

Based on a complaint received at the Southeastern Regional Office, record review and interview, the facility did not update and consult with the resident's physician or provide all pertinent information to the physician when 1 (R1) of 4 residents reviewed experienced a significant change in her medical condition. When R1 experienced a significant change in condition on [DATE], the facility failed to give the physician all pertinent information when first contacted, failed to update and consult with the physician on delays in obtaining STAT (immediate) labs and an EKG (electrocardiogram) (normal turnaround time is 4 hours, but in this situation it was 7½ hours), failed to report the results of a STAT lab until 3 hours and 20 minutes later (from 4:37 p.m. until 7:57 p.m.), and failed to update and consult with the physician when R1's SPO2 (peripheral capillary oxygen saturation) readings were below 90% while receiving oxygen administration, per physician orders. These failures created a finding of Immediate Jeopardy beginning on [DATE]. Administrator-A, Assistant Administrator-I, Assistant Director of Nursing (DON)-J and Director of Clinical Operations (DCO)-C were informed of the Immediate Jeopardy on [DATE] at 2:05 p.m. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope and severity level of D (potential for more than minimal harm/isolated) as the facility continues to follow through with audits ensuring physician notification of resident changes in condition, with results of audits reviewed by the facility's Quality Assurance Performance Improvement Committee. Findings include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's ADL (Activities of Daily Living) care plan dated as initiated on [DATE] documents under the Interventions section, Bed Mobility: Independent; Ambulation: Independent with 2 w/w (wheeled walker); Dining: Resident is independent. R1's Quarterly Neurological Observation Evaluation dated [DATE] documents, 1. Orientation: Person; 3a. Responds to simple commands? Yes; 3b. Verbalizes appropriately? Yes; 3c. Changes in baseline speech clarity? No; 4a. Alert: Yes; 7. Overall Status: Evaluation indicates no changes from baseline. R1's Quarterly MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 9, indicating that R1 is moderately cognitively impaired. Section G (Functional Status) on the MDS documents that R1 requires limited assistance and one person physical assistance for her transfer needs. Section G also documents that R1 requires supervision and only set up help to walk in her room and corridor. On [DATE] an anonymous complaint was called into the Southeastern Regional Office that alleged the complainant received a call from R1 complaining of a severe headache, chest pain and unable to eat as she couldn't keep anything down. The complaint alleged that R1 had stated to the complainant that facility staff had checked her blood pressure which was high. The complaint alleged that the complainant requested that staff call a physician, and was informed that the physician was called and orders were given to treat resident at the facility. The complaint alleged that the complainant was called the next day at 3:46 a.m. and was informed that R1 was found unresponsive and had expired. First shift [DATE] R1's nursing note dated [DATE] at 8:50 a.m. as written by the LPN (Licensed Practical Nurse)-E documents, Nurse to Physician Notification (SBAR)(Situation, Background, Assessment, Recommendation) Situation: Writer called to resident room per attending CNA (Certified Nursing Assistant) at approximately 0835 (AM). Assessment: Writer in with resident. Resident lethargic and not responding to verbal or tactile stimuli per usual self. Resident skin cool and clammy. Resp (Respirations) even and labored. Not able to speak or sit up. RN (Registered Nurse) manager in alongside writer. T (Temperature)-97.6 (degrees Fahrenheit), P (Pulse)-95, R (Respirations)-20, B/P (Blood Pressure)- ,[DATE], SPO2 (peripheral capillary oxygen saturation)-68% room air, BG (blood glucose)-109 Response: Call placed to primary physician and was updated on resident change of condition. NOR's (new orders) received for STAT (immediate) EKG (electrocardiogram) and labs. POA (power of attorney) updated on resident change of condition and new orders. O2 (oxygen) applied per NC (nasal cannula). R1's nursing noted dated [DATE] at 8:56 AM as written by the RN (Registered Nurse) Manager-D documents, Nurse to Physician Notification (SBAR) Situation: Progress Notes Assessment: Resident unable to follow directions, hand grasp. Unable to track with eyes. Abdomen soft. Skin color normal, clammy. Pulse strong and regular. HOB (head of bed) elevated. R1's [DATE] TAR (Treatment Administration Record) documents the following physician order: Oxygen ,[DATE] lpm (liters per minute) via nc (nasal cannula) prn (as needed) to keep pox (SPO2) > (above) 90% as needed; prn to keep pox >90% as needed for to keep pox>90%. R1's [DATE] MAR (Medication Administration Record) documents R1's vitals as listed on the 8:50 a.m. nursing note written by LPN-E as entered in R1's MAR indicated [REDACTED] R1's [DATE] MAR indicated [REDACTED]. R1's nursing noted dated [DATE] at 1:13 p.m. documents, Medication Administration Note Text: oxygen ,[DATE] lpm via nc prn to keep pox >90% as needed for to keep pox>90% PRN Administration was: Ineffective R1's [DATE] TAR documents the following physician order [REDACTED].> (above) 90% as needed; prn to keep pox >90% as needed for to keep pox>90%. Surveyor was unable to find any documentation that staff contacted R1's physician to inform the physician that R1's oxygen administration was ineffective at 1:13 p.m. as documented by LPN-E. R1's nursing note dated [DATE] at 1:52 p.m. as written by the LPN-E documents, Nurse to Physician/NP/PA Notification (SBAR) Situation: Background: Assessment: Response: No change in resident condition from prior assessment. In bed resting with hob (head of bed) elevated and O2 (oxygen) on at 2L (liters)/min per NC (nasal cannula). Resident appears comfortable at this time. All needs anticipated and met per staff. Awaiting WDI (Wisconsin Diagnostics) to do stat (immediate) labs and EKG. The physician was not informed of what the resident's pulse oxygenation level was or that staff thought oxygen administration was ineffective On [DATE] at 1:12 p.m., Surveyor interviewed LPN-E regarding R1's change in condition on [DATE]. Surveyor asked LPN-E to describe R1's change in condition on [DATE]. LPN-E informed Surveyor that she was called by the CNA to R1's room. LPN-E informed Surveyor that she assessed R1 per her documented nursing note. LPN-E verified to Surveyor R1's assessment and vitals as documented on [DATE] at 8:50 a.m. LPN-E informed Surveyor that R1 was unresponsive and not acting normal per her usual self. LPN-E stated that R1 is usually pleasantly confused and that on [DATE] at 8:35 a.m., R1 was having trouble breathing. LPN-E informed Surveyor that due to R1's condition, she (LPN-E) called RN Manager-D to evaluate R1. LPN-E informed Surveyor that R1 did not look well and that because of this, she (LPN-E) called MD (Medical Doctor)-F, who ordered stat (immediate) labs, an EKG and oxygen administration. Surveyor asked LPN-E why R1 was not sent to the hospital as R1's change in condition, difficulty breathing and unresponsiveness was not baseline for R1. LPN-E informed Surveyor that she (LPN-E) could only do what MD-F and RN Manager-D ordered as she is only an LPN. Surveyor asked LPN-E to describe why R1's oxygen administration was documented as ineffective at 1:13 p.m. on R1's [DATE] MAR indicated [REDACTED]. When Surveyor asked LPN-E if R1's fluctuating SPO2 readings were normal for R1, LPN-E informed Surveyor that fluctuating SPO2 reading were not normal for R1. Surveyor asked LPN-E, if she (LPN-E) would have sent out R1 to the hospital based on R1's change in condition and presentation on [DATE]. LPN-E informed Surveyor that in her (LPN-E) opinion, she would have sent R1 to the hospital based on R1's presentation, vitals and unresponsiveness. LPN-E informed Surveyor that because she is an LPN, she could not supersede R1's MD and RN order to not send R1 to the hospital. On [DATE] the facility obtained a statement from LPN-H, which was provided to the Surveyor and which states: This statement is a brief recollection of the events that occurred on [DATE] regarding R1. R1 had a change of condition. RN Manager-D and RN-K went together with writer (LPN-E) into patient's room. Upon entering the room, I observed the resident with her eyes open, not responding to verbal or tactile stimuli. While RN Manager-D assessed the resident, I took the patient's vitals. I then went to call MD-F. Writer informed MD-F that based on the nursing assessment completed, she (R1) should be sent to the hospital. MD-F then asked who are you? I told him I am the nurse caring for the resident. He asked again who are you? And I told him again that I am the nurse caring for the resident. He then told this writer that he was not going to discuss the patient with me. I was confused as to why he was asking who I was, as I introduced myself to him at the start of the call. He stated he wanted to speak to someone else who could give a proper assessment of the patient. RN Manager-D as well as RN-K were alongside me for the entire conversation. Writer handed the phone to RN Manager-D. RN Manager-D spoke to MD-F and he gave her new orders which she relayed to this writer. Upon hearing the new orders of stat labs and an EKG, this writer (LPN-E) told RN Manager-D I think she (R1) should be sent out to the hospital. RN Manager-D verbalized that the resident was a DNR and that this is what the doctor wanted. This statement is to the best of my recollection as well as knowledge. I, LPN-E was interviewed by state around 1310 (1:10 PM) on [DATE] in regards to resident (R1) who was a prior resident I was the nurse for prior to her passing. The state representative questioned why the follow up for her O2 (oxygen) was ineffective. I explained to him that it was ineffective because it was not over 90%. I told him at that time I can recall it being around ,[DATE]% with 02 (oxygen) on. The state representative asked writer why she (R1) wasn't (sic) sent to the hospital. I explained to him that her initial assessment was done by RN Manager-D, RN-K, and myself (LPN-E). I told him as an LPN I am under the direct supervision of an RN at all times. I also explained to him that I cannot supersede an RN or a primary physician in sending a resident out without a physician order [REDACTED]. On [DATE] at 1:27 p.m., Surveyor interviewed RN Manager-D regarding R1's change in condition on [DATE]. Surveyor asked RN Manager-D to described R1's change in condition on [DATE]. RN Manager-D informed Surveyor she went into R1's room and observed R1 to be unresponsive and not alert to verbal or tactile stimuli. RN Manager-D informed Surveyor that per her nursing note dated [DATE] at 8:56 a.m., R1 was not her normal self, as R1 was usually alert, forgetful and would usually be moving back and forth in her room. RN Manager-D informed Surveyor that R1 was DNR (Do Not Resuscitate) status at the time and that R1 was not talking or walking as usual. Surveyor asked RN Manager-D if she called R1's physician to report R1's change in condition as documented on [DATE]. RN Manager-D informed Surveyor that she did not call R1's physician as LPN-E contacted R1's physician. Surveyor asked RN Manager-D why she had not spoken to R1's physician or sent R1 to the hospital. RN Manager-D informed Surveyor that she did not speak with R1's physician or send out R1 to the hospital because she was told that LPN-E was handling R1's change in condition. Surveyor asked RN Manager-D if there was a delay in obtaining R1's labs and EKG as ordered by R1's physician. RN Manager-D informed Surveyor that there is usually a 4 hour turnaround time in STAT (immediate) labs and that STAT labs are not like at the hospital. Surveyor asked RN Manager-D if she had spoken with R1's physician to voice any concerns regarding R1's change in condition. RN Manager-D informed Surveyor that she had not spoken with R1's physician to voice any concerns regarding R1's change in condition because LPN-E had already spoken to R1's physician. RN Manager-D informed Surveyor that MD-F had ordered STAT labs and an EKG. Surveyor asked RN Manager-D if R1 was at her baseline. RN Manager-D informed Surveyor that at the time, R1 was not her normal self. Surveyor asked RN Manager-D if she (RN Manager-D) would have sent R1 to the hospital based on R1's vitals, SPO2 readings and condition. RN Manager-D informed Surveyor that based on R1's vitals, SPO2 readings and condition she (RN Manager-D) would have sent R1 to the hospital. RN Manager-D informed Surveyor that MD-F had been informed of R1's condition, that R1 was a DNR, and that she (RN Manager-D) was following physician orders. When Surveyor asked RN Manager-D if R1 being DNR (Do Not Resuscitate) status meant that R1 did not get medical treatment and or sent to the hospital, RN Manager-D stated that R1's DNR status did not mean that R1 did not get medical treatment and or sent to the hospital. Surveyor asked RN Manager-D if she had contacted MD-F regarding R1's delay in STAT labs and EKG. RN Manager-D informed Surveyor that she had not contacted MD-F regarding R1's delay in STAT labs and EKG. (Note: Turnaround time for the lab work and EKG ordered at 8:50 AM was 7½ hours.) As part of the additional information provided to the Surveyor, the facility gave Surveyor its interview of RN Manager D obtained on [DATE]. This interview stated: During interview with state surveyor he asked several times why resident (R1) was not sent to ER (emergency room ). Again, MD (MD-F) was called with assessment and did not want resident sent out, but to do STAT (immediate) labs and EKG. Surveyor stated that 7 hours was a long time for STAT labs to be done. I explained to him that STAT turnaround is about 4 hours. Surveyor questioned resident's B/P and again asked why I didn't send resident to ER. MD did not want resident to go to ER and ordered labs. I did check on resident several times throughout the shift and she was comfortable. I at no point told Surveyor that I would've sent the resident to the ER. I gave my assessment to MD and I followed his orders. I went with LPN-E to assess R1 on the morning of [DATE]. Assessment was charted and MD-F was called with assessment by LPN-E. LPN-E asked MD-F if the resident should be sent out, and then MD-F did not want to speak to an LPN so I spoke with him (MD-F) and gave him my assessment. MD-F stated he did not want to send the patient to ER (emergency room ) and gave stat (immediate) orders for labs and an EKG. I did check on the resident several times throughout the day and she was comfortable. Family was updated by LPN-E. Resident was a DNR (Do Not Resuscitate). On [DATE] at 11:28 a.m., Surveyor re-interviewed RN Manager-D. Surveyor asked RN Manager-D to clarify if she (RN Manager-D) had told Surveyor on [DATE] that she would have sent R1 to the hospital on [DATE]. RN Manager-D informed Surveyor that she wanted to clarify her statement and that at no time did she state she would have sent R1 to the hospital on [DATE]. RN Manager-D informed Surveyor that R1 was a DNR (Do Not Resuscitate) patient and that LPN-E had contacted MD-F about R1's change in condition. RN Manager-D informed Surveyor that she now recalled speaking with MD-F, contrary to her statement to Surveyor that she did not speak with MD-F on [DATE]. RN Manager-D informed Surveyor that MD-F did not want to speak with LPN-E. RN Manager-F informed Surveyor that she assessed, added to and agreed with LPN-E's assessment of R1 as documented on [DATE] at 8:50 AM by LPN-E. RN Manager-D informed Surveyor that because MD-F did not want to speak with LPN-E, she spoke with MD-F and informed him (MD-F) of R1's condition based on the documented assessment at 8:50 a.m. on [DATE]. Surveyor asked RN Manager-D if she had voiced any concerns to MD-F regarding R1's change in condition on [DATE]. RN Manager-D informed Surveyor that she did not voice any concerns to MD-F regarding R1's change in condition on [DATE]. RN Manager-D informed Surveyor that during the phone call, LPN-E had difficulty understanding MD-F due to MD-F's foreign accent and that she (RN Manager-D) had voiced to LPN-E that they needed to speak with a physician due to R1's change in condition. RN Manager-D informed Surveyor that she did not express her opinions to MD-F regarding R1's change in condition when she spoke to MD-F. RN Manager-D informed Surveyor that LPN-E became frustrated on the phone when informing MD-F about R1's change in condition. RN Manager-D informed Surveyor that LPN-E had wanted to send R1 to the hospital. RN Manager-D informed Surveyor that she told LPN-E that R1 was a DNR and that MD-F did not want to send R1 to the hospital. When Surveyor asked RN Manager-D if she had voiced LPN-E's desire to send R1 to the hospital to MD-F, RN Manager-D informed Surveyor that she did not voice LPN-E's desire to send R1 to the hospital to MD-F. Surveyor asked RN Manager-D if she believed that MD-F would have sent out R1 to the hospital if she (RN Manager-D) had voiced LPN-E's desire to have R1 sent to the hospital. RN Manager-D informed Surveyor that MD-F's orders change from day to day and that at times he (MD-F) does not want to speak with LPNs and other days he does. RN Manager-D informed Surveyor that voicing LPN-E's desire to send R1 to the hospital to MD-F would not have changed MD-F's orders. After interviewing RN Manager-D, Surveyor read and allowed RN Manager-D to read the above statements to ensure that the interview was accurately documented by Surveyor. RN Manager-D read the above interview and confirmed to Surveyor that the documented interview was accurate and that she (RN Manager-D) was in agreement with what was documented. Based on RN Manager-D's interview, Surveyor noted that there was no additional information provided as to why MD-F was not contacted and updated of R1's condition after 8:50 a.m. Surveyor also noted that there was no additional information provided as to why MD-F was not consulted when R1's SPO2 readings were not above 90% when vitals were obtained at 11:30 a.m. and when R1's oxygen administration was documented as ineffective at 1:13 p.m. on [DATE]. On [DATE] at 1:52 p.m., Surveyor interviewed MD-F, via telephone, regarding R1's change in condition on [DATE]. Surveyor read R1's nursing note dated [DATE] at 8:50 a.m., which documented R1 was unresponsive and lethargic, to MD-F. Surveyor then asked MD-F why he (MD-F) had not sent R1 to the hospital based on R1's documented vitals, SPO2 reading and blood pressure. MD-F informed Surveyor that he had not seen R1 and that he did not recall the exact conversation he had with R1's nurse. MD-F confirmed to Surveyor that he did receive a call regarding R1 and that maybe he was told R1 was drowsy, however that he (MD-F) could not recall what he was told by nursing staff. MD-F informed Surveyor that based on what the nursing note states, he would have sent R1 to hospital due to R1's level of consciousness and elevated systolic blood pressure of 210. MD-F informed Surveyor that R1's documented blood pressure could not be managed at the nursing home and that his (MD-F) orders of labs and an EKG were standard orders. MD-F informed Surveyor that it was not made clear to him (MD-F) that R1 was unresponsive and that maybe the quality of the nursing report given to him was not good. Surveyor asked MD-F why R1 was not sent to the hospital with an initial SPO2 reading of 68% and after R1 was placed on 2 liters of oxygen via nasal cannula. MD-F informed Surveyor that being on 2 liters of oxygen continuously, when R1 had not previously received oxygen, would constitute to him (MD-F), acute respiratory distress, which was criteria for R1 to be sent out to the hospital. MD-F informed surveyor that he (MD-F) judicially sends out residents to the hospital for low SPO2 readings and chest pain. Surveyor asked MD-F if he expected nursing staff at the facility to update him on R1's condition and or if R1 remained unresponsive. MD-F informed Surveyor that he expected nursing staff at the facility to update him as his response to R1's condition was based on the quality of the nursing report being given to him (MD-F), as he was not at the facility to see R1. Surveyor asked MD-F if facility staff had called him to give him any other update besides the lab and EKG results on [DATE] at 7:57 p.m. MD-F informed Surveyor that he had not received any other updates on R1 from facility staff besides the lab and EKG results. Surveyor was unable to locate any documentation that R1's physician was contacted after LPN-E documented on [DATE] at 1:13 p.m. that R1's oxygen administration was ineffective. Second shift [DATE] R1's nursing note dated [DATE] at 4:37 p.m. as written by the LPN Manager-G documents, Health Status Note Text: Labs faxed to MD-F; Lactic Acid 1.6; Hemoglobin 10.6; Glucose 216; Troponin High Sensitivity 51; Procalcitonin 0.10 and EKG result NSR (Normal Sinus Rhythm) with Wenckebach 2 (degree) blockage, abnormal EKG. R1's nursing note dated [DATE] at 7:57 p.m. as written by LPN Manager-G documents, Note Text: Spoke with MD-F r/t (related to) labs/ ECG, NNO's (no new orders) at this time. Surveyor noted the facility received the lab results on [DATE] at 4:37 p.m. Normal turnaround time is 4 hours while in this situation it took 7 ,[DATE] hours. Facility staff did not consult with the physician about this delay. Surveyor also noted that after receiving the results, staff did not consult with the physician concerning the lab results and the high troponin level until 7:57 p.m. (3 hours and 20 minutes later). Surveyor noted that LPN Manager-G's nursing note as documented on [DATE] at 4:37 p.m. did not include any documentation of an assessment that could be used to consult with R1's physician about R1's condition. Third shift [DATE] - [DATE] R1's [DATE] MAR indicated [REDACTED]. R1's nursing note dated [DATE] at 3:09 a.m. as written by LPN-H documents, This writer called into residents (sic) room by CNA. Resident was found to have no vital signs. Skin was warm to the touch. Resident is a no code .MD (medical doctor) paged to update on residents passing. On [DATE] at 1:21 p.m., Surveyor interviewed DCO (Director of Clinical Operations)-C regarding the expectations of the facility's nursing staff in relation to R1's change in condition, R1's assessment and lack of reassessment, communication between nursing staff on different shifts regarding R1's condition and physician notification and consultation. Surveyor asked DCO-C if nursing staff is expected to reassess and consult with the physician if a resident whom experiences a change in condition does not improve. DCO-C informed Surveyor that nursing staff is expected to reassess and contact the physician if a resident whom experiences a change in condition does not improve. Surveyor asked DCO-C if nursing staff should have contacted the physician when R1's SPO2 readings were not above 90% at 11:30 a.m. (24 hour report provided) and when LPN-E documented that R1's oxygen administration was ineffective and R1's SPO2 reading was below 90% at 1:13 p.m. on [DATE]. DCO-C informed Surveyor that nursing staff should have contacted R1's physician when R1's SPO2 readings were below 90%. Surveyor asked DCO-C why nursing staff had not contacted R1's physician at 11:30 a.m. and 1:13 p.m. on [DATE]. DCO-C informed Surveyor that she could not say why nursing did not contact R1's physician at 11:30 a.m. and 1:13 p.m. on [DATE]. Surveyor asked DCO-C about the lab results. Surveyor acknowledged that while the facility could not control the lab's arrival times, Surveyor asked DCO-C if nursing staff were expected to contact R1's physician if the lab arrival times were delayed. DCO-C informed Surveyor that she (DCO-C) expected nursing staff to first contact the lab if the arrival times were delayed. DCO-C informed Surveyor that she would also expect nursing staff to call R1's physician if there were delays. Surveyor asked DCO-C why nursing staff did not contact R1's physician when R1's labs were delayed. DCO-C informed Surveyor that she couldn't say why nursing staff did not contact R1's physician when R1's labs were delayed. Surveyor asked DCO-C if she expected nursing staff to reassess R1's change in condition throughout [DATE] and [DATE]. DCO-C informed Surveyor that she expected nursing staff to reassess and consult with R1's physician of R1's condition throughout [DATE] and [DATE]. Surveyor asked DCO-C why nursing staff had not updated R1's physician throughout [DATE]. DCO-C informed Surveyor she could not say why nursing staff had consulted with R1's physician throughout [DATE] and [DATE]. The facility's failure to provide the physician with all pertinent information, to update and consult with the physician on delays in obtaining STAT (immediate) labs and an EKG (electrocardiogram), to promptly consult with the physician when lab work returned, which included an elevated troponin level, and to update and consult the physician when R1's SPO2 (peripheral capillary oxygen saturation) readings were below 90% when on oxygen, per physician orders, created a finding of Immediate Jeopardy beginning on [DATE]. The immediate jeopardy was removed on [DATE] when the facility completed the following: - The identified resident is expired. - The RN and LPN identified in the deficiency were educated on facility Notification of Change Guideline, change in condition, notifications to MD, document observations/assessments each shift and more frequent as required for resident's conditions, any delay in outside services, such as lab, X-ray, etc. and resident not achieving levels for oxygen saturation per MD order. - Licensed staff were educated on the facility practice to review residents listed on the 24-hour report board, notifying MD, change in condition notifications to MD, document observations/assessments each shift and more frequent as required for resident's condition, any delay in outside services, such as lab, X-ray, etc. and resident not achieving levels of oxygen saturation per MD order. - In house residents have been evaluated, those experiencing a change in condition, have had MD notification, Resident and/or representative were notified. - Resident having a change in condition will have a focused observation/assessment completed by nurse. - Licensed nursing staff will receive education on change in condition, notifications to MD, document observations/assessments each shift and more frequent as required by resident's condition, any delay in outside services, such as lab, X-ray, etc. and resident not achieving levels of oxygen saturation per MD order. - LPNs will report their observations to the RN and document their findings. - If RN is in the facility, a focused assessment will be completed and documented. - MD will be notified timely by LPN or RN and any orders received will be entered and followed. - Resident and/or representative will be notified on resident's condition and MD orders. - Audits of 24 hour board report will be completed daily and compared to documentation in PCC (point click care) to ensure compliance with education. - The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement.

Based on a complaint received at the Southeastern Regional Office, record review and interview, the facility did not ensure that 1 (R1) of 4 sampled residents received continued assessments and appropriate medical care when R1 experienced a significant change in her medical condition. The facility failed to reassess R1 throughout [DATE] and [DATE], failed to update the physician on delays in obtaining STAT (immediate) labs and an EKG (electrocardiogram), delayed in discussing the lab results received at 4:37 pm until 7:57 pm (3 hours later) with the physician, failed to communicate R1's change in condition to oncoming nursing staff (2nd & 3rd shifts), and failed to reassess and update the physician when R1's SPO2 (peripheral capillary oxygen saturation) readings were below 90% while receiving oxygen administration, per physician orders. These failures created a finding of Immediate Jeopardy beginning on [DATE]. Administrator-A, Assistant Administrator-I, Assistant Director of Nursing (DON)-J and Director of Clinical Operations (DCO)-C were informed of the Immediate Jeopardy on [DATE] at 2:05 p.m. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope and severity level of D (potential for more than minimal harm/isolated) as the facility continues to follow through with audits ensuring resident assessments are completed with changes in condition, with results of audits reviewed by the facility's Quality Assurance Performance Improvement Committee. Findings include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's ADL (Activities of Daily Living) care plan dated as initiated on [DATE] documents under the Interventions section, Bed Mobility: Independent; Ambulation: Independent with 2 w/w (wheeled walker); Dining: Resident is independent. R1's Quarterly Neurological Observation Evaluation dated [DATE] documents, 1. Orientation: Person; 3a. Responds to simple commands? Yes; 3b. Verbalizes appropriately? Yes; 3c. Changes in baseline speech clarity? No; 4a. Alert: Yes; 7. Overall Status: Evaluation indicates no changes from baseline. R1's Quarterly MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 9, indicating that R1 is moderately cognitively impaired. Section G (Functional Status) on the MDS documents that R1 requires limited assistance and one person physical assistance for her transfer needs. Section G also documents that R1 requires supervision and only set up help to walk in her room and corridor. On [DATE] an anonymous complaint was called into the Southeastern Regional Office that alleged the complainant received a call from R1 complaining of a severe headache, chest pain and unable to eat as she couldn't keep anything down. The complaint alleged that R1 had stated to the complainant that facility staff had checked her blood pressure which was high. The complaint alleged that the complainant requested that staff call a physician, and was informed that the physician was called and orders were given to treat resident at the facility. The complaint alleged that the complainant was called the next day at 3:46 a.m. and was informed that R1 was found unresponsive and had expired. First shift [DATE] R1's nursing note dated [DATE] at 8:50 a.m. as written by the LPN (Licensed Practical Nurse)-E documents, Nurse to Physician Notification (SBAR)(Situation, Background, Assessment, Recommendation) Situation: Writer called to resident room per attending CNA (Certified Nursing Assistant) at approximately 0835 (AM). Assessment: Writer in with resident. Resident lethargic and not responding to verbal or tactile stimuli per usual self. Resident skin cool and clammy. Resp (Respirations) even and labored. Not able to speak or sit up. RN (Registered Nurse) manager in alongside writer. T (Temperature)-97.6 (degrees Fahrenheit), P (Pulse)-95, R (Respirations)-20, B/P (Blood Pressure)- ,[DATE], SPO2 (peripheral capillary oxygen saturation)-68% room air, BG (blood glucose)-109 Response: Call placed to primary physician and was updated on resident change of condition. NOR's (new orders) received for STAT (immediate) EKG (electrocardiogram) and labs. POA (power of attorney) updated on resident change of condition and new orders. O2 (oxygen) applied per NC (nasal cannula). R1's nursing noted dated [DATE] at 8:56 AM as written by the RN (Registered Nurse) Manager-D documents, Nurse to Physician Notification (SBAR) Situation: Progress Notes Assessment: Resident unable to follow directions, hand grasp. Unable to track with eyes. Abdomen soft. Skin color normal, clammy. Pulse strong and regular. HOB (head of bed) elevated. R1's [DATE] TAR (Treatment Administration Record) documents the following physician order: Oxygen ,[DATE] lpm (liters per minute) via nc (nasal cannula) prn (as needed) to keep pox (SPO2) > (above) 90% as needed; prn to keep pox >90% as needed for to keep pox>90%. R1's [DATE] MAR (Medication Administration Record) documents R1's vitals as listed on the 8:50 a.m. nursing note written by LPN-E as entered in R1's MAR indicated [REDACTED] R1's [DATE] MAR indicated [REDACTED]. R1's nursing noted dated [DATE] at 1:13 p.m. documents, Medication Administration Note Text: oxygen ,[DATE] lpm via nc prn to keep pox >90% as needed for to keep pox>90% PRN Administration was: Ineffective R1's [DATE] TAR documents the following physician order [REDACTED].> (above) 90% as needed; prn to keep pox >90% as needed for to keep pox>90%. Surveyor was unable to find any documentation, assessment, vitals, including SPO2 readings that to indicate that a registered nurse assessed R1 or that staff contacted R1's physician to inform the physician that R1's oxygen administration was ineffective at 1:13 p.m. as documented by LPN-E. R1's nursing note dated [DATE] at 1:52 p.m. as written by the LPN-E documents, Nurse to Physician/NP/PA Notification (SBAR) Situation: Background: Assessment: Response: No change in resident condition from prior assessment. In bed resting with hob (head of bed) elevated and O2 (oxygen) on at 2L (liters)/min per NC (nasal cannula). Resident appears comfortable at this time. All needs anticipated and met per staff. Awaiting WDI (Wisconsin Diagnostics) to do stat (immediate) labs and EKG. Surveyor noted that the LPN-E's assessment as documented on [DATE] at 1:52 p.m. was not followed up by an RN assessment, did not include vitals or documented that R1's physician was contacted after R1's oxygen administration was documented as ineffective at 1:13 PM. Surveyor also was unable to find any documentation that R1's physician was contacted to be updated and consulted on R1's condition after R1 was assessed with [REDACTED]. On [DATE] at 1:12 p.m., Surveyor interviewed LPN-E regarding R1's change in condition on [DATE]. Surveyor asked LPN-E to describe R1's change in condition on [DATE]. LPN-E informed Surveyor that she was called by the CNA to R1's room. LPN-E informed Surveyor that she assessed R1 per her documented nursing note. LPN-E verified to Surveyor R1's assessment and vitals as documented on [DATE] at 8:50 a.m. LPN-E informed Surveyor that R1 was unresponsive and not acting normal per her usual self. LPN-E stated that R1 is usually pleasantly confused and that on [DATE] at 8:35 a.m., R1 was having trouble breathing. LPN-E informed Surveyor that due to R1's condition, she (LPN-E) called RN Manager-D to evaluate R1. LPN-E informed Surveyor that R1 did not look well and that because of this, she (LPN-E) called MD (Medical Doctor)-F, who ordered stat (immediate) labs, an EKG and oxygen administration. Surveyor asked LPN-E why R1 was not sent to the hospital as R1's change in condition, difficulty breathing and unresponsiveness was not baseline for R1. LPN-E informed Surveyor that she (LPN-E) could only do what MD-F and RN Manager-D ordered as she is only an LPN. Surveyor asked LPN-E if she completed any other assessment on R1 after 1:52 p.m. as documented in LPN-E's nursing note. LPN-E informed Surveyor that she did not complete any other assessment on R1 after 1:52 p.m., as she (LPN-E) had other nursing duties to complete. LPN-E informed Surveyor that RN Manager-D had been checking on R1 and that there may be additional vitals she (LPN-E) obtained on R1 documented on the 24 hour board for [DATE]. Surveyor asked LPN-E to describe why R1's oxygen administration was documented as ineffective at 1:13 p.m. on R1's [DATE] MAR indicated [REDACTED]. When Surveyor asked LPN-E if R1's fluctuating SPO2 readings were normal for R1, LPN-E informed Surveyor that fluctuating SPO2 reading were not normal for R1. Surveyor asked LPN-E, if she (LPN-E) would have sent out R1 to the hospital based on R1's change in condition and presentation on [DATE]. LPN-E informed Surveyor that in her (LPN-E) opinion, she would have sent R1 to the hospital based on R1's presentation, vitals and unresponsiveness. LPN-E informed Surveyor that because she is an LPN, she could not supersede R1's MD and RN order to not send R1 to the hospital. On [DATE] the facility obtained a statement from LPN-H, which was provided to the Surveyor and which states: This statement is a brief recollection of the events that occurred on [DATE] regarding R1. R1 had a change of condition. RN Manager-D and RN-K went together with writer (LPN-E) into patient's room. Upon entering the room, I observed the resident with her eyes open, not responding to verbal or tactile stimuli. While RN Manager-D assessed the resident, I took the patient's vitals. I then went to call MD-F. Writer informed MD-F that based on the nursing assessment completed, she (R1) should be sent to the hospital. MD-F then asked who are you? I told him I am the nurse caring for the resident. He asked again who are you? And I told him again that I am the nurse caring for the resident. He then told this writer that he was not going to discuss the patient with me. I was confused as to why he was asking who I was, as I introduced myself to him at the start of the call. He stated he wanted to speak to someone else who could give a proper assessment of the patient. RN Manager-D as well as RN-K were alongside me for the entire conversation. Writer handed the phone to RN Manager-D. RN Manager-D spoke to MD-F and he gave her new orders which she relayed to this writer. Upon hearing the new orders of stat labs and an EKG, this writer (LPN-E) told RN Manager-D I think she (R1) should be sent out to the hospital. RN Manager-D verbalized that the resident was a DNR and that this is what the doctor wanted. This statement is to the best of my recollection as well as knowledge. I, LPN-E was interviewed by state around 1310 (1:10 PM) on [DATE] in regards to resident (R1) who was a prior resident I was the nurse for prior to her passing. The state representative wanted to know why there were no vitals after the initial assessment (at 8:30 am) up to 1600 (4:00 PM). I responded to him that I did take vs (vital signs) after that and that he could possibly find them on the 24 hour shift to shift report. I told him the unit manager RN Manager-D took over after that as I went back to my floor nursing. I also told him I was not the nurse for that unit after 400 (4:00 PM) when I had given report to oncoming nurse. He stated there were missing pieces to documentation. The state representative questioned why the follow up for her O2 (oxygen) was ineffective. I explained to him that it was ineffective because it was not over 90%. I told him at that time I can recall it being around ,[DATE]% with 02 (oxygen) on. The state representative asked writer why she (R1) wasn't (sic) sent to the hospital. I explained to him that her initial assessment was done by RN Manager-D, RN-K, and myself (LPN-E). I told him as an LPN I am under the direct supervision of an RN at all times. I also explained to him that I cannot supersede an RN or a primary physician in sending a resident out without a physician order [REDACTED]. Surveyor noted that with the additional information provided, there were only 3 sets of documented vital signs for R1: Vitals documented on the nursing note for [DATE] at 8:50 a.m., 11:30 a.m. vitals documented on the 24 hour report that was provided, and vitals taken on [DATE] at 12:40 a.m. shortly before R1 expired. No vitals were provided for [DATE] second shift. On [DATE] at 1:27 p.m., Surveyor interviewed RN Manager-D regarding R1's change in condition on [DATE]. Surveyor asked RN Manager-D to described R1's change in condition on [DATE]. RN Manager-D informed Surveyor she went into R1's room and observed R1 to be unresponsive and not alert to verbal or tactile stimuli. RN Manager-D informed Surveyor that per her nursing note dated [DATE] at 8:56 a.m., R1 was not her normal self, as R1 was usually alert, forgetful and would usually be moving back and forth in her room. RN Manager-D informed Surveyor that R1 was DNR (Do Not Resuscitate) status at the time and that R1 was not talking or walking as usual. Surveyor asked RN Manager-D if she called R1's physician to report R1's change in condition as documented on [DATE]. RN Manager-D informed Surveyor that she did not call R1's physician as LPN-E contacted R1's physician. RN Manager-D informed Surveyor that she did look into R1's room from time to time. Surveyor asked RN Manager-D if she (RN Manager-D) had assessed R1 at any other time besides her documented nursing note on [DATE] at 8:56 a.m. RN Manager-D informed Surveyor that she did not complete any other assessment on R1 after 8:56 a.m. Surveyor asked RN Manager-D why she had not spoken to R1's physician or sent R1 to the hospital. RN Manager-D informed Surveyor that she did not speak with R1's physician or send out R1 to the hospital because she was told that LPN-E was handling R1's change in condition. Surveyor asked RN Manager-D if there was a delay in obtaining R1's labs and EKG as ordered by R1's physician. RN Manager-D informed Surveyor that there is usually a 4 hour turnaround time in STAT (immediate) labs and that STAT labs are not like at the hospital. Surveyor asked RN Manager-D if she had spoken with R1's physician to voice any concerns regarding R1's change in condition. RN Manager-D informed Surveyor that she had not spoken with R1's physician to voice any concerns regarding R1's change in condition because LPN-E had already spoken to R1's physician. RN Manager-D informed Surveyor that MD-F had ordered STAT labs and an EKG. Surveyor asked RN Manager-D if she (RN Manager-D) had completed any other assessment on R1. RN Manager-D informed Surveyor that she did not complete any other assessment on R1 but that she did check on R1 and that R1 appeared comfortable. Surveyor asked RN Manager-D if R1 was at her baseline. RN Manager-D informed Surveyor that at the time, R1 was not her normal self. Surveyor asked RN Manager-D if she (RN Manager-D) would have sent R1 to the hospital based on R1's vitals, SPO2 readings and condition. RN Manager-D informed Surveyor that based on R1's vitals, SPO2 readings and condition she (RN Manager-D) would have sent R1 to the hospital. RN Manager-D informed Surveyor that MD-F had been informed of R1's condition, that R1 was a DNR, and that she (RN Manager-D) was following physician orders. When Surveyor asked RN Manager-D if R1 being DNR (Do Not Resuscitate) status meant that R1 did not get medical treatment and or sent to the hospital, RN Manager-D stated that R1's DNR status did not mean that R1 did not get medical treatment and or sent to the hospital. Surveyor asked RN Manager-D why she did not reassess R1's condition. RN Manager-D informed Surveyor that she was not sure why she (RN Manager-D) did not reassess R1. RN Manager-D informed Surveyor that MD-F did not order anything else for R1 and confirmed LPN-E's assessment dated [DATE] at 8:50 a.m. that documented R1 was unresponsive. When Surveyor asked RN Manager-D if she had performed any other assessments of R1 after adding to LPN-E's assessment as documented on [DATE] at 8:56 a.m., RN Manager-D informed Surveyor that she did not complete any other assessments on R1 as she (RN Manager-D) had other tasks to complete. Surveyor asked RN Manager-D if she was aware of any other changes to R1 after her documented assessment on [DATE] at 8:56 a.m. RN Manager-D informed Surveyor that she was not aware of any changes for R1 after her documented assessment and that she (RN Manager-D) was following MD-F's orders. Surveyor asked RN Manager-D if she had contacted MD-F regarding R1's delay in STAT labs and EKG. RN Manager-D informed Surveyor that she had not contacted MD-F regarding R1's delay in STAT labs and EKG. As part of the additional information provided to the Surveyor, the facility gave Surveyor its interview of RN Manager D obtained on [DATE]. This interview stated: During interview with state surveyor he asked several times why resident (R1) was not sent to ER (emergency room ). Again, MD (MD-F) was called with assessment and did not want resident sent out, but to do STAT (immediate) labs and EKG. Surveyor stated that 7 hours was a long time for STAT labs to be done. I explained to him that STAT turnaround is about 4 hours. Surveyor questioned resident's B/P and again asked why I didn't send resident to ER. MD did not want resident to go to ER and ordered labs. I did check on resident several times throughout the shift and she was comfortable. I at no point told Surveyor that I would've sent the resident to the ER. I gave my assessment to MD and I followed his orders. I went with LPN-E to assess R1 on the morning of [DATE]. Assessment was charted and MD-F was called with assessment by LPN-E. LPN-E asked MD-F if the resident should be sent out, and then MD-F did not want to speak to an LPN so I spoke with him (MD-F) and gave him my assessment. MD-F stated he did not want to send the patient to ER (emergency room ) and gave stat (immediate) orders for labs and an EKG. I did check on the resident several times throughout the day and she was comfortable. Family was updated by LPN-E. Resident was a DNR (Do Not Resuscitate). On [DATE] at 11:28 a.m., Surveyor re-interviewed RN Manager-D. Surveyor asked RN Manager-D to clarify if she (RN Manager-D) had told Surveyor on [DATE] that she would have sent R1 to the hospital on [DATE]. RN Manager-D informed Surveyor that she wanted to clarify her statement and that at no time did she state she would have sent R1 to the hospital on [DATE]. RN Manager-D informed Surveyor that R1 was a DNR (Do Not Resuscitate) patient and that LPN-E had contacted MD-F about R1's change in condition. RN Manager-D informed Surveyor that she now recalled speaking with MD-F, contrary to her statement to Surveyor that she did not speak with MD-F on [DATE]. RN Manager-D informed Surveyor that MD-F did not want to speak with LPN-E. RN Manager-F informed Surveyor that she assessed, added to and agreed with LPN-E's assessment of R1 as documented on [DATE] at 8:50 AM by LPN-E. RN Manager-D informed Surveyor that because MD-F did not want to speak with LPN-E, she spoke with MD-F and informed him (MD-F) of R1's condition based on the documented assessment at 8:50 a.m. on [DATE]. RN Manager-D informed Surveyor that after speaking with MD-F, she checked on R1 at 11:30 a.m. and that R1 appeared comfortable. Surveyor asked RN Manager-D if R1 was alert when she checked on her (R1) at 11:30 a.m. RN Manager-D informed Surveyor that R1 was lying in bed, with her face towards the window and not verbal. Surveyor asked RN Manager-D if R1 could speak. RN Manager-D informed Surveyor that R1 did not speak at that time. Surveyor asked RN Manager-D if she had been notified or had assessed R1 when R1's SPO2 reading was documented as 88% while on oxygen and not at or above 90% per physician orders, as documented on the [DATE] 24 hour board at 11:30 a.m. RN Manager-D informed Surveyor that she was unable to remember being notified that R1's SPO2 readings were not at or above 90%. Surveyor asked RN Manager-D if when she 'checked' on R1, if it meant that she formally assessed and collected vitals on R1. RN Manager-D informed Surveyor that she did not formally assess or collect vitals when she 'checked' on R1, that instead LPN-E was the one assessing and taking vitals on R1. Surveyor asked if RN Manager-D had reassessed R1 after LPN-E documented R1's oxygen administration as ineffective on [DATE] at 1:13 p.m. RN Manager-D informed Surveyor that she did not reassess R1 at 1:13 p.m. Surveyor asked RN Manager-D if she reassessed R1 after LPN-E documented that R1's condition had not changed on [DATE] at 1:52 PM. RN Manager-D informed Surveyor that she did not reassess R1 at 1:52 p.m. RN Manager-D informed Surveyor that she could not recall reassessing R1 again after her initial assessment with LPN-E on [DATE] at 8:50 AM. RN Manager-D informed Surveyor that she believed LPN-E was monitoring R1 and that she did not follow up on R1's condition with LPN-E. Surveyor asked RN Manager-D if she had informed the 2nd shift oncoming nursing staff of R1's change in condition when she (RN Manager-D) was relived of her duties by the oncoming shift on [DATE]. RN Manager-D informed Surveyor that she did not inform the oncoming nursing staff of R1's change in condition on [DATE]. RN Manager-D informed Surveyor that it was LPN-E's responsibility to communicate R1's change in condition to the oncoming nursing shift and. RN Manager-D informed Surveyor that she was looking in on R1 and that she (RN Manager-D) was under the belief that R1 would be okay. RN Manager-D informed Surveyor that she did not complete any other assessment on R1 besides her initial assessment with LPN-E at 8:50 AM on [DATE]. Surveyor asked RN Manager-D if she had voiced any concerns to MD-F regarding R1's change in condition on [DATE]. RN Manager-D informed Surveyor that she did not voice any concerns to MD-F regarding R1's change in condition on [DATE]. RN Manager-D informed Surveyor that during the phone call, LPN-E had difficulty understanding MD-F due to MD-F's foreign accent and that she (RN Manager-D) had voiced to LPN-E that they needed to speak with a physician due to R1's change in condition. RN Manager-D informed Surveyor that she did not express her opinions to MD-F regarding R1's change in condition when she spoke to MD-F. RN Manager-D informed Surveyor that LPN-E became frustrated on the phone when informing MD-F about R1's change in condition. RN Manager-D informed Surveyor that LPN-E had wanted to send R1 to the hospital. RN Manager-D informed Surveyor that she told LPN-E that R1 was a DNR and that MD-F did not want to send R1 to the hospital. When Surveyor asked RN Manager-D if she had voiced LPN-E's desire to send R1 to the hospital to MD-F, RN Manager-D informed Surveyor that she did not voice LPN-E's desire to send R1 to the hospital to MD-F. Surveyor asked RN Manager-D if she believed that MD-F would have sent out R1 to the hospital if she (RN Manager-D) had voiced LPN-E's desire to have R1 sent to the hospital. RN Manager-D informed Surveyor that MD-F's orders change from day to day and that at times he (MD-F) does not want to speak with LPNs and other days he does. RN Manager-D informed Surveyor that voicing LPN-E's desire to send R1 to the hospital to MD-F would not have changed MD-F's orders. After interviewing RN Manager-D, Surveyor read and allowed RN Manager-D to read the above statements to ensure that the interview was accurately documented by Surveyor. RN Manager-D read the above interview and confirmed to Surveyor that the documented interview was accurate and that she (RN Manager-D) was in agreement with what was documented. Based on RN Manager-D's interview, Surveyor noted that there was no additional information as why R1 was not reassessed by RN Manager-D when R1's condition did not change after 8:50 a.m., when R1's SPO2 readings were not above 90%, per physician orders, when vitals were obtained at 11:30 a.m. and when R1's oxygen administration was documented as ineffective at 1:13 p.m. on [DATE]. Surveyor noted that there was no additional information provided as to why MD-F was not contacted and updated of R1's condition after 8:50 a.m. Surveyor also noted that there was no additional information provided as to why MD-F was not consulted when R1's SPO2 readings were not above 90% when vitals were obtained at 11:30 a.m. and when R1's oxygen administration was documented as ineffective at 1:13 p.m. on [DATE]. Surveyor also noted that additional information provided as to why RN Manager-D did not inform 2nd shift nursing staff of R1's change in condition by 1st shift nursing staff on [DATE]. Surveyor was unable to interview RN-K, whom was also present when R1 had a change of condition on [DATE], because RN-K was no longer employed by the facility during the time of the survey. On [DATE] at 1:52 p.m., Surveyor interviewed MD-F, via telephone, regarding R1's change in condition on [DATE]. Surveyor read R1's nursing note dated [DATE] at 8:50 a.m., which documented R1 was unresponsive and lethargic, to MD-F. Surveyor then asked MD-F why he (MD-F) had not sent R1 to the hospital based on R1's documented vitals, SPO2 reading and blood pressure. MD-F informed Surveyor that he had not seen R1 and that he did not recall the exact conversation he had with R1's nurse. MD-F confirmed to Surveyor that he did receive a call regarding R1 and that maybe he was told R1 was drowsy, however that he (MD-F) could not recall what he was told by nursing staff. MD-F informed Surveyor that based on what the nursing note states, he would have sent R1 to hospital due to R1's level of consciousness and elevated systolic blood pressure of 210. MD-F informed Surveyor that R1's documented blood pressure could not be managed at the nursing home and that his (MD-F) orders of labs and an EKG were standard orders. MD-F informed Surveyor that it was not made clear to him (MD-F) that R1 was unresponsive and that maybe the quality of the nursing report given to him was not good. Surveyor asked MD-F why R1 was not sent to the hospital with an initial SPO2 reading of 68% and after R1 was placed on 2 liters of oxygen via nasal cannula. MD-F informed Surveyor that being on 2 liters of oxygen continuously, when R1 had not previously received oxygen, would constitute to him (MD-F), acute respiratory distress, which was criteria for R1 to be sent out to the hospital. MD-F informed surveyor that he (MD-F) judicially sends out residents to the hospital for low SPO2 readings and chest pain. Surveyor asked MD-F if he expected nursing staff at the facility to update him on R1's condition and or if R1 remained unresponsive. MD-F informed Surveyor that he expected nursing staff at the facility to update him as his response to R1's condition was based on the quality of the nursing report being given to him (MD-F), as he was not at the facility to see R1. Surveyor asked MD-F if facility staff had called him to give him any other update besides the lab and EKG results on [DATE] at 7:57 p.m. MD-F informed Surveyor that he had not received any other updates on R1 from facility staff besides the lab and EKG results. Surveyor was unable to locate any documentation that R1 was reassessed by nursing staff on [DATE] after 1:52 p.m. Surveyor was unable to locate any documentation that R1 was reassessed by nursing staff after 8:56 a.m. on [DATE], after RN Manager-D and LPN-E initially assessed R1. Surveyor was unable to locate any documentation that R1's physician was contacted after LPN-E documented on [DATE] at 1:13 p.m. that R1's oxygen administration was ineffective. Surveyor was unable to locate any documentation that R1's condition was monitored and reassessed by nursing staff on [DATE] after 1:52 p.m. Surveyor was unable to locate any documentation that R1 had additional vitals taken on [DATE] after 8:35 a.m. and until [DATE] at 12:40 a.m. Second shift [DATE] R1's nursing note dated [DATE] at 4:37 p.m. as written by the LPN Manager-G documents, Health Status Note Text: Labs faxed to MD-F; Lactic Acid 1.6; Hemoglobin 10.6; Glucose 216; Troponin High Sensitivity 51; Procalcitonin 0.10 and EKG result NSR (Normal Sinus Rhythm) with Wenckebach 2 (degree) blockage, abnormal EKG. R1's nursing note dated [DATE] at 7:57 p.m. as written by LPN Manager-G documents, Note Text: Spoke with MD-F r/t (related to) labs/ ECG, NNO's (no new orders) at this time. Surveyor noted the facility received the lab results on [DATE] at 4:37 p.m. Per facility staff, normal turnaround time is 4 hours; in this case, the facility did not receive the results until 7 ½ hours later and did not apprise the physician of this delay. Once the results were received, which included an abnormally high troponin level, the facility did not consult with the physician until 7:57 p.m. (3 hours later) Surveyor noted that the LPN Manager-G's note as documented on [DATE] at 4:37 p.m. did not include any documentation that R1 had vitals taken, was reassessed and or monitored by LPN Manager-G or any other second shift nursing staff. On [DATE] at 12:05 p.m., Surveyor interviewed LPN Manager-G, who was the second shift manager on [DATE], regarding R1's change in condition. Surveyor asked LPN Manager-G if she had completed an assessment or have been notified by nursing staff on 1st shift on [DATE] about R1's change in condition. LPN Manager-G informed Surveyor that she had not been told by any nursing staff on 1st shift that R1 had experienced a change in condition. LPN Manager-G informed Surveyor that all she had been told by nursing staff on 1st shift was that R1 was awaiting labs. LPN Manager-G informed Surveyor that she did not complete an assessment on R1 on [DATE]. LPN Manager-G informed Surveyor that that she could not recall seeing R1 and that she would complete an assessment on a resident only if the resident was listed on the 24 hour board, experienced a major change, or if a floor nurse requested she (LPN Manager-G) complete an assessment. Surveyor asked LPN Manager-G if she had obtained vitals on R1 and or if she was aware that R1 was listed on the 24 hour board for [DATE]. LPN Manager-G informed Surveyor that she did no obtain vitals on R1 and that she was not aware that R1 was listed on the 24 hour board on [DATE]. Based on LPN Manager-G's interview, Surveyor noted that there was not additional information provided as to why LPN Manager-G was not informed of R1's change in condition by 1st shift nursing staff on [DATE]. Surveyor also noted that there was not additional information provided as to why R1 was not reassessed or had vitals obtained on 2nd shift of [DATE]. Third shift [DATE] - [DATE] R1's [DATE] MAR indicated [REDACTED]. R1's nursing note dated [DATE] at 3:09 a.m. as written by LPN-H documents, This writer called into residents (sic) room by CNA. Resident was found to have no vital signs. Skin was warm to the touch. Resident is a no code .MD (medical doctor) paged to update on residents passing. On [DATE] at 10:03 a.m., Surveyor interviewed LPN-H, whom worked 3rd shift on [DATE] into [DATE], and obtained R1's vitals on [DATE] at 12:40 a.m. Surveyor asked LPN-H if she took R1's vitals on 3rd shift on [DATE] at 12:40 a.m. as documented in R1's [DATE] MAR. LPN-H verified to Surveyor that she (LPN-H) took R1's vitals on 3(TRUNCATED)

Based on observations, record review and interviews, the facility did not ensure the care and services necessary to prevent decline in 1 of 1 (R151) residents reviewed for quality of care. * R151 was admitted on [DATE] with a diabetic right foot wound and the necessary equipment NPWU (negative pressure wound unit/vac) to care for R151 was not available upon facility admission. The NPWU became available on 1/8/20. The wound worsened and on 1/15/20 developed necrotic tissue in the facility Findings include: R151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].Diabetes, Non-pressure chronic ulcer of right foot, [MEDICAL CONDITION]([MEDICAL CONDITION]-Stroke). R151's 1/3/20 hospital discharge records indicated the plan: NPWU (negative pressure wound unit) to be placed to right foot wound upon admission to facility with black sponge and suction at 125 mmHg. R151 had a non-healing right 5th toe amputation (12/24/19) with right foot debridement (12/26/19) and incision and drainage of right foot infection (12/29/19) during the hospitalization . On 2/17/20 at 10:00 AM, Surveyor observed R151 in the bed with feet elevated, stockings and blue slippers. R151 stated there is pain from a right foot surgical diabetic wound. R151 stated the facility did not have a NPWU upon admission so the right foot surgical wound got worse. On 2/19/20 at 10:05 AM, Surveyor interviewed AD-G (Admissions) and Liaison-P (Community Liaison) regarding R155's clinical and timeline of NPWU ordering and delivery. R155's facility admission information indicated R151 was accepted for care on 1/2/20 by Liaison-P. R151's clinical review with the order for the NPWU was received by the facility on Friday 1/3/20 at 9:00 AM. AD-G stated R151's clinical review with the order for the NPWU was emailed to Liaison-P on 1/3/20 at 9:00 AM, then the clinical review was emailed to the facility team on Friday 1/3/20 at 12:34 PM. AD-G stated he does the face sheet and the benefits but the facility would order R155's NPWU. *Surveyor noted R151 arrived at the facility on Saturday 1/4/20 as the scheduled discharge on 1/3/20 was canceled by the hospital late in the day on 1/3/20. *Surveyor noted the facility did not order R151's NPWU on 1/3/20 in preparation for R151's diabetic foot care in the facility. R151's right foot surgical wound order upon admission 1/4/20 indicated NPWU to be placed with black sponge and suction at 125 mmHg every Monday, Wednesday, and Friday. The facility staff called the physician for new orders on 1/4/20 as a NPWU was not available for R151. On 1/4/20, the physician ordered a wet to dry dressing with a pad, gauze wrap, and ace wrap daily for the right foot surgical wound until the NPWU arrives. According to the National Institute of Health at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 70/ a comparison of vacuum assisted closure and moist wound dressings indicated the vacuum treatment appears to be as safe and more effective than moist dressings for the treatment of [REDACTED]. Surveyor noted R151's NPWU was delivered to the facility on [DATE] and initiated on R151's 5th day after admission. Surveyor reviewed R151's right foot diabetic wound care facility assessment documentation which indicated: On 1/8/20, R151's right foot surgical wound measured 7.8 x 6 cm, unknown depth, with 80% [MEDICATION NAME] tissue with 20% loosely adherent slough and the NPWU was initiated on the right foot. *Surveyor noted R151's right foot surgical wound assessments were not done until 1/8/20, on the 5th day after admission. **Surveyor noted discrepancies and gaps in R151's TAR (Treatment Administration Record) regarding the right foot surgical wound care and placement of R151's NPWU. R151's TAR indicated documentation of a NPWU change on 1/6/20 when the equipment was not available in the facility. Even though R151's NPWU was placed on R151's right foot on 1/8/20, R151's TAR continues to reflect documentation of a wet to dry dressing on 1/8 and 1/9, in direct contrast to the NPWU being placed according to wound assessments documentation on 1/8/20. Surveyor noted that when the facility placed the NPWU on R151's right foot on 1/8/20, the facility did not obtain a phyisican's treatment order for the NPWU until 1/10/20, and continued with the wet to dry dressing. R151's physician order, dated 1/10/20, indicated NPWU to right foot surgical wound with dressing change including black sponge cut to size of wound bed and 125 mm Hg every Monday, Wednesday, Friday, and as needed was discontinued on 1/12/20. R151's physician order, dated 1/12/20, indicated NPWU to right foot surgical wound with dressing change including black sponge cut to size of wound bed and 125 mm Hg every Monday, Wednesday, Friday, and as needed was discontinued on 1/14/20. R151's TAR indicated NPWU dressing was not changed on Friday 1/10/20 and R151's NPWU dressing was changed on Monday 1/13/20. On 1/14/20, R151 had a follow up appointment for the right foot at the vascular surgeon. The vascular surgeon consultation notes indicated a NPWU was supposed to be placed on admission to the facility on [DATE]. The vascular surgeon's plan for R151 included a NPWU vacation for a week due to the facility noncompliance with the application of the NPWU on admission and the facility not completing NPWU dressing changes at the facility and the right foot was becoming macerated. The 1/14/20 vascular surgeon's plan included change from NPWU to a damp to dry dressing on the right foot surgical wound site. The vascular surgeon appointments for R151 continued on 1/23, 2/3, and 2/18/20 but a NPWU was not reordered for R151. On 1/15/20, Facility documentation indicated R151's right foot surgical wound measured 6.8 x 6.4 x 0.5 cm with 60% [MEDICATION NAME] tissue with 5% loosely adherent slough and 35% necrotic tissue. *Surveyor noted R151 developed necrotic tissue on the right foot surgical wound on the 11th day after admission. On 1/22/20, Facility documentation indicated R151's right foot surgical wound measured 6 x 5.8 x 0.3 cm with 70% [MEDICATION NAME] tissue, 20% loosely adherent slough and 10% necrotic tissue. On 1/29/20, Facility documentation indicated R151's right foot surgical wound measured 8 x 7 x 0.2 cm with 80% red tissue and 20% slough. On 2/5/20, Facility documentation indicated R151's right foot surgical wound measured 8 x 7 x 0.2 cm with 80% red tissue and 20% slough. On 2/12/20, Facility documentation indicated R151's right foot surgical wound measured 7.3 x 6.5 x 0.2 cm with red tissue and 20% loosely adherent slough. On 2/19/20, Facility documentation indicated R151's right foot surgical wound measured 6.5 x 5.5 x 0.2 with 80% granulation tissue and 20% slough. On 2/19/20, at 11:51 AM, Surveyor reviewed R151's wound care with NHA-A (Nursing Home Administrator) including the facility delay in ordering the NPWU upon acceptance of care on Friday 1/3/20 for R151's right foot surgical wound and R151's subsequent development of necrotic tissue. On 2/20/20, Surveyor shared information with the facility administration team during exit. No further information was provided.

Based on observations, record review and interviews, the facility did not always ensure they provided 4 out of 6 residents (R71, R100, R164, R323) reviewed for pressure injuries,with the necessary care and services to prevent pressure ulcers from developing and promote the healing of existing pressure ulcers by providing treatment and services consistent with professional standards of practice. * R71 has been assessed to be at risk for pressure injury development and on 11/22/19 developed an unstageable pressure injury to the right heel. R71's pressure ulcer was not appropriately assessed, there was a delay in notifying the physician, a delay in obtaining a treatment and the plan of care was not updated timely and was not followed to promote the healing of the pressure ulcer. On 12/6/19 the area increased in width and depth. On 2/17/20 at 8:47 a.m. R71 was observed in the dining room with her feet planted firmly on the dining room floor and did not have protective boots on her feet or other pressure relief between her feet and the hard surface. On 02/18/20 at 02:09 p.m. R71 was observed asleep in wheelchair in dining room with regular socks on and her feet resting on ground. R71 was observed with no foot rests on wheelchair. On 02/19/20 07:44 AM, Surveyor observed R71 asleep in bed R71 with gripper socks on and was not wearing no boots. R71's feet were resting directly on mattress. There was no pillows at the foot of the bed to offer additional pressure relief. On 2/20/20 at 7:45 a.m. R71's feet were observed resting directly on the mattress, both boots were under the blanket and not on the R71's feet. * R100 has been assessed to be at risk for pressure ulcer development and on 12/17/19 R100 was readmitted to the facility with a Stage 2 pressure injury behind his left ear, from the use of oxygen tubing. On 12/22/19, R100 had a new physician's orders [REDACTED]. On 12/30/19 the pressure injury deteriorated as it was documented as Stage 3 with slough and purulent drainage. There was no noted change to the pressure injury treatment nor was there evidence that R100's physician was notified. On 1/13/20, R100's care plan was updated and indicated for R100 to wear ear pads to his oxygen tubing. On 2/17, 2/18 and 2/19/20, R100 was observed with oxygen tubing resting on the pressure injury on his left ear. R100 did not have padding to the oxygen tubing as per care plan and there was no dry gauze on the pressure injury as indicated by the physician's orders [REDACTED]. R100 said that he wanted the padding but staff had not provided him with an ear pad to his left ear. * R164 was assessed to be at risk for pressure injury development. R164 developed a pressure injury to the left upper knee and the left lower knee. The pressure injuries were first identified on 11/1/19; but the first assessments of the pressure injuries were not completed until 11/13/19. There was no indication in the medical record that R164's physician was notified of the pressure injuries. The only documentation related to physician notification began on 1/21/20 when the Medical Doctor began to provide weekly skin care to R164's pressure injuries. A pressure injury care plan related to R164's actual pressure injuries was not developed until 11/21/19. The care plan did not address how pressure relief would be provided to R164's knee where he had two facility acquired pressure injuries. The facility did not provide appropriate treatment and services to promote the healing of these wounds when there was a delay in obtaining a treatment order and notifying the primary physician. On 11/13/19 the upper left knee was noted to be an Unstageable pressure injury that measured 1.5 cm x 1.4 cm x 0.0 cm, with 10% of the area having necrotic tissue. The lower left knee was noted to be a Stage 3 pressure injury that measured 1.5 cm x 1.2 cm x 0.1 cm, with 10% of the area having slough. There were no treatment orders from the physician for the left upper knee wound or the left lower knee wound. On 1/21/20 R164 was treated and evaluated by MD - W. There was no evidence in R164's medical record that treatments had been ordered by MD - W for the two pressure injuries on R164's left knee. There was a change in the description of R164's wounds. The upper left knee was documented as a Stage 3 pressure wound that measured 1.5 cm x 1.2 cm x 0.1 cm, with 80% of the area having slough. (This pressure injury had previously been documented as an Unstageable pressure injury by the facility.) The lower left knee was documented as an Unstageable Deep Tissue Injury that measured 1.0 cm x 0.8 cm x 0.1 cm, with 100% necrotic tissue. (This pressure injury had previously been documented as an Stage 3 pressure injury by the facility.) On 1/29/20 R164 had the following physician orders [REDACTED]. The treatment was to be completed daily and as needed. The left lower knee pressure injury was to be cleansed with normal saline and patted dry. Apply Xeroform followed by border gauze dressing. The treatment was to be completed each day and as needed. Although it appeared that R164's pressure injuries were healing, R164's care plan was not updated with interventions to prevent pressure to his left stump from his prosthesis. The weekly skin notes indicated that R164 was encouraged not to wear his prosthesis to promote healing of his wounds; but that R164 chose not to do this. The care plan did not address R164's non-compliance with this recommendation. * R323 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R323 did not have a comprehensive assessment of the pressure injury to the sacrum or left buttock, did not have a plan of care that addressed interventions to promote healing or prevention of further areas of skin impairment from developing, and the treatment on the Treatment Administration Record (TAR) for the buttock/coccyx area is not an appropriate treatment for [REDACTED]. Example 1 involving R71, Example 2 involving R100, and Example 3 involving R164, rise to a scope and severity level of a G (harm/isolated). This is evidenced by: Surveyor reviewed the facility's policy and procedure titled which indicates in part: Skin Management Guideline, effective date 11/28/2017. Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedure: (includes) 1. Prevention of Pressure Ulcers: * All residents admitted to the facility will be evaluated for actual and potential skin integrity issues. * A standardized pressure ulcer risk evaluation, the Braden Scale should be completed weekly for the first 4 weeks post admission, quarterly and with a change of condition (i.e., pressure ulcer development, change in mobility, continence status, nutrition, etc.). * An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with change in condition as needed. The plan of care will identify impairments and predicting factors. Interventions for prevention, removing and reducing predicating factors and treatment for [REDACTED]. B. Monitoring of Skin Integrity: (includes) * weekly skin observation on the bath/ shower day will be performed by a licensed nurse, the care plan for skin integrity is to be evaluated and revised based on response, outcomes and needs of the resident. The physician will be consulted with changes suggesting impairment in skin integrity. II. treatment of [REDACTED]. * If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedures is to be implemented: 1.) Review the wound formulary for guidance 2.) Consult with Physician/ Nurse Practitioner and Resident Representative. 7.) Initiate Braden Scale and initiate investigation process if new onset. 8.) Evaluate interventions per risk factors identified and re-evaluate and modify the plan of care based on root cause analysis for new skin alterations. 9.) Update the care plan for skin integrity and nursing assistant care cards with skin concern, appropriate risk factors, turning intervals and interventions as appropriate. 10.) Initiate the Wound Initial Documentation Observation in Point Click Care (electronic medical record) 1. R71 was originally admitted on [DATE] and has [DIAGNOSES REDACTED]. The facility initiated a plan of care on 7/16/2019 that states that R71 has potential for impairment to skin integrity due to incontinence, fragile skin decline in condition-end of life care with hospice services. Listed interventions included: dietary consult, educate resident/ family the importance of changing positions for prevention of pressure ulcers, encourage activity as tolerated, monitor skin when providing cares, notify nurse of any changes in skin appearance, encourage food nutrition and hydration in order to promote healthier skin. It was noted that the plan of care did not have any interventions listed for pressure relief while in bed or chair. Significant Change Nutrition Assessment, dated 9/26/19, states that R71 is underweight, severe muscle and fat loss, has had a 12% weight loss in the past month due to poor intake and 19.5 % weight loss over the last 3 months. R71 is noted to have a weight of 99 pounds at the time of the assessment. According to the significant change Minimum Data Set ((MDS) dated [DATE], R71 does not have a pressure ulcer/ injury. R71 is at risk of developing pressure ulcers/ injuries. Pressure reducing device for chair- yes. Pressure reducing device for bed- yes. Turning and repositioning program- no. Nutrition or hydration intervention to manage skin problems- no. The Care Area Assessment (CAA) for Pressure Ulcer/Injury, dated 10/2/19, stated R71 is at risk for pressure ulcer/injury due to incontinent of bowel and bladder and impaired mobility. Has been frequently incontinent of bowel and bladder. Has declined in all ADL's (activities of daily living). R71 is currently cued/ assisted to toilet every 2-3 hours while awake. Has pressure reducing mattress to bed and cushion to wheelchair. Skin is monitored daily with cares and weekly with bath preference for redness/ rash. bruises/ open areas. Will proceed to care plan. R71 is hospice care. The EMR (electronic medical record) indicates that a Braden Assessment was conducted on 10/22/19 and indicates that R71 had a score of 19- very limited risk for pressure ulcer development. Progress note dated 11/20/2019 at 2:42 p.m., Nurse to Physician/NP/PA Notification (SBAR) Situation: CNA this AM shift reported noticing an area to resident's right heel during care. Assessment: This nurse assessed area, measures 3 cm length by 1.2 cm (width) by 0.1 cm (depth). Noted scant amount of cream colored drainage to distal end of the area. Cleansed area with normal saline, covered with dry, non-adherent dressing. Response: Call placed to hospice nurse to return call (Name, RN with Legacy Hospice), Notified resident's POA, Will also notify facility wound care nurse to review area for further orders. Will Request: Requesting that wound nurse and hospice nurse assess/review area for further treatment orders, will add to acute charting r/t (related to) area. Progress note dated 11/20/2019 at 4:51 p.m., *Nurse to Physician/NP/PA Notification (SBAR) Situation: Response: Hospice RN updated on resident change of condition. Verbalizes she will be in sometime this week. Progress note dated 11/21/2019 at 10:14 a.m. states; Skin/Wound Note (Narrative) Note Text: Assessed new area to right heel. Has unstageable area to mid right heel measuring 0.7 X 2.2 X 0.1 depth at lateral edge. 90% eschar with 10% slough to lateral edge. Area cleansed with NS. Applied skin prep to periwound and eschar, f/b (followed by) border dressing. Will update hospice and request pressure relief air mattress and bilateral heel boots. A review of the Pressure Ulcer Unavoidability form, signed completed on 11/22/19, states R71 now has a right heel pressure ulcer, 0.7 cm length by 2.2 centimeters width by 0.1 centimeters depth., unstageable. Risks factors states that R71's has foot rests on wheelchair and R71 frequently crosses legs and rubs heels on footrests. Education/ Interventions states that R71 is to wear bilateral heel boots in bed and when up. Remove each shift to provide cares and observe skin for changes, Hospice to provide air mattress for pressure reduction in bed. Describe prior interventions: frequent repositioning, use of pillows for positioning in bed. Describe non-compliance with interventions: R71 frequently rubs heels on bed or footrests of wheelchair. Pushes heel protectors off by rubbing against surfaces as above. Summary: receiving hospice services for end stage dementia. Resident (71) unable to follow commands. Observed frequently rubbing heels and feet on foot pedals of wheelchair and crossing legs when sitting and lying in bed. Surveyor noted that the plan of care did not list any interventions to protect R71 from developing an area of skin impairment prior to 11/20/19 for the observations of her continuously rubbing her heels on the footrests of the wheelchair or foot board of bed. It was also noted there was nothing on the care plan about rejection of heel protection. A review of the EMR showed that R71 did not have a weekly skin observation, performed by a licensed nurse from 9/24/19-12/1019. The facility was not able to provide any further information that weekly skin checks were performed as per the plan of care. A review of R71's plan of care showed that on 11/22/19, a plan of care was developed on 11/22/19 stating that R71 has a pressure ulcer wound to the right heel. Listed interventions included to ensure heels are elevated while resident is lying in bed, identify/ document potential causative factors and eliminate/resolve where possible, resident needs pressure reducing cushion to protect skin while up in chair, and evaluate and treat per physician orders. It was noted the plan of care did not address how to reduce pressure when R71 is up in her wheelchair and is known to rub heels on the footrests of the wheelchair or to reduce pressure in bed when she crosses her legs or rubs on the foot-board. A review of the physician orders [REDACTED]. It was noted the first time this treatment is signed out as completed is on 11/27/19. Progress note dated 11/29/2019 states; Dressing changed this shift to R heel (o/a). Small amount of drainage noted to old dressing. No c/o pain or discomfort voiced. Will continue to monitor. Progress note dated 12/5/2019 states; Dressing changed this AM to resident's right heel. Noted some cream colored drainage to old dressing. Dressing remains intact at end of AM shift. Will continue to monitor. Surveyor asked to review the weekly, comprehensive wound assessments of R71's right heel pressure ulcer. It was noted that there was no comprehensive assessment of the right heel pressure ulcer from 11/22/19- 12/6/19. The wound assessment details report, dated 12/6/2019 states that R71 has an unstageable pressure ulcer to the right heel. Area now measures 2.20 centimeters length, 2.5 centimeters width by .10 centimeters depth. Undermining - unknown, exudate scant/ serosanguineous, periwound has maceration and bogginess. The current plan and comments states, 12/6/19 at 3:40 p.m., This wound was identified on 11/20/19 and somehow removed from system. A pressure Ulcer Unavoidability assessment was performed at that time as well as staff statements and TSI (unknown). Current treatment is for skin prep and dressing to area daily and as needed. Hospice updated regarding measurements. Further review of the plan of care for R71 showed that on 12/24/19, an intervention was added to the pressure ulcer to right heel plan of care stating the R71 needs assistance to apply bilateral heel boots to be worn at bedtime. It was noted there was no further interventions regarding the use of the pressure relieving boots on the plan of care until 12/24/19 and the area was first noted 11/20/19. It was also stated on 11/20/19 that new interventions should be for R71 to wear bilateral boots in bed and when up and to remove each shift to provide cares. This intervention was never added to the plan of care. Surveyor made observations of R71 on 2/17/19 at 8:47 a.m. in the dining room for the breakfast meal. At this time, it was noted that R71 had her feet planted firmly on the dining room floor and did not have an protective boots on her feet or other pressure relief between her feet and the hard surface. Surveyor made observation of R71 on 02/18/20 at 02:09 p.m. asleep in wheelchair in dining room regular socks on, feet resting on ground. R71 was observed seated on a cushion with no foot rests on her wheelchair. On 02/19/20 07:44 AM, Surveyor made observations of R71 asleep in bed with her call lite in reach and the air mattress set on #3. The Certified Nursing Assistant (CNA) came into R71's room to awaken resident. The CNA moved the covers, and it was noted that R71 has gripper socks on, no boots, feet resting directly on mattress. It was noted there was no pillows at the foot of the bed to offer additional pressure relief. Surveyor was provided with a copy of the CNA care card on 2/19/18 that documents that R71 has a right heel wound, protector boots, air mattress with bolsters, pressure reducing cushion chair. Surveyor interviewed RN- Unit Manager- D on 2/19/20 at 1:35 p.m. RN-D stated she was transitioned into the wound nurse during the time of November, 2019. The previous wound nurse was no longer employed at the facility. RN-D was asked if she notified the physician on 11/21/19 after she evaluated R71's new area of skin impairment to the right heel. RN-D stated she does not recall if she notified the MD or not. RN- D stated they will also notify hospice, if they don't respond will call the physician. RN-D stated if she receives a new physician order [REDACTED]. RN- D was unable to state about the interventions on the care plan and why the boots were not added until 12/24/19. RN-D stated there was a period of 1-2 weeks where they were having trouble with the computer program they use to document wound assessments. RN-D was asked if there was any assessment of R71's wound from 11/21/19- 12/6/19. RN-D stated if there was a computer problem there would be other means to document assessments either on paper and scanned into the electronic medical record or write within the progress notes. RN-D was not able to provide any evidence that an assessment was completed from 11/21/19 - 12/6/19. RN-D stated that the nurses will complete a thorough weekly skin assessment on every resident, regardless if they have an open area or not. This information is documented within the medical record. RN-D was not able to state why there was nothing in R71's medical record that a weekly skin assessment was conducted by a nurse from 9/24/19-12/10/19. RN-D was not able to provide additional information about the development of the open area and also what was on the plan of care for prevention prior to the pressure ulcer developing on 11/20/19. Surveyor interviewed Assistant Director of Nursing (ADON)-C and observed the treatment to R71's right heel on 2/20/20 at 7:45 a.m. ADON-C stated they are currently using hydrogel to the pressure ulcer because there is a cap on the area and they are hoping this will lift to expose the skin under the area. The pressure ulcer remains unstageable, but has shown progression towards healing. ADON-C removed the blanket from R71's lower half, exposing R71's right and left feet. It was observed that both feet were resting directly on the mattress. Both boots were under the blanket and not on the R71's feet. ADON - C stated she must have kicked the boots off. Further observation of the boots showed that the velcro of both boots was very worn and were not attached in a way that would hold the boots in place on R71's feet. ADON-C stated these boots should not be used and she would find a new pair of boots from the inventory at the facility. ADON-C performed the treatment and stated the area is better. Surveyor asked ADON-C what is the procedure to obtain a new or change of treatment orders for a resident that is receiving hospice services from another provider. ADON-C stated that the facility nurse will call the primary physician and obtain a new order or order change and then the nurse will let the hospice provider know about the treatment order. ADON-C stated that hospice will usually just agree with the recommendation from the facility nurse. ADON-C stated that hospice also does not conduct assessments of the wound, they just rely on the assessments that are conducted by the facility's wound team. 2. R100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R100 had a 4/25/19 physician's orders [REDACTED]. R100 was re-admitted to the facility on [DATE] with a Stage 2 pressure injury behind his left ear. The facility developed a pressure injury care plan for R100 on 12/17/19 which noted the following; R100 had a pressure injury in the fold of his left ear related to oxygen tubing. The following interventions were listed: administer treatments as ordered, educate the resident on prevention, follow facility protocol, monitor the dressing each shift, evaluate and measure the pressure injury weekly, and report changes in the pressure injury. There was no plan to provide pressure relief from the oxygen tubing to R100's left ear. This intervention was not added to the care plan until 1/13/20 (27 days after re-admission). WEEKLY PRESSURE INJURY ASSESSMENTS R100 had the following physician's orders [REDACTED]. Apply skin prep to periwound followed by small [MEDICATION NAME] dressing every 3 days and as needed on the evening shift. The pressure injury was documented as Stage 2 and measured 1.4 cm x 0.5 cm x 0.1 cm. On 12/22/19, R100 had a new physician's orders [REDACTED]. Apply triple antibiotic ointment to wound followed by 2x2 dressing twice daily and as needed. The pressure injury was assessed on 12/23/19. The pressure injury was documented as Stage 2 and measured 1.0 cm x 0.5 cm x 0.1 cm. On 12/30/19 the pressure injury got worse. It was documented as Stage 3 with slough and purulent drainage. The pressure injury measured 1.4 cm x 0.7 cm x 0.1 cm. There was no noted change to the pressure injury treatment nor was there evidence that R100's physician was notified. The 12/30/19 nurses' progress note indicated that R100 continued to put oxygen tubing very tight to his ears and as a result, the left ear wound increased in size and stage. R100 was educated on keeping the ear tubing loose and was instructed to inform staff when his ear protectors needed replacing. Surveyor noted nursing staff should have been monitoring to ensure R100 had a pressure relieving device such as ear protectors to his left ear. On 1/6/20 the pressure injury was documented as Stage 3, but no slough or purulent drainage was noted. The pressure injury measured 1.0 cm x 1.0 cm x 0.0 cm. On 1/13/20 the care plan was updated and indicated that R100 was to wear ear pads to his oxygen tubing. The physician ordered a new treatment: Cleanse behind left ear at crease with normal saline and pat dry. Apply skin prep to periwound, apply wound get to wound followed by 2 x 2 dressing each day and as needed. The pressure injury was documented as Stage 3. It measured 0.8 cm x 0.5 cm x 0.1 cm. The facility continued to evaluate the pressure injury weekly. As of 2/12/20, the pressure injury was documented as Stage 3 and measured 0.6 cm x 0.2 cm x 0.1 cm. The 2/12/20 physician's orders [REDACTED]. Assure resident has oxygen tubing protector in place every day shift and every evening shift. On 2/17/20 R100's Certified Nurisng Assistant (CNA) care card documented: Open area behind left ear. Make sure oxygen tubing has padding on area behind ear. OBSERVATIONS On 2/17/20 at 12:56 PM, R100 was observed to have a pressure injury behind his left ear. R100 was observed with oxygen tubing resting on the pressure injury on his left ear. There was no padding to the oxygen tubing as directed on R100's care plan. There was no dry gauze on the pressure injury, as indicated in the physician's orders [REDACTED].>On 02/17/20 at 1:18 PM, R100 was observed with oxygen tubing resting on the pressure injury on his left ear. There was no padding to the oxygen tubing as directed on R100's care plan. There was no dry gauze on the pressure injury, as indicated in the physician's orders [REDACTED].>On 02/18/20 at 8:17 AM, R100 was observed with oxygen tubing resting on the pressure injury on his left ear. There was no padding to the oxygen tubing as directed on R100's care plan. There was no dry gauze on the pressure injury, as indicated in the physician's orders [REDACTED]. On 02/19/20 at 8:51, R100 was observed with oxygen tubing resting on the pressure injury on his left ear. There was no padding to the oxygen tubing as directed on R100's care plan. There was no dry gauze on the pressure injury, as indicated in the physician's orders [REDACTED].>On 2/19/20 at 11:02 AM, R100 was observed in his wheelchair in the hallway. The oxygen tubing was resting on the pressure injury on his left ear. There was no padding to the oxygen tubing as directed on R100's care plan. There was no dry gauze on the pressure injury, as indicated in the physician's orders [REDACTED]. On 2/19/20 at 12:11 PM, R100 was observed in his wheelchair in the hallway. He had gauze to his left ear and an ear pad had been provided to his left ear. ON 2/19/20 at 3:05 PM, Director of Nursing (DON) - B and Nursing Home Administrator (NHA)- A were informed that R100 had been observed without pressure relief to the pressure injury to his left ear from 2/17 - 2/19/20. No additional information was provided. On 2/20/20 at 12:24 PM RN Manager (RN Mgr) - D was interviewed. RN Mgr - D had completed weekly pressure injury assessments for R100. When asked about the pressure injury becoming worse on 12/30/19 when the pressure injury went from Stage 2 to Stage 3; RN Mgr - D said that she changed the pressure injury to Stage 3 because slough was present on the pressure injury. 3. R164 was admitted to the facility on [DATE] with a Left Leg [MEDICAL CONDITION], Stroke with weakness and paralysis to his right dominant side, End Stage [MEDICAL CONDITION] with [MEDICAL TREATMENT], Diabetes (DM), and [MEDICAL CONDITIONS]. R164 had an Admission Minimum Data Set ((MDS) dated [DATE]. It noted that R164 had no pressure injuries; but was at risk for the development of pressure injuries. The 6/9/19 Care Area Assessment (CAA) for pressure injury noted that R164's left stump would be monitored for pressure areas related to his prosthesis (artificial leg). On 5/31/19 a pressure injury care plan was developed. It noted that R164 was a risk for skin impairment related to limited mobility, [MEDICAL CONDITION], and DM. Interventions included: apply barrier cream, elevate heels, educate resident to reposition himself, ensure proper footwear, monitor skin when providing cares, right elbow protector, and wheelchair pressure reduction cushion. There were no specific interventions to monitor R164's Left stump and prosthesis, per the CAA. On 8/16/19 a Braden Scale was completed. R164 scored a 17 and was noted to be at risk for pressure injuries. The facility's Wound Assessment Details Reports were reviewed. R164 had a facility acquired Unstageable pressure injury to his left upper knee and a facility acquired Stage 3 pressure injury to his left lower knee. The pressure injuries were first identified on 11/1/19; but the first assessments of the pressure injuries were not completed until 11/13/19. There was no indication in the medical record that R164's physician had been notified of the pressure injuries. The only documentation related to physician notification began on 1/21/20 when MD (Medical Doctor) - W began to provide weekly skin care to R164's pressure injuries. A pressure injury care plan related to R164's actual pressure injuries was not developed until 11/21/19. The care plan noted that R164 had actual skin impairment related to pressure ulcers and vascular wounds. The interventions included: evaluate and treat per physician's orders [REDACTED]. The care plan did not address how pressure relief would be provided to R164's knee where he had two facility acquired pressure injuries. WEEKLY PRESSURE INJURY ASSESSMENTS On 11/13/19 the upper left knee was noted to be an Unstageable pressure injury that measured 1.5 cm x 1.4 cm x 0.0 cm, with 10% of the area having necrotic tissue. The lower left knee was noted to be a Stage 3 pressure injury that measured 1.5 cm x 1.2 cm x 0.1 cm, with 10% of the area having slough. There were no treatment orders from the physician for the left upper knee wound or the left lower knee wound. The facility continued to do weekly assessments of the two pressure injuries on R164's left knee. On 1/15/20 the upper left knee was documented as an unstageable pressure injury that measured 1.5 cm x 1.2 cm x 0.1 cm, with 40% of

Based on observation, interview and record review the facility did not ensure 1 (R117) of 1 residents on an antipsychotic medication received her physician ordered antipsychotic medication. R117 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Findings include: R117 was admitted to the facility on [DATE] at 7:50 p.m. with [DIAGNOSES REDACTED]. R117 also has a [DIAGNOSES REDACTED]. R117's hospital discharge medication included [MEDICATION NAME] 100 mg (milligram) three times a day and [MEDICATION NAME] 150 mg nightly. The hospital discharge summary indicated R117 was due [MEDICATION NAME] 150 mg on 12/27/19 at bedtime and [MEDICATION NAME] 100 mg on 12/28/19. The MAR (medication administration record) for December 2019 indicates R117 did not receive any [MEDICATION NAME] medications on 12/27/19 and 12/28/19 at bedtime and R117 did not receive [MEDICATION NAME] 100 mg three times a day on 12/28/19 and 12/29/19. The nurses note dated 12/29/2019 at 3:52 p.m. indicated Res (R117) noted hitting self and pulling hair. Res also yelling/ shouting out loud. writer redirected. 2nd call placed to Curtis ambulance stated they would be at facility by 4pm. The nurses note dated 12/29/2019 at 3:46 p.m. indicated Md (MD U) at facility . Called and spoke with pharmacy. Nor'd (new orders) send res to St. Francis hospital. called placed to 1st contact brother updated. The hospital record dated 12/29/19 indicates R117 was admitted for acute [MEDICAL CONDITION]. It also indicates Shortly after arriving at the Villa at Bradley Estates she had decompensation of psychiatric illness. This is because she did not receive her [MEDICATION NAME]. This patient has a long-standing history of psychiatric illness and has failed multiple other medications but she has been stable on [MEDICATION NAME]. In order to prescribe [MEDICATION NAME], a physician has to be registered with the [MEDICATION NAME] registry and I am not registered. Therefore, I was not authorized to prescribe this medication. She was then readmitted to St. Francis and was seen by (another physician) from psychiatry. He is her outpatient psychiatrist and has been following her for some time. He recommended that because she had not been receiving [MEDICATION NAME] that the dose be titrated gradually. Accordingly, she remained in hospital while she had day to day adjustments in her medication. R117 was readmitted to the facility on [DATE]. On 2/19/20 at 3:13 p.m., during the daily exit meeting with Interim Director of Nurses (DON) B and Interim Nursing Home Administrator (NHA) A, Surveyor explained the concern R117 was admitted on [DATE] and did not receive her antipsychotic medication. R117 decompensated and was readmitted to the hospital for psychotic episode. On 2/20/20 at 9:39 a.m. Surveyor was presented with a fax from the pharmacy indicating on 12/28/19 the pharmacy called the facility (doesn't say who they spoke with at the facility) to notify them MD U was not certified to prescribe [MEDICATION NAME]. It also indicates on 12/30/19 MD U called the pharmacy to inquire why the [MEDICATION NAME] couldn't be dispensed and was told that he wasn't on the certified prescriber registry. Surveyor asked Interim NHA A why wasn't MD U notified of this on 12/28/19 when the facility became aware that R117's antipsychotic medication could not be filled. NHA A stated she was not sure why MD U was not made aware. On 2/20/20 at 2:07 p.m. Surveyor explained to Interim NHA A the concern R117 was admitted to the facility and was not provided her antipsychotic medication which caused her to have an acute [MEDICAL CONDITION] resulting in being sent to the hospital. Interim NHA A stated she understood the concern and had no additional information.

Uncorrected deficiency from survey event: CVUP11 Based on interview and record review the facility did not provide adequate supervision and assistance devices for 1 of 5 sampled residents (R14) when staff transferred R14 in a manner contrary to the care plan. R14 required the assistance of 2 staff and the sit-stand lift for transfers. On 8/14/19 two CNAs transferred R14 with a gait belt and pivot transfer and R14 sustained bilateral femur fractures. Findings include: R14 is [AGE] years old and has [DIAGNOSES REDACTED]. R14 is moderately cognitively impaired. She requires extensive assistance from 2 staff for bed mobility and is totally dependent on two staff for transfers. R14 is unable to walk in her room, even with assistance. R14's care plan, dated 7/1/18, documented that R14 required the sit-stand mechanical lift for transfers. According to the progress notes, on 8/14/19 (time unknown), R14 complained of right knee pain during morning cares. R14 said that she could not stand up and was unable to use the sit-stand lift. CNA - C decided that she would transfer R14 by using a gait belt and sliding R14 from the bed to the wheelchair. CNA - C did not inform the nurse and asked CNA - D to assist her. CNA - C and CNA - D then transferred R14, by sliding her from the bed to the wheelchair. A gait belt was used. After the transfer, CNA - C informed LPN - [NAME] of the preceding information. LPN - [NAME] observed R14 and noted that her right knee was swollen and R14 was complaining of pain. Nurse Practitioner (NP) - F was notified and ordered an X-ray of R14's right knee. The initial X-ray showed that R14 had a fracture to her right knee. NP - F ordered that R14 be sent to the hospital for further evaluation. R14 was transferred to the hospital on [DATE] at approximately 12:40 PM. On 8/15/19 at approximately 1:00 PM, the facility received the hospital report. R14 had bilateral distal femur fractures, which were repaired surgically. CNA - C could not be interviewed as she was no longer employed at the facility. The facility had interviewed CNA - C on 8/14/19 and 8/16/19. This interview was documented by the facility. CNA - C said that she had had put R14's legs in the sit-stand lift and R14 said that she could not stand. CNA - C told R14 that it was okay and that R14 did not have to stand. CNA - C got another CNA to help transfer R14. CNA - C said that R14 was transferred into the wheelchair from her bed. CNA - C said, 'I never stood her at all, I didn't get a chance to. She (R14) said she wasn't going to stand. When me and the other aide transferred her, her legs never touched the ground. I got the nurse after we transferred her to the w/c (wheelchair).' CNA - D was interviewed by surveyor on 9/4/19 at 1:00 PM. CNA - D said that CNA - C had asked her to help transfer R14. CNA - C put a gait belt on R14. R14 was lifted up by the CNAs using the gait belt and R14's pants. When asked if R14's feet touched the ground, CNA - D confirmed that R14's feet did touch the ground during the transfer. CNA - D said that they would not have been able to move R14 from her bed to the wheelchair without R14's feet touching the ground. CNA - D said that R14 was pivot transferred from her bed to the wheelchair. The hospital record dated 8/14/19 was reviewed. Upon admission to the hospital, R14 complained of significant bilateral leg pain. The right femur X-ray showed that R14 had a mildly comminuted oblique (angled) [MEDICAL CONDITION] femur. The left X-ray showed that R14 had a comminuted [MEDICAL CONDITION] femur. According to www.spine-health.com/glossary/comminuted-fracture, a comminuted fracture is a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma such as in vehicular accidents. On 9/5/19 at 12:36 PM, the preceding information was shared with Nursing Home Administrator - A and Director of Nursing (DON) - B. DON - B did confirm that CNA - C had not transferred R14 in accordance with R14's care plan.

Based on observation, interview, and record review, the facility did not provide adequate supervision for 2 of 11 sampled residents (R5 & R2) related to smoking and knowing a resident's whereabouts. * On 6/27/19 staff found R5, who uses continuous oxygen, smoking in his room. There is no documentation where R5's oxygen tank was and whether it was off or on. However, even if the tank was off, there is off-gassing that occurs making the area around the tank oxygen-[MEDICATION NAME]. According to a news article by the Massachusetts General Hospital, Smokers who use home oxygen may understand the need to turn the tank off before lighting up, but may not realize that the danger persists, even when the oxygen isn't flowing. Oxygen can build up not only in the home, but on the hair, clothes, and body of the patient and ignite when a heat source-like a cigarette-comes close to the face, causing [MEDICAL CONDITION]. There is no safe way to smoke when using home oxygen. Until patients quit, they can practice safer smoking. Should an individual need to smoke, it's important to first turn off the tank, and wait 10 full minutes before going outside to smoke. https://www.massgeneral.org/News/newsarticle.aspx?id=2091 The facility counseled R5 about smoking in his room, took R5's smoking materials, and began room searches. Over the next eight days, staff found two packs of cigarettes in R5's room on 6/28/19 and 7/2/19. Staff did not reassess R5's ability to smoke independently and continued to allow him to go to the smoking courtyard independently. According to staff, R5 always removed his oxygen before going outside to smoke. At times, R5 would stop at the nurses' station and ask staff to refill the tank while he was outside smoking. On 7/14/19, R5 went to the smoking courtyard to smoke. R5 failed to remove his oxygen tank and failed to turn it off. He came back into the facility asking for help because a flash fire had burned his face and melted the plastic cannula in his nose. R5 was sent to the burn center of a local hospital where he was diagnosed with [REDACTED]. R5 remained at the hospital overnight and went home the next day with an order for [REDACTED]. The facility's failure to reassess R5's ability to smoke safely and to provide the supervision needed to ensure R5's safety and the safety of those around him created a finding of immediate jeopardy that began on 6/27/19. Nursing Home Administrator (NHA) - A and Director of Nursing (DON) - B were notified of the immediate jeopardy on 7/25/19 at 4:20 PM. R5's lack of safety, when smoking in his room with oxygen, created serious harm for R5 and to the 31 other residents who lived on his unit. The facility removed the immediate jeopardy on 7/26/19. The deficient practice continues at a severity/scope level of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its action plan for its 30 residents who smoke, and as evidenced by the following example: * R2 routinely propelled his wheelchair in and out of the facility's outside courtyard. Because staff thought that R2 was independent the staff did not routinely supervise R2. R2 was not seen by staff for approximately 4 hours. R4 was found outside and unresponsive. R4 was transferred to the hospital where it was determined that he had a UTI (Urinary Tract Infection) and had [MEDICAL CONDITION] (a serious infection in the blood). Nursing Home Administrator (NHA) - A and Director of Nursing (DON) - B were notified of the immediate jeopardy on 7/25/19 at 4:20 PM. Findings include: 1.) R5 is [AGE] years old and was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 6/5/19, R5 had a physician's orders [REDACTED]. A Minimum Data Set, completed 6/13/19 noted that R5 was cognitively intact, independent in his activities of daily living, and used a walker for ambulation. R5 had a Smoking Risk Evaluation completed by the facility on 6/5/19. R5 was deemed to be an independent smoker and was able to keep his smoking materials on his person. R5's care plan, dated 5/15/19, noted that R5 is an independent smoker and allowed to keep smoking materials in his room. PROGRESS NOTES On 6/27/19, R5 was witnessed smoking in his room. The smoking materials were removed and staff discussed the risks of smoking while on oxygen. R5 agreed not to smoke in his room. There was no documentation in the medical record that R5 had been reassessed to determine if he was able to smoke independently. R5's care plan was updated on 6/27/19 as follows. (R5's) smoking materials to be secured by facility staff. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Staff began room checks and continued these until at least 7/5/19. On 6/28/19 and 7/2/19, staff completed a room check and 2 packs of cigarettes were found in R5's room on each day. The cigarettes were given to the unit nurse. There is no evidence that staff reassessed R5's ability to smoke independently. There were no updates to the care plan to ensure R5's safety and the safety of others should R5 decide to smoke in his room where there was oxygen. On 7/14/19 R5 went to the outside courtyard to smoke and he did not take his oxygen and nasal cannula off. R5 apparently lit his cigarette and a flash fire. The incident was not witnessed by staff. STAFF INTERVIEWS LPN - C was interviewed on 7/24/19 at 1:50 PM. On 7/14/15 at approximately 11:45 am, R5 approached LPN - C, asking for help because he said his nasal cannula was stuck in his nose. R5 had black residue around his mouth and his nasal cannula was burned on the ends that went into his nostrils. RN - I was summoned to assess R5. RN - I was interviewed on 7/23/19 at 3:09 PM. RN - I assessed R5. R5's mustache and beard were burned and he had black residue over his nose and cheeks. There was a plastic piece from his cannula that was inside his nostrils. RN - I called 911. R5's MD was updated. R5 was transferred to the burn center at a local hospital, where he was admitted overnight. HOSPITAL DISCHARGE SUMMARY The 7/15/19 hospital discharge summary indicated that R5 was admitted for a flash burn to the face from smoking while on oxygen. R5 [MEDICAL CONDITION] his nostrils, upper lip, and left cheek. R5 had been admitted to the hospital for observation and [MEDICAL CONDITION] not as severe as expected. R5 was able to use a nasal cannula. The plan was to wash wounds daily and apply an antibiotic ointment once a day. The wounds were expected to heal without complication. R5 was discharged from the hospital on [DATE] and readmitted to the facility that same day. R5's ASSESSMENT AND CARE PLAN On 7/17/19, the facility reassessed R5 and determined that he was an unsafe smoker because he refused to follow the facility's safe smoking policy. The facility updated R5's care plan on 7/17/19 as follows. R4 was to be a supervised smoker, due to a history of smoking with oxygen. R5's smoking materials were to be stored in the nurse's cart. The charge nurse was to be notified immediately if it was suspected that R5 had violated the facility's smoking policy. However, the assessment did not address the fact that R5 had smoked in his room on 6/27/19 while he had oxygen in his room. A care plan was not developed to ensure his safety and those around him if R5 would decide to smoke in his room. FACILITY FOLLOW-UP On 7/25/19 at 10:00 AM, Director of Nursing (DON) - B and Director of Social Services (DSS) - J were interviewed about the facility's follow up. The incident occurred on Sunday 7/14/19. Immediately that same day, the facility determined that any resident who smoked and used oxygen would be a supervised smoker. The facility had 30 residents who smoked and 4 of these residents used oxygen. Staff education regarding this policy began on 7/14/19. Additionally, the facility already had staff assigned to check the patio each hour to ensure that residents were hydrated and not exposed to the heat for too long. These staff would now check on residents who were smoking to ensure that they were [MEDICATION NAME] safe smoking habits. DON - B said that the facility wanted to first talk to the State Ombudsman, before making any additional changes to the smoking policy. The facility wanted guidance from the Ombudsman, so that residents' rights' to smoke were not violated. DSS - J said that the Ombudsman was contacted on Monday 7/15/19. The Ombudsman sent regulatory information related to residents' rights' to smoke. DSS - J received the information on 7/15/19 and forwarded a copy to Nursing Home Administrator (NHA) - A and DON - B. On 7/18/19 the facility changed their smoking policy. NHA - A sent a letter to all residents who smoked and/or their responsible parties on 7/18/19. The letter said that the only area that is approved for smoking was the outside courtyard. Smoking was to be allowed only at the following times for ALL residents: 6:30-7:00 am, 9:00-9:30 am, 1:00-1:30 PM, 4:00-4:30 PM, and 8:00-8:30 PM. OBSERVATIONS On 7/23/19 at 2:50 PM, the surveyor made the following observations in the smoking courtyard. This was not a designated smoking time, according to the smoking times noted above and no staff were in the smoking courtyard. R9 had a cigarette and was was observed to borrow a lighter from R10 to light his cigarette. R10 was not smoking. R11 was smoking. When asked if they could smoke at anytime in the courtyard, R9 said that they could not smoke at anytime but did not explain why he was smoking at a non-designated smoking time. R9 said that he had a smoking apron that he used for safety. The smoking apron was placed on the back of R9's wheelchair and was not covering R9. These 3 residents were not following the facility's smoking policy that indicated all residents who smoke are to be supervised and are only allowed to smoke at the times designated by the facility. INTERVIEW with NHA and DON On 7/23/19 at 3:11 PM, the preceding information was shared with NHA - A and DON - B. NHA - A said that it was difficult to prevent residents from going out to smoke in the courtyard during non-designated smoking times. The surveyor questioned how the facility was supervising residents to ensure that the residents were following the safe smoking policy. NHA - A said that the only way the facility would know if residents were not following the safe smoking policy is if the staff observed that. The surveyor asked what type of supervision was in place to ensure that R5 was not smoking in his room which placed him and others on his unit at risk for harm. NHA - A said that it was not possible to supervise all smokers 24 hours daily and the facility was trying to balance safety and residents' rights' to smoke. SMOKING POLICY CHANGE On 7/25/19 at 10:00 am, DON - B were interviewed. The smoking courtyard was going to be supervised by a CNA 24 hours daily, for 7 days each week. This plan was implemented on 7/25/19 at 6:30 am. All residents who smoke had an updated smoking assessment. A new letter was sent to all residents and/or responsible parties indicating that an incident had occurred and the facility had set some rules related to smoking. The letter explained that cigarettes and smoking materials should not be shared among residents, to ensure that residents who need supervision and assistance are provided with such. The facility's failure to reassess R5's ability to smoke safely and to provide the supervision needed to ensure R5's safety and the safety of those around him created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 7/26/19 when it had completed the following. R5 had a new smoking assessment completed to assess level of supervision and interventions needed to assure the safety of self, other residents and staff. The care plan has been updated to reflect the assessment. All residents who smoke, have had a new smoking assessment completed to assess level of supervision and interventions needed to assure the safety of self, other residents and staff. Each resident's care plan has been updated based on new smoking assessment to include individualized interventions related to safe smoking. Assessments will be updated quarterly, upon observed changes in compliance with smoking guideline's or upon a change in condition. A revised smoking assessment tool has been implemented and used to assess all current smokers and will be used for new admissions. The facility smoking policy has been reviewed and updated. Residents and responsible parties have been notified of the guidelines for being allowed to smoke while at the facility. All staff were educated by 7/26/19 on policy revisions, specific interventions for each resident, and smoking guideline. Staff on vacation, LOA will be educated prior to the start of their returning shift. Smoking books have been developed and are available for staff use at each nurse's station and at the reception desk to identify residents who smoke as well as their individualized plan of care related to smoking. The Ombudsman has been notified and has provided guidance with attaining compliance with changes to the facility policy and smoking guidelines while maintaining resident rights. Monitoring will be accomplished through direct supervision of the designated smoking area by assigned staff daily. Residents who are determined to have violated the facility safe smoking guidelines will be monitored for compliance daily for 1 week, weekly for 3 weeks, and through routine staff observations. Monitoring of smoking assessments will be done by the Administrator / Assistant Administrator for all residents who smoke and for new admissions. Results of audits will be reported to the QAPI committee for review and follow-up. The deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) until the facility can show sustained compliance, and as evidenced by the following: 2.) R2 is [AGE] years old and has a [DIAGNOSES REDACTED]. His Minimum Data Set (MDS), dated [DATE], noted that R2 was cognitively intact. The 6/6/19 Care Area Assessment (CAA) noted the following information. R2 is alert and oriented and able to make his needs known. He is resistive to staff helping him with cares because he still feels he is capable. R2 requires supervision and verbal cues with transfers and toileting. R2 will attempt to take care of himself, when incontinent. Staff is to assist with toileting as he will allow. The care plan was not updated after the 6/5/19 MDS and 6/6/19 CA[NAME] The care plan, with an initiation date of 2014, noted that R2 was incontinent of bowel and bladder, used disposable briefs, and toileted himself. R2 OBSERVED BY STAFF ON 6/29/19 On 7/15/19, Director of Nursing (DON) - B provided the following information as to specific times that staff had provided care to R2 on 6/29/19. DON - B and Nursing Home Administrator (NHA) - A said that the facility did not have an established policy or protocol on how often residents should be checked on by staff. DON - B and NHA - A said that R2 was very independent and was able to come and go on his own. NHA - A said that generally residents should be checked on every 2 hours. At 8:30 am, R2 was observed in the dining room at breakfast when LPN - C administered his medication to him. LPN - C was interviewed on 7/16/19 at 11:42 am and confirmed this information. LPN - C said that she was the usual nurse on the Day Shift for R2. LPN - C said that R2 appeared to be his usual self and LPN - C did not note any signs or symptoms of a change in condition for R2. When asked how often staff should check R2, LPN - C said that staff would check him every 2 - 2 1/2 hours, related to his toileting needs. At 12 noon, CNA - D documented that R2 had eaten 51-75% of his meal. CNA - also provided a written statement that he had seen R2 at lunch. No time was specified. CNA - D was no longer employed at the facility and was unavailable for interview. Between 12:30 PM and 1:00 PM, LPN - [NAME] interacted with R2. LPN - [NAME] said that R2 was sitting in the doorway of his room and refusing to allow CNA - D to enter his room. LPN - [NAME] was unsure why CNA - D needed to enter the room and thought it was maybe to care for R2's roommate. LPN - [NAME] said that R2 can be resistive at times and so she talked to R2 and convinced R2 to allow CNA - D to enter the room. LPN - [NAME] was interviewed on 7/16/19 and confirmed this information. Shift Change occurs at the facility at 2:30 PM. LPN - F and CNA - G had been assigned to care for R2 on the PM Shift on 6/29/19. LPN - F was interviewed on 7/16/19 at 11:26 am. LPN - F said that she did not see R2 when the shift began at 2:30 PM. LPN - F said that she had received report from the Day Shift Nurse that R2 was his usual self and had no acute medical concerns that required monitoring. When asked how often residents should be checked by staff, LPN - F said that if a resident was incontinent they should be checked every 2 hours. LPN - F said that R2 was pretty independent so it was difficult to say how often staff should check on R2. CNA - G was interviewed on 7/16/19 at 2:35 PM. CNA - G said that she had not seen R2 when she worked the PM shift on 6/29/19. CNA - G said that R2 was very independent and would independently wheel himself outside to the courtyard and then back inside the facility. CNA - G said that R2 would not allow staff to assist him and when she tried to help R2, he would curse and tell her to leave. CNA - G said that she would leave R2 to care for himself because otherwise R2 became agitated. At approximately 5:15 LPN - F was looking for R2 so that she could administer his medication to him. LPN - F found R2 outside in the courtyard. R2 was unresponsive. LPN - F was interviewed on 7/16/19 at 11:26 am. LPN - F said that she was in the dining room at 5:00 PM, passing medication to residents. LPN - R said that R2 was not in the dining room as he usually was. LPN - F said that she thought R2 was in his room. LPN - F said that at 5:15 PM, she was in the hallway and on her way to administer medications to R2 when another resident told her that she should check on R2, as he had been outside for a long time. LPN - F went outside and found R2 unresponsive. 911 was called and R2 was admitted to the hospital with [REDACTED]. STAFF SUPERVISION OF R2 FROM 1:00 PM - 5:15 PM ON 6/29/19 On 7/16/19 at 2:40 PM, the preceding information was reviewed with Director of Nursing (DON) - B. DON - B said that R2 had been seen in the courtyard at 3:00 PM on 6/29/19 by R4. DON - B said that R4 was alert, oriented, and able to provide accurate information. On 7/16/19 at 2:45 PM, R4 was interviewed. R4 said that she had seen R2 go outside to the courtyard at approximately 2:00 PM. R4 said that R2 was outside from 2:00 PM - 5:00 PM. R4 said that it appeared R2 was sleeping. R4 said that R2 would usually go outside, fall asleep for a while, and then go back inside the facility. R4 said that it was unusual for R2 to be sleeping from 2:00 PM until 5:00 PM outside. R4 said that R2 could be difficult and would swear at R4 and other residents if they tried to talk to R2. R4 said that she did not interact with R2 during this time and R4 thought it was unlikely that other residents would check on him, because of his agitated reaction. R4 was asked about the time she initially saw R2 outside. The surveyor told R4 that facility staff said that R4 had reported to the facility that it was 3:00 PM when she had seen R2 go outside. R4 said that she was sure she saw R2 outside at 2:00 PM because it was before the 2:30 PM shift change. (The facility's PM Shift does begin at 2:30 PM.) On 7/16/19 at 4:10 PM, the preceding information was shared with Administrator - A and DON - B. The surveyor indicated that R2 had not been checked on by staff from 1:00 PM until approximately 5:15 PM which was more than 4 hours. DON - B said that RN - I, who was the PM Shift Supervisor on 6/29/19, had seen R2. DON - B said that she would contact RN - I to obtain additional information. On 7/17/19 at 7:45 AM, DON - B said that she had was unable to contact RN - I. DON - B said that she then called all staff who had worked on the PM Shift on 6/29/19. DON - B had interviewed LPN - H via the phone on 7/17/19 at 6:55 AM. DON - B provided the following information. LPN - H said that on 6/29/19 at 2:00 - 2:30 PM, she had seen R2 near the vending machines. LPN - H said that she usually sees R2 near the vending machine and will often buy him a snack. LPN - H said that she did not see R2 go outside. Based on his need for supervision and verbal cues with transfers and toileting, R2 should have been checked on more frequently than every 4 hours. R2 continues to go outside in the courtyard on his own. R2 continues to be resistive to care and direction from staff. R2's care plan, dated 7/10/19, has not been updated to direct staff how often R2 needs to be checked on and what staff need to do when R2 will not follow staff direction so that R2 is adequately supervised.

Based on record review and interviews, the facility did not immediately consult with the resident's physician when there was a significant change of condition for 1 (R1) of 9 sampled residents. *R1 experienced a change of condition on 6/28/18, demonstrated by increased lethargy, a reading of HI on the facility glucometer, and refusal of food for several days. Although R1 had a history of [REDACTED]. Registered Nurse (RN)-C recognized the change of condition during the evening of 6/28/18. RN-C notified her charge nurse, Licensed Practical Nurse (LPN)-D, who was to notify the physician. LPN-D paged the physician, who did not call back. There was no further effort made to notify the physician of R1's change of condition. On 6/29/18, R1's Power of Attorney (POA)-E arrived to the facility in the early evening to visit. POA-E found R1 minimally responsive and told LPN-D she wanted R1 sent to the hospital. Documentation indicated R1 was unresponsive to verbal stimuli, and BG (blood glucose) HI (Over 600). 911 was called and R1 was sent to the hospital where he was diagnosed with [REDACTED]. The facility's failure to ensure that R1's physician was immediately consulted regarding a change of condition created a finding of Immediate Jeopardy beginning on 6/28/18. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 8/30/18 at 10:20am. The Immediate Jeopardy was removed on 7/12/18 and corrected the deficient practice on 7/31/18. This is being cited as past noncompliance. Findings include: *R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a Minimum (MDS) data set [DATE], R1 was severely cognitively impaired. The record revealed R1 has an activated POA. Upon admission, R1's goal was to regain his strength and return to a community living situation. R1 was hospitalized from 6/6 - 6/11/18 for hyperglycemic hyperosmolar nonketoti[DIAGNOSES REDACTED]. R1 was hospitalized after he experienced a change of condition during which he had difficulty concentrating, was very thirsty and had a blood sugar reading of HI. Hyperosmolar hyperglycemic nonketoti[DIAGNOSES REDACTED] is a complication of Type 2 Diabetes Mellitus (DM) and has an estimated mortality rate of up to 20%. It is characterized by [MEDICAL CONDITION], extreme dehydration, hyperosmolar (thicker) plasma and altered consciousness. Complications include coma, [MEDICAL CONDITION] and death. (merckmanuals.com). Following R1's return to the facility, R1's record shows he refused to take his medications including insulin, refused to allow blood glucose (BS) monitoring, and refused cares. Documentation of refusals are noted on the Medication Administration Records and in the progress notes. A review of a physician's progress note dated 6/23/18 revealed the physician was aware of R1's medication refusals, including insulin and refusals of care. The physician noted that R1's appetite had been poor recently. A review of appetite monitoring data from the computerized record for the month of (MONTH) (YEAR) reveals R1's appetite had started to decrease on 6/19/18, when R1 ate 0-25% for all three meals. R1's appetite was variable (including refusals of all meals on 6/23/18), until after breakfast on 6/25/18. R1 ate 26-50% for breakfast on 6/25/18, then refused all meals until hosptalized on [DATE]. A review of the Medication Administration Record [REDACTED]. R1 refused blood sugar checks on 6/23 and 6/24/18. On 6/25/18 at noon R1's blood sugar was 561. The physician was notified. R1 refused further blood sugar monitoring until the evening of 6/28/18. Documentation in progress notes indicate R1 tested positive for [MEDICAL CONDITION] on 6/27/18. On 6/27/18, LPN-F documented that R1 appears dry and possibly dehydrated, fluids are offered and refused, resident refusing meals, medications and glucose monitoring. Not eating or drinking could have led to dehydration. A nursing note on 6/27/18 indicated the resident appeared dry and dehydrated. According to a study published by the National Institute of Health (http://www.ncbi.nlm.nih.gov/pubmed/ 084), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were 151-153 and to 71.4% whose sodium level exceeded 154. On 6/28/18 at 10:13, Registered Nurse (RN)-C documented: Resident has been in bed throughout shift d/t (due to) refusal to get out of bed. Resident has not eaten d/t refusing to eat. Resident has been sleeping throughout shift. Resident refused medications throughout entire shift. Writer went into room at HS (hour of sleep) for a final assessment of resident and he appeared lethargic. His mouth was dry and he did not verbally respond to any commands. He was able to shake his head yes or no when asked a question. Writer informed resident that he appeared weak and seemed to have a change in condition and may need to be sent to hospital. Resident nodded his head as if to agree and understand what writer was saying. Writer took resident VS (vital signs)134/49 lying down on R (right) arm, 100% on RA (room air) and pulse of 78. Writer assessed resident's BS (Blood Sugar) which was too high to read on glucometer. Writer informed charge nurse of resident's change in condition. Writer also contacted his Activated POA (Power of Attorney) regarding his change of condition. Resident will continue to be monitored in facility until further notice. The surveyor spoke with RN-C on 8/29/18, at 10:00am. RN-C stated the facility protocol was for the unit nurse to report changes to the charge nurse, who in turn will notify the physician. RN-C stated she reported the change of condition to charge nurse Licensed Practical Nurse (LPN)-D. The surveyor asked if RN-C was aware that R1 had not eaten since the morning of 6/25/18. RN-C stated she did not know R1 had not eaten for several days, and had she known she would have gone to the Director of Nursing (DON) with concerns about R1's status. The surveyor spoke with LPN-D on 8/29/18, at 10:40am. The surveyor asked if LPN-D had contacted the physician regarding R1's change of condition on 6/28/18. LPN-D stated she had paged the physician but he had not returned the page. The surveyor asked if LPN-D was aware that R1 had not been eating since the morning of 6/25/18. LPN-D stated she was not aware R1 had not eaten for several days and had she been aware she would have more aggressively tried to reach the physician. On 6/29/18 at 12:35am, R1's vital signs were taken and documented. Vital signs were stable. On 6/29/18 at 3:58pm, Medication Aid-G documented R1 refused all medication, stated he was throwing up medication, informed supervisors for follow-up. The next entry in the progress notes was on 6/29/18 at 7:24pm, by LPN-D. LPN-D wrote Resident non responsive to verbal stimuli, family is insisting that resident be sent to hosp. because it is unusual for him to not respond to me per his sister POA. BG (blood glucose)HI. Temp. 96.4 ax (axillary) 80-20-PO (pulse oximetry) 98% room air. Spoke with Dr. Received order to send out per POA's request. On 8/23/18 at 1:45pm, the surveyor spoke with Certified Nursing Assistant (CNA)-H. CNA-H stated she was familiar with R1's care. CNA-H stated R1 did not respond much the last few days before he went to the hospital. CNA-H stated R1 was weaker and less verbal. Prior to the last few days, R1 would aggressively refuse cares. The last few days he did not complain at all about cares being done. On 8/29/18 at 9:35am, the surveyor spoke with R1's POA-E, POA-E stated she came to the facility between 5:30-6:00p.m., to talk to Social Worker (SW)-I about some care concerns. During that conversation, SW-I brought up the subject of hospice care for R1 and POA-E told SW-I she was not interested in hospice. POA-E stated she then went to R1's room. R1 was minimally responsive. POA-E was trying to wake him up but he did not arouse. POA-E stated she was slapping R1's face trying to arouse him without success. POA-E stated she told the nurse she could not arouse R1. The nurse stated she would call the physician and see what he wanted to do. POA-E stated she wanted R1 sent to hospital 911. POA-E stated the nurse called 911, who came right away and took R1 to the hospital. POA-E stated she was in the room when the paramedics arrived. POA-E stated the nurse told paramedics R1 had been unresponsive for 2 days. According to the hospital record, R1 was admitted to the hospital on [DATE], with [MEDICAL CONDITION], hyperosmolar non-ketotic state and [DIAGNOSES REDACTED]. According to The Merck Manual, Hyperosmolar hyperglycemic state . is a complication of type 2 diabetes mellitus and has an estimated mortality rate of up to 20% . It usually develops after a period of symptomatic [MEDICAL CONDITION] in which fluid intake is inadequate to prevent extreme dehydration due to the [MEDICAL CONDITION]-induced osmotic diuresis. Precipitating factors include Acute infections and other medical conditions Drugs that impair glucose tolerance (glucocorticoids) or increase fluid loss (diuretics) Non-adherence to diabetes treatment. (https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/hyperosmolar-hyperglycemic-state-hhs) Similarly, the AMDA Guidelines in Diabetes Management in the Post-Acute and Long-Term Care Setting note, The hyperosmolar hyperglycemic state is a particularly serious complication of diabetes in older adults that carries a 15% mortality rate. Its prognosis worsens with extreme old age and in the presence of coma and [MEDICAL CONDITION]. The facility's failure to notify the physician of the significant change in R1's condition on 6/28/18, including his blood glucose readings of HI, his refusal to eat,and his weakened condition created a situation of Immediate Jeopardy, which is being cited as past noncompliance. The facility removed the immediate jeopardy on 7/12/18 when: *All nurses completed inservice training with the Director of Nursing, involving changes of condition and physician/family notifications. *The facility changed protocols for documenting on shift reports to include a multi-layered system of checks and balances to ensure all change of condition reports are acted upon and notifications are made. This included a new form for Change of Condition/24 Hour Reports which require all needed interventions to be complete before discontinued from the report. *Instituted a Nutrition at Risk meeting weekly to monitor all changes in intake, appetite and weight changes. The deficient practice was corrected 7/31/18.

Based on observation, interview and record review the facility did not ensure that a resident who entered the facility with a pressure injury received treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for 1 of 6 (R15) residents reviewed for pressure injuries. R15 was admitted to the facility with a left leg immobilizer. Staff did not monitor R15's skin under the immobilizer, resulting in an avoidable medical device acquired stage 3 pressure injury to her posterior foot and a stage 2 pressure injury to her dorsal foot. Resident also had 2 stage 2 pressure injuries on her buttocks upon admission which were treated and subsequently healed. Findings include: Surveyor reviewed the Facility's Skin Breakdown Prevention form dated (revised) (MONTH) 2014 which documented: It is the responsibility of the Charge Nurse and the Nursing Assistant to ensure that preventative measures are implemented for identified moderate and high risk residents. It is the responsibility of the DON (Director of Nursing)/ADON (Assistant Director of Nursing)/Treatment Nurse to ensure that all residents are assessed for skin risk and interventions and preventative measures are implemented to maintain integrity of the skin. R15 was admitted to the facility with [DIAGNOSES REDACTED]. R15's hospital discharge summary dated 2/20/18 documented a left lateral tibial plateau fracture. Patient was seen by orthopedic and they recommended conservative management. Discharge exam documented left leg with immobilizer. R15's Braden risk assessment dated [DATE] scored a 16 indicating R15 is at risk for developing pressure injuries. Surveyor review of R15's Care Plan revealed no documented interventions regarding R15's immobilizer prior to the pressure injury development. R15's Wound Assessment Details Report for the wound on the left dorsal (top) foot dated 3/21/18 documented: Classification: Blister Source: Facility acquired Date identified: 3/20/18 Clinical stage: Intact skin Measurements: 7.5 cm (centimeters) x 5.0 cm Exudate (fluid) scant, serous Tissue type: Intact skin 100% Surveyor observation of the facility's picture of the wound appears as a flat blister on the top of the foot at the ankle, extending up the leg. Wound Assessment Details Report for the wound on the left dorsal foot dated 3/28/18 documented: All of the same above information except: Tissue type: Intact skin 50%, bright pink or red 50% R15's Wound Assessment Details Report for the wound on the left posterior foot dated 3/26/18 documented: Classification: Abrasion Source: Facility acquired Date identified: 3/26/18 Clinical stage: Full thickness Measurements: 3.0 cm x 3.0 cm x 0.1 cm Exudate: Scant, serous Tissue type: Bright pink or red 25%, Slough loosely adherent 75% Surveyor observation of the facility's picture of the wound appears as a full thickness tissue loss stage 3 pressure injury. Review of R15's (MONTH) (YEAR) TAR (Treatment Administration Record) revealed no documentation of checking R15's skin integrity under the immobilizer. Surveyor noted the daily diabetic foot check at bedtime with an order date of 2/20/18 had missing documentation of completion for 2/21 and 2/27/18. Review of R15's (MONTH) (YEAR) TAR revealed no documentation of checking R15's skin integrity under the immobilizer until 3/21/18 after R15 developed the pressure injury. Surveyor noted the daily diabetic foot check at bedtime had missing documentation of completion for 3/2, 3/5, 3/12, 3/15, 3/18, 3/20 and 3/23/18. Surveyor reviewed the facility's Pressure Ulcer Assessment, Identification and Treatment Guideline dated (revised) (MONTH) 2014 which documents the NPUAP (National Pressure Ulcer Advisory Panel) definition of pressure ulcers in the following categories: Stage I (1): Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage II (2): Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III (3): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. On 4/23/18 at 2:45 pm Surveyor spoke with Physical Therapist (PT)-E who stated she remembers R15 had 2 left knee immobilizers. The larger (black) one slid down and needed readjusting and caused irritation which she believed was on her ankle or the back of her ankle, so it was switched to the shorter one. PT-E stated she does not remember when the immobilizer was switched. PT-E stated nursing was allowed to remove the immobilizer (if she remembered correctly) but therapy would remove it at least weekly and clean it. PT-E indicated to Surveyor that the immobilizer was causing skin irritation. On 4/24/18 at 8:50 am Surveyor spoke with RN Wound Care Nurse-D who stated she remembered the immobilizer was Huge and stated: It was rubbing on the back of her heel and therapy gave her a shorter one. She reported the other wound care nurse (RN Wound Care Nurse-C) was following R15's wounds. On 4/24/18 at 9:30 am Surveyor spoke with RN Wound Care Nurse-C who stated he remembered the resident. He reported both wound nurses followed the resident, but does not recall who identified the wound on the heel. Surveyor advised him the Wound Assessment Details Report documents he identified and assessed both of the wounds on R15's left foot. He stated the date documented on the wound assessment details report is the date he identified the wounds. He stated he classified the wound on R15's heel as an abrasion because the brace was rubbing on her skin causing irritation. Surveyor asked about his documentation of 75% slough in the wound, he stated he was not aware slough indicated a stage 3 pressure injury because he thought it was originally an abrasion. He stated the wound did have slough, but he staged it as an abrasion because it was from rubbing and not pressure. RN Wound Care Nurse-C stated the blister on the top of R15's foot was also caused by the brace rubbing on her skin. Asked why he did not classify the wound as a stage 2 pressure injury, he stated he was not aware a blister would be classified as stage 2 because, again, it was caused by rubbing and not pressure. Surveyor asked about his documentation of the stage 2 pressure injury as 100% intact skin, yet he documented serous exudate. RN Wound Care Nurse stated: I don't know. The blister was not fluid filled anymore so I didn't classify it as a stage 2. RN Wound Care Nurse-C stated he was not aware if or how often nursing was checking R15's skin under the immobilizer. On 4/24/18 at 10:01 am Surveyor spoke with resident's family member-L. They stated R15 had a private caregiver that would visit at least 2-3 times a week and she told them about the blister a week before they visited on 3/18/18. Family member-L stated they visited the resident at the facility on 3/18/18 and gave her a bed bath. Family member-L stated they visualized both of the wounds, on the back of her heel and the top of her foot. Family member-L stated they asked the nurse about them and she didn't know anything about the wounds and told them they had no documentation of the wounds. Family member-L stated they are a nurse and did not understand how they did not know anything about the wounds. On 4/26/18 at 12:15 pm Surveyor spoke with R15's personal Caregiver-M. She stated she has been taking care of R15 for 7 or 8 years. She reported she would visit the resident at the facility almost daily. She stated: It was about a week before (family member-L) visited, I noticed the blister on the top of her foot and told the therapist. She stated the resident was wearing the long brace at the time. She stated she did not see the back of her leg at that time. R15's PT daily treatment note dated 3/14/18 documented: Adjustment of knee immobilizer to use smaller one per patient request. Writer had communicated with OT (occupation therapy) prior to session and found that larger immobilizer was causing a blister and slipped repeatedly down patients leg. R15's PT Therapist Progress note dated 3/14/18 documented: Fitting and adjustment of knee immobilizer to improve skin integrity as bulkier immobilizer frequently slipped down causing a blister. Review of R15's (MONTH) (YEAR) TAR revealed a treatment order dated 3/21/18 for the left dorsal foot every day shift Monday, Wednesday and Friday for wound care cleanse with normal saline, followed by skin prep to blister, followed by border gauze. Surveyor noted there was no treatment initiated on the TAR for R15's left posterior leg wound when initially discovered on 3/26/18. Surveyor interview with the wound care nurses indicate R15's wounds were caused by the immobilizer rubbing on her skin. In addition the therapy notes document the immobilizer was causing a blister. On 4/25/18 at 3 pm Surveyor informed DON-B and the NHA (Nursing Home Administrator) in training of the above findings. No additional information was provided. On 4/26/18 at 11:30 am Surveyor received a call from NHA-A requesting additional information be sent to Surveyor for review. Surveyor reviewed the additional information which included: An interview/statement record dated 4/26/18 at 9:58 am from PT-E which documents: During sessions she adjusted and/or cleaned the inside of resident's long black immobilizer as needed due to dry skin and downward slippage and each time she completed a skin check to make sure of no new/changed condition. The statement PT-E previously provided to the Surveyor did not mention the completion of a skin check. In addition, her statement to the Surveyor stated therapy removed the brace at least weekly to clean it. The additional information included an interview/statement record dated 4/26/18 at 9:20 am from CNA (Certified Nursing Assistant)-N to Director of Nurses-B documenting: She (CNA-N) took care of resident multiple times. Resident wears a brace that goes from upper leg almost by groin to almost by ankle. Every morning I come in resident has black immobilizer on it that had bars and straps the went down it. I removed the brace when doing cares. (Surveyor noted she made no mention of completing a skin check.) The statement further documents: Brace slides downward if top strap isn't fastened tight enough. Resident preferred to wear a pair of black K-Swiss shoes that were too tight even when feet were (sic) swollen. Tried to talk her into not wearing these shoes due to the swelling and resident still insisted on wearing these shoes. Spoke with caregiver about bringing in other shoes, which caregiver did, but resident still refused to wear those shoes that would fit better. (Surveyor noted no documentation the CNA informed the nurse of the shoes being too tight, nor any documentation of the shoes being too tight.) Surveyor noted at the end of the interview it was added: (In early part of statement, staff member had stated that she had switched to smaller white brace due to rubbing and sliding down - per therapy.) Additional information received from the facility indicates these pressure injuries were unavoidable related in part to R15's non-compliance. The facility included highlighted documents indicating the resident was non-compliant however review of the additional supporting documentation indicates the noncompliance referenced in the hospital related specifically respiratory treatments/shortness of breath. The noncompliance referenced in the facility record is related to diet and treatment specific to diabetic care. Surveyor again noted this was not specifically care planned or addressed by the facility prior to R15 developing these pressure injuries. Surveyor noted this additional information was provided after Surveyor had shared concerns with facility administration regarding the R15 2 facility acquired stage 3 and stage 2 pressure injuries.

Based on record review and interviews, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #14) of 12 sampled residents with falls. Resident #14 experienced 38 falls between September 2015 and July 2016. Fall Occurrence reports were not completed, root cause was not always determined, interventions were not put into place to prevent future falls and the care plan was not always followed to prevent falls. A fall on 7/24/26, where the care plan was not followed resulted in a fracture of 2 cervical vertebrae. Findings include: Surveyor # reviewed Resident #14's record on 8/24-9/1/16. Resident #14 had been admitted on [DATE], with [DIAGNOSES REDACTED]. Between admission in September 2015 through 7/24/16, Resident #14 experienced 38 falls. Documentation in the progress notes indicate falls occurred on 9/18, 9/20, 9/25, 9/27 x 2, 9/30, 10/5, 10/11, 10/13, 10/16, 10/18, 10/19 x 2, 10/23, 10/29, 10/30 x 2, 11/1, 11/6, 11/8, 11/9, 11/18, 11/26, 12/6, 12/17, 12/18, 12/20, 12/26/15 and 1/22, 2/26, 2/29, 4/13, 4/20, 4/23, 6/8, 7/2, 7/8 and 7/24/16. A review of the facility policy titled Fall Prevention Program, last revised Mach 2015, reveals the facility fall prevention program includes measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. In the care plan section of the Fall Prevention Program, it states the care plan addresses each fall, and interventions are changed with each fall as appropriate. The Fall Prevention Program also states the risk management meeting agenda will include a discussion of the daily fall review with the IDT (interdisciplinary team), and recommendations for changes in the plan of care to minimize reoccurrence. Surveyor # spoke with Director of Nursing (DON)-B on 9/1/16 at 3:15pm. DON-B stated that the IDT should address interventions with each fall, either to change or recommend to continue the current interventions. The facility is to complete an Occurrence Report for each fall as part of its Risk Watch Occurrence Reporting Process. The protocol for completing the Risk Watch Occurrence was included with the Fall Prevention Program policy. Surveyor # requested copies of the Occurrence Reports for all of Resident #14's falls. The Occurrence Reports are designed to describe the circumstances of the fall, investigate and complete a root cause analysis, and address adequacy of interventions. The Occurrence Reports also indicate if an injury occurred with a fall. Surveyor # reviewed all Occurrence Reports and reviewed the progress notes in the clinical record. The following describe discrepancies between documentation in the clinical records and occurrence reports or delays by the IDT in reviewing falls for recommendation of interventions. According to documentation in the progress notes, Resident #14 experienced falls for which there was no Occurrence Report completed, therefore no evaluation of the adequacy of interventions or need for changes on 9/18, 9/30, 10/11, 10/13, 10/16, 10/19, 10/23, 10/30, 11/1 and 11/9/15. Resident #14 experienced 2 falls on 9/27/15. Both of the Occurrence Reports indicated there were no injuries. The progress notes describe a skin tear to the left elbow. Resident #14 had a witnessed fall on 10/5/15. He was standing in the hallway with the therapist and had a gait belt on. His eyes rolled back and he fell backwards. At the time sitting and standing blood pressures indicated orthostatic hypotension. The IDT did not evaluate the fall of 10/5/15 until 10/12/15, at which time daily blood pressures for 1 week were initiated. An Occurrence Report dated 11/18/15, indicates Resident #14 fell when he attempted to ambulate without assistance. The Occurrence Report stated there was no injury, however the nursing progress notes dated 11/18/15 indicated there was a linear abrasion to the right posterior back noted after the fall. Some time prior to this fall Resident #14 was given a helmet to help protect his head during falls. On 11/26/15, Resident #14 crawled out of bed onto the floor mat. The Occurrence Report does not address the adequacy of current interventions or suggest changes in interventions. Resident #14 fell on [DATE]. According to the Occurrence Report the IDT did not meet until 12/14/15, at which time the IDT recommended a psychiatric review of medications for impulsivity. On 12/18/15, Resident #14 fell on his face and had facial bruising and bleeding from both nostrils. Resident #14 was sent to the hospital for an evaluation and returned with a report indicating a probable nasal bone fracture. The progress notes indicated Resident #14 returned to the facility on [DATE] at 12:45am, with a fractured nose. The Occurrence Report for the fall of 12/18/15, completed on 12/21/15, states no fracture noted. The Occurrence Report does not address the adequacy of current interventions or suggest changes in interventions. On 12/20/15, Resident #14 fell face first on the floor, breaking his dentures. Resident #14 was sent back to the emergency room , returning to the facility on [DATE]. There are 2 Occurrence Reports for the 12/20/15 fall. The conclusion on the first Occurrence Report does not address the adequacy of current interventions or suggest changes in interventions. The Second Occurrence Report for the fall of 12/20/15, indicates the IDT met on 12/28/15, 8 days after the fall and recommended a therapy screen, 3 day bowel and bladder diary and consult with the primary physician regarding medications. Resident #14 was hospitalized for [REDACTED]. Resident #14 stood up on 1/22/16 an fell to the floor. The Occurrence Report indicates the IDT met on 2/8/16, and does not address the adequacy of current interventions or suggest changes in interventions. Resident #14 was hospitalized from [DATE] until 2/6/16, for an abscess on the left buttock. Resident #14 was found sitting on the floor in the dining room on 4/23/16. The recommended intervention was to be up for meals only. Lay down 1/2 hour after meals. A review of the falls care plan revealed this intervention was not added to the care plan. Resident #14 got up from the wheelchair falling to the floor on 7/2/16. The nurse had been present but turned her back to care for another resident. The conclusion does not address the adequacy of current interventions or suggest changes in interventions. Resident #14 fell while attempting to self transfer on 7/24/16 at 7:30pm, sustaining a laceration to the eyebrow. He was sent to the emergency room where it was discovered he had C5 & C6 vertebral fractures. After this fall it was added to the care plan to lie down 1/2 hour after meals. Resident #14 was given a peddle broda chair on 7/27/16, and has sustained no further falls through 9/1/16.

Based on observation, interview, record review and facility investigation, the facility did not provide each resident with personal privacy in the area of bathing for 1 of 22 residents observed during the survey. * On 8/18/15, Resident #17 reported to Surveyor that about a month ago, a male staff member walked into the bathtub/spa area while Resident #17 was in the bathtub. Resident #17 stated it really bothered her that this male staff member saw Resident #17 while in the bath tub and that this was not respectful. Resident #17 reported that the Bath Aide who was present during this incident allowed the male to enter the spa/bathing area. Resident #17 had previously been taking a bath in the whirlpool tub 3 times a week. Since this incident which occurred on 7/27/15, Resident #17 has not taken a bath while at the facility. Resident #17 either washes up at the sink in her room or will drive to her sister's home to take a shower and wash her hair. Findings include: On 8/19 through 8/26/15, Surveyor # reviewed Resident #17's medical record. Resident #17 was admitted into the facility on [DATE]. Resident #17's Minimum Data Set ((MDS) dated [DATE] and 8/11/15 indicates Resident #17 is understood and is able to understand. She has clear speech, and adequate vision with no short term or long term memory deficits. The 11/20/14 MDS rates Resident #17's Brief Interview for Mental Status (BIMs) score at 15 which indicates Resident #17 is cognitively intact. The MDS indicates Resident #17's short and long term memory is OK. The 11/20/14 MDS also indicates it is very important for Resident #17 to choose between a tub bath, shower, bed bath, or sponge bath. The quarterly MDS indicates Resident is totally dependent on bathing needing the assistance of 1 person physical assist. Resident #17's care plan dated 11/14/14 indicates that Resident has the potential for ADL self-care performance deficit with a goal that resident will improve current level of function through review date. Interventions include; encourage the resident to participate to the fullest extent possible with each interaction, assist of one staff and extensive hands on assistance for personal cares, monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. On 8/18/15 between 2:15 p.m. and 2:30 p.m., Surveyor # interviewed Resident #17 who sought out Surveyor to express concerns regarding her bathing at the facility. Resident #17 stated that one morning while she was in the bathtub, a guy came in with his personal cell phone. Resident stated, I was sitting there butt naked. This occurred about a month ago. I don't use the bath tub .he was an employee, I don't know his name, he is in laundry, the person sitting at the door she (Bath Aide-N) let him come in, he had towels to put on the rack. She (Bath Aide-N) could have taken the towels from him and stopped him from coming in. Privacy curtain, he could see me buck naked and he was on his phone. When she (Bath Aide-N) did that (let him come in) that didn't respect me. I did not want him to see me butt naked in the tub. I used to take 3 baths a week with her. I don't go in there (referring to the bathtub/spa) anymore. I wash myself in my room. The next day she (Bath Aide-N) apologized. That really bothered me, that's my privacy. When he came to clean my room (afterwards) I told him, it was wrong of you to come into the bathing area while I was naked, do not come in on me when I am naked. That really bothered me. They didn't tell anyone, the only person I told was my nurse (LPN-K). I thought she (LPN-K) would say something. I didn't appreciate him coming in and she (Bath Aide-N) laughing. This happened more then a couple of weeks ago, I take my bath in my room now, I haven't had a bath (in the spa) since. On 8/19/15 at 12:15 p.m. Surveyor # interviewed LPN-K who stated that the bath situation occurred maybe last month. LPN-K stated she went in (to Resident #17's room) and Resident #17 stated, When I was given a bath yesterday a guy came around the curtain (privacy curtain) looked at her and gave eye contact. She said he came around the curtain had eye contact with him and she was naked. I immediately went and told Bath Aide-N that Resident told me a male came in and had eye contact with her. Bath Aide-N usually sits outside the curtain. Bath Aide-N stated it didn't happen like that, she said the privacy curtain was pulled and he would have to come all away around her if the curtain was pulled. LPN-K reported that Bath Aide-N works Monday through Friday and that Resident #17 would have a bath 2 or 3 times a week on Mondays, Wednesdays, and Friday's. LPN-K stated, No, I didn't let anyone in Social Service know, just Bath Aide-N. On 8/19/15 at 12:20 p.m., Surveyor # interviewed Bath Aide-N who reported she is the Bath Aide for Resident #17, who currently has had no bathes. Bath Aide-N stated Resident #17 would get a bath in the tub. Bath Aide-N stated Resident #17 gets baths Mondays, Wednesdays, and Fridays, 3 times a week, and that it has been awhile since she has had one. Bath Aide-N reported she ran out of towels and he came in to bring more towels, he was like 6 feet away when he came in to bring more towels, he knocked on the door and brought them in, he wouldn't see anything because the privacy curtain was pulled. I was sitting right here next to the tub, I didn't even see him, I heard a knock. No, he wasn't talking on a phone, his hands were full, I said just give them (towels) to me and he went. When I tell Resident #17 it is time for a bath, she states, 'I pass, I didn't like that man coming in' that's how it's been for weeks. This incident occurred the last time she had a bath. There was no sign (for in use) for the spa door before or after the incident. Bath Aide-N provided Surveyor # with a copy of the last shower/bath record. Bath Aide-N confirmed Resident 17's last bath was on 7/27/15 and this is when the incident occurred. On 8/18/15 at 2:38 a.m., Surveyor # interviewed Director of Social Services (DSS)-J who was recently hired at the facility approximately 3 weeks ago. Surveyor # discussed Resident #17's lack of privacy concern during a bath. DSS-J stated this was the first time hearing about it. DSS-J stated that Social Worker (SW)-O has been working with Resident #17 on discharge planning and was surprised Resident #17 would not have said anything to SW-O. DSS-J stated she would check into this. On 8/19/15 at 1:40 p.m. Surveyor # interviewed SW-O who stated Resident #17 never mentioned this (referring to the bathing issue) to me before. SW-O stated she spoke to Administrator-A and Director of Nursing-B who filled out a grievance. SW-O stated the housekeeper knocked on the door because the CNA requested a towel after he left Resident asked who it was and the name provided was housekeeper Q. Since then he has seen Resident almost daily and they almost always have intimate conversations. DON-B has everything and has spoken to Resident #17. On 8/19/15, Surveyor # reviewed the facility's grievance report, which indicated DON-B followed up on Resident #17's concern which was brought to the facility's attention on 8/18/15. The facility's grievance report indicates date received as 8/18/15 at 1900 (6:00 p.m.). The report description indicates resident's concern of a man from housekeeping bringing in towels and seeing resident while walking around and talking on cell phone, with resident not feeling comfortable .of telling the nurse and that resident doesn't take baths here that she goes home and takes one. The findings from the facility's investigation indicate that the DON-B spoke to all staff involved and unable to support resident's statement. Writer also went to shower room and curtain is intact for use at tub area. Per interview, description were consistent with CNA, Housekeeper and Nurses. The CNA asked housekeeping for towels, housekeeping handed towels to CNA and nurse followed up in Resident's complaint and immediately that evening spoke to the CNA. Corrective Action Taken: To add sign to shower door when resident bathing. Resident states she'll go home to take showers. The facility's investigation includes a signed statement by Bath Aide-N which indicates, About 5 weeks ago, I supervised Resident #17 taking a bath. I needed some towels and Housekeeping Q brought some towels into shower room and left. The curtain was pulled and I got up and took the towels from him and Resident #17 asked who that was and I said housekeeping. I told her who it was. Resident #17 stated is that a man? I said yes, and she responded stating, I don't want him to see all of this gesturing to her body. I responded by telling her he can't see you and we both laughed about it. Housekeeper Q's signed a statement dated 8/19/15 which indicates, I got a call from Bath Aide-N to bring towels into the shower room. I brought the towels and left out. Did you see resident? No, there was curtain in place. Have you seen Resident since then? yes, we speak everyday and are cordial with one another. Do you thinks she feels uncomfortable or do you feel uncomfortable? No. On 8/19/15 at 3:05 p.m., Surveyor # met with Administrator-A and Director of Nursing-B regarding Resident #17's concerns. Director of Nursing-B stated, Resident goes home every day to take a shower, she goes out per her preference. We discussed posting a sign outside the spa door for her and she did not want it. On 8/20/15 at 8:35 a.m., Surveyors # and # went into the 300 unit's spa/bath tub area. Surveyors # and # observed the whirlpool tub privacy curtain goes partially around the tub and does not provide full visual privacy. While Surveyors were in the spa/tub room with the door closed, at 8:46 a.m., Restorative Rehab Aid-G entered the spa/tub room without knocking to get towels. At 8:54 a.m., Certified Nursing Assistant (CNA)-R entered the spa/tub room without knocking to get towels. On 8/20/15 from 12:20 to 12:55 p.m., Surveyors # and # again interviewed Resident #17. Resident #17 stated that the privacy curtain in the spa was pulled 1/2 way. At the time of the bath, the male didn't knock just opened the door. The Bath Aide usually sits back by the tub; however on this day, the Bath Aide was sitting right inside by the door. The Director of Nursing (DON) came in the next day after I talked with you (to Surveyor # ), the DON kept asking, 'Are you sure?' Resident #17 stated, Why would I lie about something like that? Now I take wash ups at my sink or go to my sister's house. When Surveyor # asked Resident #17 how this incident affected her, Resident #17 stated, I don't like how it's no privacy and no one has said anything about the incident. Nobody but the DON and the staff involved know. There should be a bath sign that says, 'No Men Enter.' No one thinks it important but me. I just go to my sister's house during the day time to take a shower. I feel more comfortable there than here. Resident stated she would probably feel better if some specialized training was taking place. I know he saw me, he looked right at me. The next day (after the incident) she (Resident #17) asked Bath Aide-N why would you let him in the bathroom? Bath Aide-N laughed. When the male entered the bathroom, he was on his phone and looked at Bath Aide-N and Bath Aide-N laughed. Resident stated she only told LPN-K that she was very offended. The DON only asked me a couple of questions. The next day Resident #17 was asked for a shower and said, no, I can't I was offended by what happened. The facility doesn't know how to protect the residents. I'm not trying to sue but it's just wrong. I will not take a bath at all. At this point, Surveyors # and # observed Resident #17 putting her hand to her chest, trying to maintain composure as she was becoming teary eyed and emotional. Since the incident on 7/25/15 when Housekeeping Q walked in on Resident #17 while she was bathing, Resident #17 has avoided a fear-inducing situation by showering and bathing at her sister's house. Resident #17 continues to express ongoing feelings of humiliation from the violation of her privacy rights.

Based on interview and record review, facility staff did not ensure 1 of 3 Residents (Resident #7) at risk for dehydration received sufficient fluids to maintain proper hydration and health. Staff did not transcribe an order received 5/14/15 for a supplement and subsequently it was not provided four times a day as ordered. Staff combined food and fluid intake into one meal percentage value, thus, the facility did not have a comprehensive plan to ensure that when partial meal percentages are documented staff would clearly know how much fluid was consumed. Additionally, the facility did not ensure that staff entered the correct code values for each meal to ensure correct calculations of meal intake, and staff did not document intake of any kind for half of Resident #7's last 19 dinner meals prior to hospitalization . As a result of the above, no one knew how much fluid the resident was actually consuming. There were no documented assessments by nursing of the resident's hydrational status after 4/18/15 that looked at whether the resident's mucous membranes, lips or tongue were moist. Resident #7 was hosptalized on [DATE] following a [MEDICAL CONDITION]. Resident #7's sodium level at the time was 162 mmol/L(millimole per liter). [MEDICAL CONDITION] (elevated sodium in the blood) is defined as > (greater than) 146 mmol/L. The Neurology consult once Resident #7 states the [MEDICAL CONDITION] was more likely symptomatic [MEDICAL CONDITION] (due to dehydration) rather than an overt [MEDICAL CONDITION]. Resident #7 required 4.8 liters of fluid to be rehydrated. The facility's failure to ensure that Resident #7 received proper fluid intake to prevent [MEDICAL CONDITION] and hospitalization created a situation of Immediate Jeopardy for Resident #7 that started on 5/14/15. The facility Administration was informed of the immediate jeopardy on 6/10/15 at approximately 10:54 am. The facility removed the Immediate Jeopardy on 6/11/15. The deficient practice continues at a scope and severity of an E (potential for harm/widespread) as the facility continues to implement its action plan for Residents identified at risk for dehydration. Findings include: Surveyor # reviewed Resident #7's closed medical record regarding a complaint indicating that Resident #7 was admitted to the hospital with [REDACTED]. Resident #7 remained in the hospital at the time of the survey. Resident #7 was admitted to the facility on [DATE] after a hospitalization for [MEDICAL CONDITION]. Resident #7 has [DIAGNOSES REDACTED]. Resident #7 was sent to the ED (Emergency Department) on 5/31/15 and admitted to the hospital with [REDACTED]. A Neurology consult (detailed later) states the [MEDICAL CONDITION] were most likely symptomatic [MEDICAL CONDITION] rather than an overt [MEDICAL CONDITION]. Resident #7's sodium level was 162 on admission to the ED. The reference range/normal levels are 135-145. ASSESSMENTS/EVALUATION Resident #7 had a Hydration Risk Screener completed on 4/18/15 indicating he scored a 6. The Screener should have scored an 8 because staff did not factor in the resident's weight loss. On 6/8/15 and 6/9/15 at multiple times throughout both dates, Surveyor # asked RN (Registered Nurse) Clinical Director-C and DON (Director of Nursing)-B what a score of 6 or 8 means-does it indicate the Resident is at risk for dehydration? low risk? high risk? not at risk? etc. Both indicated they did not know what a score of 6 or an 8 meant. The Hydration Risk Screener completed 4/18/15 indicates Resident #7 had moist mucous membranes, lips and tongue were moist; was bed bound; needs limited physical assistance with fluid intake and eating; is incontinent of urine; has 1-2 predisposing factors (factors listed are: history of UTI, infection, fever, [DIAGNOSES REDACTED]. Nursing considerations checked on the Screener are: Notify PMD (primary medical doctor) and responsible party of any abnormal findings; I & O (intake and output) per facility protocol; Monitor VS (vital signs) Q (every) shift; Labs per MD orders. A section for Body weight in kilograms (kg)-weight in pounds divided by 2.2 and Fluid Requirement: kg x 30 ml (milliliter)=24 hour fluid requirement is also left blank. The Summary section is blank. The Screener assessment was completed by a LPN (licensed practical nurse) and does not reflect that an RN actually conducted the assessment and/or analyzed the data collected as required under the Wisconsin Nurse Practice Act N6. Resident #7's Initial MDS (Minimum Data Set) with as Assessment Reference Date of 4/24/15 indicates Resident #7 has short and long term memory problems, and moderately impaired cognitive skills for daily decision making- decisions poor, cues/supervision required. Resident #7 is also noted to have fluctuating inattention- easily distracted, out of touch or difficulty following what was said, and fluctuating altered levels of consciousness. Resident #7 is noted to feel tired, having little energy 2-6 days out of past two weeks. Resident #7 requires extensive assistance of one person for eating and drinking. Resident #7's Initial MDS indicates he is 66 inches tall (5 feet, 6 inches), and weighs 151 pounds. Under Section K.0100 Swallowing Disorder, Resident #7 is noted to have a loss of liquids/solids from mouth when eating or drinking. Staff noted Resident #7 has had a weight loss of 5% or more in the last month or loss of 10% in last 6 months, and he is not on a physician-prescribed weight loss regimen. Resident #7 is noted to receive a mechanically altered diet (change in texture of food or liquid) and a therapeutic diet. Resident #7's Nutritional Status CAA (Care Area Assessment) dated 4/27/15 indicates Resident #7 has Functional Problems that affect ability to eat; swallowing problem and Inability to perform ADLs (Activities of Daily Living) without significant physical assistance are checked. The CAA also indicates Resident #7 has: -Cognitive, mental status, and behavioral problems that can interfere with eating: Other dementia and Poor memory; -Communication problems: Difficulty making self understood, and Difficulty understanding others; -Other diseases and conditions that can affect appetite or nutritional needs:[MEDICAL CONDITION]([MEDICAL CONDITION], respiratory disease, and weight loss. An Admission Nutritional assessment dated [DATE] completed by RD (Registered Dietitian)-J indicates the following Estimated Nutrient Needs: Total Calories: 1700-2040 calories; Protein 68 (grams); Fluid: 1700-2040 (cc's). The form asks Does total intake meet estimated needs and RD-J answered Yes. The Assessment continues: Nutrition Diagnosis: [REDACTED]. Nutritional Interventions: Mechanical soft diet, supplement BID with meals, monitor weight, appetite, tolerance of diet. Nutritional Goals: Will tolerate least restrictive diet without signs/symptoms of difficulty. Will have no s/s (signs/symptoms) of dehydration; will maintain weight between 145-155 pounds. A Nutritional Data V2 assessment also completed 4/20/15 states Resident #7 has had a significant weight loss; Oral intake conditions- swallowing disorder; Dehydration Risk Factors: Daily laxative use, dementia, dysphagia; Feeding ability: supervision. Resident #7 had lab work done on 4/21/15 showing his sodium was 144 mmol/L (millimole per Liter). The normal range is 135-145, so 144 is only 1 mmol/L away from the highest reading of the normal range; a reading of 146 or over can be considered [MEDICAL CONDITION], or dehydration. CARE PLAN Resident #7's Care Plan includes a Focus for Swallowing Difficulty, but does not include a specific Focus for Risk of dehydration. The Swallowing Difficulty Focus was initiated 4/20/15 and states: -Swallowing difficulty related to history [MEDICAL CONDITION] dysphagia AEB need for mechanical altered diet. -4/24/15: Difficulty swallowing liquids/meds, ST (speech therapy) downgraded diet to puree. -4/30/15 Diet upgraded to mechanical soft, no grits per ST. Focus Goals are: (with target date of 5/7/15): -Will tolerate least restrictive diet without s/s of difficulty; -Will have no s/s dehydration; -Will maintain weight between 145-155 pounds. Interventions initiated 4/20/15 are: -Assist Resident as needed during meals; -Honor food preferences; -Monitor food and fluid intake; -Monitor tolerance to diet consistency; -Monitor weight; -Provide diet as ordered, no grits. Additional interventions added are: -Provide meals in supervised dining room (added 4/24/15) and Provide scoop plate at each meal (added 5/21/15). Resident #7's care plan Focus for ADLs includes an Intervention: The Resident requires hands on assistance of one staff for eating (initiated 5/12/15). PROGRESS NOTES/REPORTS Resident #7's record contains Nutrition/Dietary Notes dated 4/23/15 stating NAR (Nutrition at Risk): Resident observed at lunch today, liquids spilling out of mouth while drinking. ST observed same. ST working with Resident to address dysphagia and speech/language. ST to update dietary regarding any necessary food/fluid modifications following assessment. Continue mechanical soft with thin liquids at this time. A Nutrition/Dietary Note dated 4/24/15 states MNT (Medical Nutrition Therapy): Resident noted to have difficulty swallowing meds this morning, liquid spills out of mouth. ST downgraded diet to puree. Despite the fact that liquids were spilling out of the resident's mouth on both 4/23/15 and 4/24/15, no plan was put in place to specifically monitor fluid intake. A Nutrition/Dietary note dated 4/30/15 states Per ST, diet consistency upgraded from puree to mechanical soft, not to receive grits due to coughing. The Nutrition/Dietary note dated 5/14/15 indicates Resident #7 is losing weight. RD-J wrote recommend adding 60 cc's of 2Cal/cc (supplement) QID (four times a day) with med pass . Nurses' Notes dated 5/14/15 at 18:57 (5:57 p.m.), written by RN-T state she called Resident #7's physician- call with weight loss, per RD 2cal/cc 60 ml po (by mouth) qid ordered, no new orders from Dr. This order was not implemented following receipt. Surveyor # reviewed Resident #7's MAR's (Medication Administration Records) for May, 2015. There is no indication Resident #7 received the 60 cc's of 2cal supplement four times a day starting 5/14/15. No Telephone physician's orders [REDACTED]. Had Resident #7 received this supplement as ordered, he would have received another 240 cc's of fluid per day. RN-T did not know why the physician's orders [REDACTED].#7 starting 5/14/15. Resident #7's CareTracker VHC-Resident Meal Alternate Report provided to Surveyors on 6/8/15 shows staff document meal intake as one total percentage of both food and fluids. With a few exceptions and a few blank entries, from 4/17/15 through 5/12/15, the documentation shows Resident #7 consumed 100% of breakfast, lunch and dinner. The May MAR indicated [REDACTED]. No follow-up was conducted to ensure staff were documenting the food/fluid intakes correctly. Surveyor # did observe that when staff enter only amounts consumed for two meals, and leave the third meal blank, the computer program calculates the Average Meal Intake using only the two meals that have an amount entered, and dividing by 2. For example, on 5/13/15 (and other dates), staff documented Resident #7 consumed 100% of breakfast and lunch, but left dinner blank, the program shows the Average Meal intake for that day was 100%, even though there is no entry for dinner at all. RD-J, RN-C, DON-B were unaware of that process of calculation. They all assumed if the Average Meal Intake showed 100% that would mean Resident #7 ate 100% of all three meals, which is not always the case. This occurred on 13 days in May. Of the 19 days from 5/13/15 to Resident #7's discharge to the hospital on [DATE], staff did not enter any amount of food/fluid consumed for dinner on just over half of the days (10 of the 19 days- 5/13, 5/14, 5/18, 5/19, 5/21, 5/22, 5/23, 5/25, 5/26, and 5/27). Regarding the last day, 5/31/15, during interviews CNA (Certified Nursing Assistant)-U and RN-S told Surveyor # Resident #7 did not eat any of his dinner that night, but staff entered 100% food and fluid consumed. In addition, an LPN (Licensed Practical Nurse) documented in the nurses' notes on 5/31/15 at 1:28 p.m. Resident #7 ate 50% of meal and tolerated well fluid intake tolerated well no cough or congestion . yet the CareTracker shows 75% Breakfast Intake and 100% Lunch Intake. One entry showed Resident #7 consumed only 25% of food and fluids (5/28) at dinner; 50% of dinner on 5/24 and 75% of dinner on 5/20. Staff are not able to determine of the 25%, 50% or 75% consumed, how much - if any, fluids were consumed. On 6/8/15 at 1:18 p.m., Surveyor # interviewed CNA-Q, who stated Resident #7 could eat somewhat by himself, but was messy- he'd spill a lot so staff would help him. CNA-Q stated Resident #7 would eat /drink between 50-100%. On 6/8/15 at 1:35 p.m., when asked how they were monitoring Resident #7's intake, RN Manger-D stated they have weekly meetings to discuss residents with skin, weight and fall issues. RN-D did not have any information regarding why over half of the last 19 opportunities to document the dinner meal, food and fluid intake were blank. RN-D stated RD-J would inform them if anyone was flagging for weight loss and they would review interventions and make sure current interventions were in place. On 6/8/15 at 2:34 p.m., RD-J informed Surveyor # the CareTracker Intakes are a combination of the food and fluid a resident consumes; if staff document a resident consumed 50%, it is not possible to know for sure how much of the 50% was food and how much was fluid. Surveyor # asked if RD-J documents how much fluid is provided with a Resident's meals to ensure the fluid provided is meeting their estimated fluid needs. RD-J stated she does not document how much fluid is provided, but a typical diet provides at least 420 cc's of fluid with each meal, or 1260 cc's a day. Resident #7 also receives 8 ounces of Ensure twice a day, adding another 480 cc's for a total of 1740 cc's., just over Resident #7's minimum estimated fluid needs. (RD-J estimated Resident #7's estimated fluid needs to be 1700-2040 cc's a day). On 5/29/15, RD-J recommended Resident #7 receive 120 cc's of 2cal supplement four times a day. This order was obtained and transcribed, but the first time the supplement was given was the morning of 5/31/15, and Resident #7 was sent to the hospital later on 5/31/15. RD-J stated she was not aware that the previous recommendation from 5/14/15 of 60 cc's of 2cal four times a day was never provided. Surveyor # noted RD-J documented a Nutrition/Dietary Note on 5/21/15 (adding use of scoop plate at meals) and on 5/29/15 (weight loss), but made no mention of a second sodium reading of 144 (high normal) obtained 5/14/15, and fluids provided were just barely meeting the low end of his estimated fluid needs. RD-J did not recall if she was aware of that lab result, and while the 2cal was added in response to his continued weight loss, it would have provided extra fluid. On 6/9/15 at 1:15 p.m. Surveyor # interviewed DON-B and noted the Care Plan states to Monitor food and fluid intake, but it does not say who should monitor, how often, how it should be done, where it would be documented, also noting that Resident #7's Hydration Risk Screener identified as Nursing Interventions: I & O (intake and output) per facility protocol and Monitor VS (vital signs) Q (every) shift. Surveyor # asked what the facility's I & O policy is. DON-B stated they only record I&O if the physician orders [REDACTED]. Surveyor # asked how they know how much fluid a resident consumes if they combine food and fluid intake into one total. DON-B stated they expect CNAs to report to the nurse if the Resident does not consume most of their fluids, or when the CNAs pass water to the residents in their rooms, they should be aware if the resident is not drinking any water. In addition to not accurately monitoring Resident #7's intake, there were no documented assessments by nursing of Resident #7's hydrational status after 4/18/15 that looked at whether the resident's mucous membranes, lips or tongue were moist. On 6/10/15 at 8:58 a.m., Surveyors received and reviewed facility policies and procedures related to hydration. The facility's Nutrition Program Outline (no date), states Residents with unplanned weight loss or gain, newly identified change in appetite or changes that affect nutrition and hydration should be discussed daily in clinical stand up. Suggest that a list of those residents be maintained on 24 hour report sheet for nurses to document response to interventions. As of 6/10/15 at 4:00 p.m., facility staff was unable to locate the 24 hour report sheets for the time in question related to Resident #7's care. The facility's Resident Hydration and Prevention of Dehydration policy (2001 MedPass, Inc., revised April 2007), adopted by the facility 9/12/14, includes: -The dietitian will assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need. -Minimum fluid needs will be calculated and documented on initial, annual and significant change assessments using current Standards of Practice . -Nursing will assess for signs and symptoms of dehydration during daily care. -Staff will provide and encourage intake of bedtime, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml (milliliters)/day to nursing staff. -If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. Physician will be informed. -Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. -The Dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake . -Nursing will monitor and document fluid intake and the Dietitian will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. HOSPITAL RECORD Surveyor # reviewed Resident #7's hospital record that starts 5/31/15 in the ED (Emergency Department). The documentation states Labs with severe [MEDICAL CONDITION], elevated BUN (blood urea nitrogen- elevated with dehydration, among other causes), AKI (acute kidney injury) indicative of hypovolemia .Aggressive fluids started . Lab results: BUN 62 mg/dL (milligrams per deciliter) (normal range 6-23); sodium 162 mmol/ L (millimoles per liter) (normal range 136-145); chloride 120 mmol/L (normal range 98-107); Creatinine 1.60 mg/dL) (normal range 0.70-1.30). ED Assessment/Plan: -[MEDICAL CONDITION]: possibly secondary to [MEDICAL CONDITION] .; -[MEDICAL CONDITION]: Possible hemoconcentration elevation due to poor hydration status. Possible contributor to [MEDICAL CONDITION] episode . -Metabolic alkalosis: likely due to hemoconcentration with elevated chloride. Most likely due to dehydration as stated above; 2 Liters NS (normal saline) IVF (intravenous fluids) in ED. -Malnutrition/dehydration: Patient very cachectic (condition of physical wasting with loss of wright and muscle mass due to disease) on exam. Family states nursing home not giving him enough water, receives Ensure .received 2 liters IVF in ED. -Acute kidney injury: Likely pre-renal given dehydration as discussed above. Additional notes state: Per nursing home, patient has been eating less. In the ED, he was noted to have a sodium of 162. 2L of normal saline was ordered. It was very difficult to maintain IV access . (Surveyor note-This can be a result of severe dehydration). Given history from nursing home, [MEDICAL CONDITION] and AKI likely secondary to decreased PO (by mouth) intake. Patient has difficult IV access, will order midline. (Midline is IV inserted in upper arm). Free water deficit is 4.8 Liters. Physical Exam: Cachectic .dry mucous membranes . Neurology Consult Note: 6/1/15 at 1:33 a.m.: Impression/Plan: .Additionally, with correction of his [MEDICAL CONDITION] we suspect that he will improve clinically to his baseline- in fact it seems less likely that this clinical episode represented an overt [MEDICAL CONDITION] and more likely was symptomatic [MEDICAL CONDITION]. At the daily exit meeting on 6/9/15, Surveyor # shared the above concerns regarding monitoring Resident #7's hydration status, noting Resident #7 is indicated on the Roster/Sample Matrix 802 as having hydration concerns; a goal on the swallowing difficulty care plan is Resident #7 will have no signs of symptoms of dehydration, an intervention on that care plan is to monitor fluid intake, yet there is no way to know how much fluid Resident #7 consumes if the total meal is less than 100%; documentation for Resident #7's dinner meal is blank for half of his last 19 dinners-and that includes his fluid intake; the facility Hydration policy states aides should report fluid intake of less than 1200 cc's yet there is no way for this to be ascertained; the facility's Nutrition Program Outline states Residents with unplanned weight loss or changes that affect nutrition and hydration should be documented on the 24 hour report-but those reports are not available; an order for [REDACTED]. According to Medscape (www.medscape.com/view article/ 8 <http://www.medscape.com/view article/ 8>) Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) 590-596: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately In the older adult dehydration often causes atypical symptoms such as confusion, constipation or falls Body weight proved to be the most responsive to changes in hydration Patients consuming less than 50% of meals are at high risk for dehydration. According to a study published by the National Institute of Health (<http://www.ncbi.nlm.nih.gov/pubmed/ 084>), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were 151-153 and to 71.4% whose sodium level exceeded 154. (This resident's sodium level was 162.) The facility's failure to ensure that Resident #7 received proper hydration in order to prevent hospitalization and a [MEDICAL CONDITION] as a symptom of dehydration created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on 6/11/15 when they implemented the following: ~ The facility reviewed and revised all facility policies related to hydration and dehydration. ~ The facility's Hydration Risk Screening Tool Assessment was reviewed and revised. ~ All facility residents were assessed for hydration risk and a system was established to ensure completion upon admission, readmission, significant change and quarterly. Residents identified at risk will be referred to the dietitian for further review. ~ Residents identified at risk will be reviewed at the daily clinical meeting and weekly at the Nutritional at Risk meeting. ~ The facility developed a system to ensure that Residents not improving or responding will be further assessed and evaluated by medical staff. ~ The facility established an audit system to ensure implementation of the action plan. ~ Nursing staff were educated on assessment, documentation, calculation of fluid intake, use of MARs/TARs, recognizing lab values of concern and signs and symptoms of possible dehydration. ~ CNA's were educated on reporting changes in Resident's status, changes in urine, how to encourage intake and fluid monitoring including documentation in CareTracker.

Based on record review and interviews, facility staff did not ensure 2 of 2 residents (#7 and #8), reviewed for weight loss, maintained acceptable parameters of weight. Resident #7, who had experienced recent weight loss prior to admission, experienced a significant weight loss within the first 30 days of his admission to the facility. Resident #7 was not weighed until the 6th day of his admission. The weight obtained that day was approximately 4 pounds less than the hospital discharge weight, and even with the inaccurate weight, Resident #7 lost 7.0% of his weight in 30 days. Staff did not transcribe an order for [REDACTED].#7 did not receive it. Staff did not attempt other interventions such as increasing portion size, adding calories to foods Resident #7 was eating -(super cereal, super potatoes, etc.), offering snacks of Resident #7's liking. Staff did not weigh Resident #7 weekly as their policy directs- with his last weight in the facility on 5/19/15 of 131 pounds. Resident #7 was admitted to the hospital on [DATE] weighing 121 pounds. Documentation of meal intakes for ten of Resident #7's last 19 dinners were left blank so staff had no way to determine what he consumed for those meals, if anything. Resident #8 had a significant weight loss in March 2015 and a significant weight gain in June 2015 without a plausible cause. The facility suspected that the resident was not being consistently weighed by staff, but had not corrected this problem as of June 10, 2015. Because the facility did not know if Resident #8's weights were accurate from March - June 2015, they were not able to adequately assess his nutritional status. Findings include: 1.) Surveyor # reviewed Resident #7's closed medical record with regard to a complaint that he was admitted to the hospital with [REDACTED]. Resident #7 remained in the hospital at the time of the survey. Resident #7 was admitted to the facility on [DATE] after a hospitalization for [MEDICAL CONDITION]. Resident #7 also has [DIAGNOSES REDACTED]. Resident #7 was sent to the ED (Emergency Department) on 5/31/15 and admitted to the hospital with [REDACTED]. Resident #7's documented weight in the ED on 5/31/15 was 112 lbs. (pounds) 8 oz. (ounces). The last documented weight in Resident #7's weight at the facility is 131 lbs. on 5/19/15. The facility records meal food and fluid intake combined as one percentage of meal consumed, so it is not possible to separate food and fluid intake amounts. Therefore some information regarding hydration status is pertinent since the two (foods and fluids) are documented as a combined value. The hospital record includes: ED Assessment/Plan: -[MEDICAL CONDITION]: possibly secondary to [MEDICAL CONDITION] .; -[MEDICAL CONDITION]: Possible hemoconcentration elevation due to poor hydration status. Possible contributor to [MEDICAL CONDITION] episode . -Metabolic alkalosis: likely due to hemoconcentration with elevated chloride. Most likely due to dehydration as stated above; 2 Liters NS (normal saline) IVF (intravenous fluids) in ED. -Malnutrition/dehydration: Patient very cachectic (condition of physical wasting with loss of wright and muscle mass due to disease) on exam. Family states nursing home not giving him enough water, receives Ensure .received 2 liters IVF in ED. -Acute kidney injury: Likely prerenal given dehydration as discussed above. Additional notes state: Per nursing home, patient has been eating less. In the ED, he was noted to have a sodium of 162. 2L of normal saline was ordered. It was very difficult to maintain IV access . (Surveyor note-this can be a result of severe dehydration). Given history from nursing home, [MEDICAL CONDITION] and AKI likely secondary to decreased PO (by mouth) intake. Patient has difficult IV access, will order midline. (Midline is IV inserted in upper arm). Free water deficit is 4.8 Liters. Physical Exam: Very cachectic (emaciated, physical wasting, loss of weight and muscle mass) .dry mucous membranes . Neurology Consult Note: 6/1/15 at 1:33 a.m.: Impression/Plan: .Additionally, with correction of his [MEDICAL CONDITION] we suspect that he will improve clinically to his baseline- in fact it seems less likely that this clinical episode represented an overt [MEDICAL CONDITION] and more likely was symptomatic [MEDICAL CONDITION]. A Medicine Progress Note (Hospital) dated 6/2/15 states Malnutrition: Patient very cachectic on exam. Per family, has not been eating well for weeks. Has a documented 20-30 pound weight loss since March. (Note: Resident #7 was hospitalized at that same hospital in March, 2015 and again 4/12/15-4/17/15. Resident #7's discharge weight from the hospital on [DATE] was 144.7 pounds.) Assessments/Evaluations Resident #7's Initial MDS (Minimum Data Set) with as Assessment Reference Date of 4/24/15 indicates Resident #7 has short and long term memory problems, and moderately impaired cognitive skills for daily decision making- decisions poor, cues/supervision required. Resident #7 is also noted to have fluctuating inattention- easily distracted, out of touch or difficulty following what was said, and fluctuating altered levels of consciousness. Resident #7 is noted to feel tired, having little energy 2-6 days out of past two weeks. Resident #7 requires extensive assistance of one person for eating and drinking. Resident #7's Initial MDS indicates he is 66 inches tall (5 feet, 6 inches), and weighs 151 pounds. Under Section K.0100 Swallowing Disorder, Resident #7 is noted to have a loss of liquids/solids from mouth when eating or drinking. Staff noted Resident #7 has had a weight loss of 5% or more in the last month or loss of 10% in last 6 months, and he is not on a physician-prescribed weight loss regimen. Resident #7 is noted to receive a mechanically altered diet (change in texture of food or liquid) and a therapeutic diet. Resident #7's Nutritional Status CAA (Care Area Assessment) dated 4/27/15 indicates Resident #7 has Functional Problems that affect ability to eat; swallowing problem and Inability to perform ADLs (Activities of Daily Living) without significant physical assistance are checked. The CAA also indicates Resident #7 has: -Cognitive, mental status, and behavioral problems that can interfere with eating: Other dementia and Poor memory; -Communication problems: Difficulty making self understood, and Difficulty understanding others; -Other diseases and conditions that can affect appetite or nutritional needs:[MEDICAL CONDITION]([MEDICAL CONDITION], respiratory disease, and weight loss. The CAA states Resident #7 was admitted to the facility following hospitalization for [MEDICAL CONDITION], UTI, [MEDICAL CONDITION]; other Diagnoses: [REDACTED]. Pertinent medications include: Senna, [MEDICATION NAME] . Drank Ensure twice daily at home, likes water, dislikes milk, coffee .Swallow difficulty related to dysphagia, history [MEDICAL CONDITION] (as evidence by) need for mechanically altered diet. Recommend 8 ounces Ensure BID (twice a day) with medication pass. An Admission Nutritional assessment dated [DATE] completed by RD (Registered dietitian)-J indicates the following Estimated Nutrient Needs: Total Calories: 1700-2040 calories; Protein 68 (grams); Fluid: 1700-2040 (cc's). The form asks Does total intake meet estimated needs and RD-J answered Yes. The Assessment continues: Nutrition Diagnosis: [REDACTED]. Nutritional Interventions: Mechanical soft diet, supplement BID with meals, monitor weight, appetite, tolerance of diet. Nutritional Goals: Will tolerate least restrictive diet without signs/symptoms of difficulty; Will have no s/s (signs/symptoms) of dehydration; will maintain weight between 145-155 pounds. A Nutritional Data V2 assessment also completed 4/20/15 states Resident #7 has had a significant weight loss; Oral intake conditions- swallowing disorder; Dehydration Risk Factors: Daily laxative use, dementia, dysphagia; Feeding ability: supervision. The facility Roster/Sample Matrix CMS form 802 provided to Surveyors on 6/4/15 shows Resident #7 is not identified as having Excessive Weight Loss/Gain. The Instructions for form 802 state this includes Residents with an unintended weight loss/gain of >5% in one month or >10% in six months, or is at nutritional risk. CARE PLAN Resident #7's Care Plan includes a Focus for Swallowing Difficulty, but does not include a specific Focus for weight loss. The Swallowing Difficulty Focus was initiated 4/20/15 and states: -Swallowing difficulty related to history [MEDICAL CONDITION] dysphagia AEB need for mechanical altered diet. -4/24/15: Difficulty swallowing liquids/meds, ST (speech therapy) downgraded diet to puree. -4/30/15 Diet upgraded to mechanical soft, no grits per ST. Focus Goals are: (with target date of 5/7/15): -Will tolerate least restrictive diet without s/s of difficulty; -Will have no s/s dehydration; -Will maintain weight between 145-155 pounds. Interventions initiated 4/20/15 are: -Assist Resident as needed during meals; -Honor food preferences; -Monitor food and fluid intake; -Monitor tolerance to diet consistency; -Monitor weight; -Provide diet as ordered, no grits. Additional interventions added are: -Provide meals in supervised dining room (added 4/24/15) and Provide scoop plate at each meal (added 5/21/15). Resident #7's care plan Focus for ADLs includes an Intervention: The Resident requires hands on assistance of one staff for eating (initiated 5/12/15). WEIGHTS/ MARs (Medication Administration Record) Surveyor # reviewed Resident #7's documented weights taken from admission 4/17/15 through discharge 5/31/15. Staff documented: 4/22/15 140.9 (mechanical lift) (Note: first weight obtained in facility-on day 6 of admission.) 4/27/15 142.3 5/3/15 136.1 5/6/15 143 5/9/15 139.6 (wheelchair) 5/12/15 134.7 5/19/15 131 Warnings: 04/22/15 140.9 lbs., -7.0%, -9.9 lbs. Except where noted above, it is not known what type of scale Resident #7 was weighed with. Surveyor # reviewed Resident #7's April, 2015 MAR and noted an order/entry stating: Admission weight on day of admission, one time only, start date 4/17/15 at 9:16 a.m., to be obtained by 4/17/15 at 2359 (11:59 p.m.). No staff signed/initialed that Resident #7's weight was obtained on 4/17/15. The April MAR contained a second order to obtain Resident #7's Admission weight- stating: Admission weight on day of admission one time a day every 7 days for monitoring weight for 4 weeks, starting 4/18/15 at 9:00 a.m. This, too, is blank- no staff signed/initialed this indicating they obtained Resident #7's weight on 4/18/15. The April MAR contains yet another order to obtain Resident #7's Admission weight. On 4/22/15 the following was added to the MAR: Admission weight x 3 days one time a day for 3 days, starting 4/22/15 at 9:00 a.m. Staff initialed that they obtained a weight of 140.9 pounds on 4/22/15, but then no weights were taken on 4/23 or 4/24. Resident #7's next documented weight was obtained 5 days later, on 4/27/15. PROGRESS NOTES/REPORTS Resident #7's record contains Nutrition/Dietary Notes dated 4/23/15 stating NAR (Nutrition at Risk): Resident observed at lunch today, liquids spilling out of mouth while drinking. ST observed same. ST working with Resident to address dysphagia and speech/language. ST to update dietary regarding any necessary food/fluid modifications following assessment. Continue mechanical soft with thin liquids at this time. A Nutrition/Dietary Note dated 4/24/15 states MNT (Medical Nutrition Therapy): Resident noted to have difficulty swallowing meds this morning, liquid spills out of mouth. ST downgraded diet to puree. A Nutrition/Dietary note dated 4/30/15 states Per ST, diet consistency upgraded from puree to mechanical soft, not to receive grits due to coughing. The Nutrition/Dietary note dated 5/14/15 by RD (Registered dietitian)-J states Resident #7 weight upon admission = 140.9 on 4/22/15; (Surveyor note: Resident #7 was admitted to the facility on [DATE]- not 4/22/15); CBW (current body weight) 5/12/15 = 134.7#, weight loss of 4.4% within 30 days. Eating meals in Villa Café for supervision/assistance. Tolerating mechanical soft diet, consuming liquids without difficulty. Has order for 8 ounces Ensure BID (twice a day) breakfast/supper. Most recent BMP normal except for glucose = 49, not diabetic. [DIAGNOSES REDACTED]. Recommend adding 60 cc's of 2Cal/cc (supplement) QID (four times a day) with med pass. Notify MD/family of weight loss. Continue to monitor as needed. Nurses' Notes dated 5/14/15 at 18:57 (5:57 p.m.), written by RN (Registered Nurse)-T state she called Resident #7's physician- call with weight loss, per RD 2cal/cc 60 ml po (by mouth) qid ordered, no new orders from Dr. On 6/8/15 at approximately 4:20 p.m., Surveyor # interviewed RN-T at the facility. After reviewing the 5/14/15 note, RN-T stated she could have written the note better, and confirmed the MD did agree to and order the 2cal supplement recommended by RD-S; but the MD had no additional orders. Surveyor # reviewed Resident #7's MAR's (Medication Administration Records) for May, 2015. This is where nurses document administration and acceptance of supplements. There is no indication Resident #7 received the 60 cc's of 2cal supplement four times a day starting 5/14/15. No Telephone Order was observed for the supplement, either. Had Resident #7 received this supplement as ordered, he would have received another 480 calories per day. RN-T did not know why the physician's orders [REDACTED].#7 starting 5/14/15. RD-J documented a Nutrition/Dietary Note on 5/21/15 noting Resident #7 would benefit from using a scoop plate at meals. The meal ticket and Plan of Care were updated. On 5/29/15, RD-J documented another Nutrition/Dietary Note stating: Care conference held with IDT (Interdisciplinary Team), CC (Community Care) and family via phone. Recently Resident has (been) pocketing food in mouth, appetite has declined. Significant weight loss noted since admission from 140.9# on 4/22 to 131# on 5/19. Weight loss of 7% within 30 days. Current diet order is mechanical soft, has order for Ensure BID with meals. CC to give authorization for ST (speech therapy) screen/evaluation, will also check labs. Resident's (family) aware of weight loss. Recommend notifying MD of weight loss and for 120 cc's 2cal/cc supplement QID (four times a day) with med pass. Adjust diet, supplements pending ST assessment. (Note: This (5/29/15) is the last Nutrition/Dietary note. It references a weight taken on 5/19/15, ten days earlier. And the Admission weight was actually taken on Resident #7's sixth day in the facility- admitted [DATE] at 9:45 a.m., weight obtained 4/22). The order for 120 cc's of 2cal supplement four times a day was obtained and transcribed as of 5/31/15 at 2100 (9:00 p.m.)-after Resident #7 was sent to the hospital around 7:00 p.m. on 5/31/15, so he never did receive the 2cal supplement. RD-J stated she was not aware that the previous recommendation from 5/14/15 of 60 cc's of 2cal four times a day was never provided. Resident #7's CareTracker VHC-Resident Meal Alternate Report provided to Surveyors on 6/8/15 shows staff document meal intake as one total percentage of both food and fluids. With a few exceptions and a few blank entries, from 4/17/15 through 5/12/15, the documentation shows Resident #7 consumes 100% of breakfast, lunch and dinner. The May MAR showed Resident #7 also consumed 100% of his twice-a-day Ensure, yet he continued to lose weight. No follow-up was conducted to ensure staff were documenting the food/fluid intakes correctly. Surveyor # did observe that when staff enter only amounts consumed for two meals, and leave the third meal blank, the computer program calculates the Average Meal Intake using only the two meals that have an amount entered, and dividing by 2. For example, on 5/13/15 (and other dates), staff documented Resident #7 consumed 100% of breakfast and lunch, but left dinner blank, the program shows the Average Meal intake for that day was 100%, even though there is no entry for dinner at all. RD-J, RN-C, DON-B were unaware of that process of calculation. They all assumed if the Average Meal Intake showed 100%, that would mean Resident #7 ate 100% of all three meals, which is not always the case. This occurred on 13 days in May. Of the 19 days from 5/13/15 to Resident #7's discharge to the hospital on [DATE], staff did not enter any amount of food/fluid consumed for dinner on just over half of the days (10 of the 19 days- 5/13, 5/14, 5/18, 5/19, 5/21, 5/22, 5/23, 5/25, 5/26, and 5/27). Regarding the last day, 5/31/15, during interviews regarding Resident #7's [MEDICAL CONDITION] that led to his hospitalization CNA (Certified Nursing Assistant)-U and RN-S told Surveyor # Resident #7 did not eat any of his dinner that night, but staff entered 100% food and fluid consumed. In addition, a LPN (Licensed Practical Nurse) documented in the nurses' notes on 5/31/15 at 1:28 p.m. Resident #7 ate 50% of meal and tolerated well fluid intake tolerated well no cough or congestion .; yet the CareTracker shows 75% Breakfast Intake and 100% Lunch Intake. Of the entries that were completed for the last 19 dinners, one entry showed Resident #7 consumed only 25% of food and fluids (5/28) at dinner; 50% of dinner on 5/24 and 75% of dinner on 5/20. On 6/8/15 at 1:18 p.m., Surveyor # interviewed CNA-Q, who stated Resident #7 could eat somewhat by himself, but was messy- he'd spill a lot so staff would help him. CNA-Q stated Resident #7 would eat /drink between 50-100%. On 6/8/15 at 1:35 p.m., when asked how they were monitoring Resident #7's intake, RN Manger-D stated they have weekly meetings to discuss residents with skin, weight and fall issues. RN-D did not have any information regarding why over half of the last 19 opportunities to document dinner meal food and fluid intake were blank. RN-D stated RD-J would inform them if anyone was flagging for weight loss and they would review interventions and make sure current interventions were in place. RN-D stated they just added another supplement (2cal) prior to Resident #7 being sent out to the hospital. RN-D was not aware of other interventions added to address Resident #7's weight loss. On 6/8/15 at 2:34 p.m., RD-J informed Surveyor # the CareTracker Intakes are a combination of the food and fluid a resident consumes; if staff document a resident consumed 50%, it is not possible to know for sure how much of the 50% was food and how much was fluid. Surveyor # asked if RD-J documents how many calories are provided with a Resident's meals to ensure the food provided is meeting their estimated caloric needs. RD-J stated she does not document how many calories are provided, but a typical mechanical soft diet provides about 2200 calories and 85-90 grams of protein a day. Resident #7 also receives 8 ounces of Ensure twice a day, adding another 340 calories and 19 grams of protein per can. RD-J estimated Resident #7's caloric needs to be 1700-2040 calories a day. RD-J stated she did not know why Resident #7 continued to lose weight despite meal and Ensure intakes reported as 100%, and she added the 2cal supplement to address the weight loss. Surveyor # asked if RD-J tried any other interventions such as adding larger portions, adding calories to the food he was eating since his intake was good, super cereal and super mashed potatoes, extra snacks of his preference, etc. RD-J stated it appears the supplement was the only added intervention. RD-J stated she obtained the Admission weight of 151# used on the Initial MDS from the Hospital record. Upon further research, she realized that was Resident #7's weight on admission to the hospital on [DATE], and he lost weight during the hospital stay, dropping down to 139 at one point. RD-J stated she should not have used the hospital weight but should have obtained an admission weight at the facility. (Hospital discharge weight 4/17/15 was 144.7#). RD-J stated they are working on getting consistent weights when asked about the variations in weight: 6.2# loss from 4/27 to 5/3 (142.3 to 136.1) followed by 6.9# gain between 5/3 and 5/6 (136.1 to 143). RD-J did not know why Resident #7 did not have any more weights after 5/19/15; she would have expected them to weigh a resident with weight loss every week. On 6/9/15 at 1:15 p.m. Surveyor # interviewed DON-B and noted the Care Plan states to Monitor food and fluid intake and Monitor weight but it does not say who should monitor, how often, how it should be done, where it would be documented. DON-B stated CNAs document a resident's food and fluid intake in CareTracker. They obtain weekly weights for several weeks after admission and if a Resident is losing weight that is not planned. DON-B stated she would provide facility policies. On 6/10/15 at 8:58 a.m., Surveyors received and reviewed facility policies and procedures related to weight loss. The facility's Nutrition Program Outline (no date), states Residents with unplanned weight loss or gain, newly identified change in appetite or changes that affect nutrition and hydration should be discussed daily in clinical stand up. Suggest that a list of those residents be maintained on 24 hour report sheet for nurses to document response to interventions. (As of 6/10/15 at 4:00 p.m., facility staff was unable to locate the 24 hour report sheets for the time in question.) The Outline also states: Complete weekly weights when: New/Readmission, Unstable resident who is not eating, Unstable weight issues, Weight loss of 5% in one month, Residents who are at high risk for weight loss or continued weight loss. 3-Day Calorie Counts and weights: Any Resident who has not eaten >50% in 2 consecutive meals; Any Resident who consistently has a change in appetite for three days. The facility's Weight Assessment and Intervention policy (2001 MedPass, Inc., revised August, 2008), adopted by the facility 9/12/14, includes: -The nursing staff will measure resident weight upon admission, and weekly for three weeks thereafter. If resident is admitted from a hospital, facility should not use hospital weight as admission weight. If no weight concerns are noted at this point, weights will be measured monthly thereafter. -Any weight change of greater than or less than (sic) 5 pounds within 30 days will be retaken for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. -The dietitian will respond within 24 hours of receipt of written notification. -The dietitian will also review the unit Weight Record to follow individual weight trends over time. Negative trends will be assessed and addressed by the dietitian whether or not the definition of Significant Weight Change is met. -Significant Weight Changes are defined as: a. more or less than 5% within 30 days; b. 7.5% or less within 90 days; and c. more or less than 10% within 6 months. (Surveyor Note: the Significant Weight Changes are taken verbatim from the policy provided, even though clinically they do not make sense. For example, except for a resident who gains or loses exactly 5% within 30 days, all residents would fit into a. more or less than 5% within 30 days, even a resident with no change in weight. Similarly for b. 7.5% or less within 90 days-that would include residents with no weight loss or gain up to a loss or gain of 7.5%, but would not include a resident with a 7.6 % or greater loss or gain - the very residents they should be assessing. Again, unless a resident gains or loses exactly 10% in 6 months, all other residents would meet criteria c. more or less than 10% within 6 months; even residents with no weight loss since that would be less than a 10% change.) -If a weight loss or gain meets the definition of Significant, the dietitian should discuss with the Interdisciplinary Team is a Significant Change MDS is necessary. -Care Plan Interventions will consider: a. severity of change; b. medical diagnoses; c. ADL status; d. Medications; e. Psychological status; f. Family input; g. Resident preferences; h. Input from direct caregivers. The facility policy Administration of Fluids and Electrolytes 2001 Med-Pass, Inc. (Revised August 2008) includes a section regarding Undesirable Weight Loss which states: Interventions for undesirable weight loss or gain should focus first on food (e.g. extra food, snacks, calorie-dense food, etc.). Liquid nutritional supplements, per facility formulary, may be considered if resident caloric input remains inadequate to stabilize or increase weight. Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician may order tests, appetite stimulants, or medications as appropriate. In the American Family Physician article Unintentional Weight Loss in Older Adults, it states: Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of [MEDICAL CONDITION] in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments. Am Fam Physician. 2014 May 1;89(9):718-722, Unintentional Weight Loss in Older Adults <http://www.aafp.org/afp/2014/0501/p718.html> Excerpts from Unintended Weight Loss in Older Adults: ADA Evidence-Based Practice Guidelines include: -Unintended weight loss in older adults is a harmful and [MEDICAL CONDITION] event that should be prevented if at all possible. -Accurate weight measurements are vital to nutritional assessment and care. - .studies support an association between underweight and/or unintended weight loss and increased mortality. At the daily exit meeting on 6/9/15, Surveyor # shared the above concerns regarding monitoring Resident #7's weight loss, noting Resident #7 is not indicated on the Roster/Sample Matrix 802 as having weight loss, yet he has lost 7.0% in 30 days; the care plan states to monitor food and fluid intake, yet documentation for Resident #7's dinner meal is blank for half of his last 19 dinners; the facility's Nutrition Program Outline states Residents with unplanned weight loss or changes that affect nutrition and hydration should be documented on the 24 hour report-but those reports are not available; an order for [REDACTED].#7; Resident #7's Admission weight was not taken until the 6th day he was in the facility; fluctuations of 6 pound gains and losses within a few days were not addressed; and while the 2cal supplement was ordered (but not given) starting 5/14/15, other interventions noted in the facility policy, including extra food/larger portions, snacks, calorie-dense food, etc. were not implemented even though for the first several weeks in the facility, staff document Resident #7 eating 100% and taking 100% of his Ensure, (while continuing to lose weight), indicating those interventions may be accepted by Resident #7. No further information was provided. 2.) Resident #8's medical record was reviewed 6/4 - 6/10/15 by Surveyor # . Resident #8 is [AGE] years old and has [DIAGNOSES REDACTED]. Resident #8 is 5'11' tall. According to the March 12, 2015 Dietary Note, Resident #8 had a significant weight loss of 10% in the last 30 days. His weight in February 2015 was 186# (186 pounds). His weight for March 2015 was 164.5#. Resident #8 was then re-weighed and at that time he weighed 166.4#. Dietitian - J noted that Resident #8's average meal intake had been 98% of his Regular, No Salt Packet Diet. The Dietitian recommended the following supplements to increase weight: Two Cal four times daily, Magic Cup twice daily with meals, and Pro stat 30 cc daily. The Dietitian also recommended that Resident #8 have lab work done. On 6-8-15 at 1:35 PM, Surveyor # met with Dietitian - J, who said that she was unsure why Resident #8 had lost weight. After his weight loss, the Dietitian had made observations of Resident #8 eating in the dining room and his intake had appeared good. When asked, Resident #8 told the Dietitian that he did not know why he had lost weight. His family was interviewed and reported that Resident #8 did not like the food. Resident #8's preferences were obtained and the results were care planned. The recommended labs, noted above, were completed and were within normal limits. Resident #8's weight stabilized in March, April, and May 2015, ranging in the mid 160's. His last recorded weight was 166.1# on 5-1-15. Surveyor # noted that Resident #8 was not receiving medications that might affect his weight loss; nor did he have any other [DIAGNOSES REDACTED]. Dietitian - J confirmed this. Surveyor # indicated that it did not seem plausible that Resident #8 could have lost almost 20 pounds in 30 days, in the absence of any clinical conditions. Surveyor # indicated that it appeared that Resident #8 did not actually lose 20 pounds and it appeared that the documentation was incorrect. Dietitian - J agreed. The Dietitian indicated that it was preferred that all residents be weighed while sitting in the shower chair, but that this was not consistently done by staff. She indicated that at times residents might be weighed while seated in their wheelchair. Dietitian - J said that she and the Director of Nursing (DON)-B were working on this issue. On 6-8-15 at 3PM, Surveyor # met with facility staff , including DON-B. DON-B said that the facility had identified that there might be a problem with residents being consistently weighed. When asked, DON-B said that the facility had identified this concern a few months ago. Surveyor # asked what the facility had done to correct the problem, but the facility did not identify what they had done nor that they had fixed the problem. On 6-9-15 at 8:00 am, Surveyor # interviewed Licensed Practical Nurse (LPN) - L. She said that residents were weighed while seated in the shower chair, wheelchair, or mechanical lift. She said that if it was a resident's shower day, the resident would be weighed while in the shower chair. However, if it was not the resident's shower day and the resident was dressed and seated in their wheelchair, staff would weigh the resident in their wheelchair. On 6-9-15 at 8:05 am, Surveyor # interviewed Certified Nursing Assistant (CNA) - K. CNA - K had taken care of Resident #8 and was familiar with him. CNA - K said that Resident #8 was weighed while seated in his wheelchair. On 6-9-15 at 8:40 am, Surveyor # interviewed LPN - M. She said that residents were weig

Based on observation, interview and record review the Facility did not ensure that 2 (Resident's #8 & #5) of 10 sampled Resident's with pain received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with their comprehensive assessment and plan of care. Resident #8 was observed during multiple observations to be crying out in pain. The Facility did not comprehensively assess the Resident's pain and did not contact the physician regarding the Resident's pain. Resident #5 had severe pain in her coccyx and bilateral buttocks radiating down both legs. Resident #5 reported severe pain almost daily and would be given PRN [MEDICATION NAME], but staff did not conduct a comprehensive pain assessment reviewing the amount of PRN (as needed) narcotic pain medication she was receiving and considering around-the-clock dosing to prevent Resident #5's pain from getting so severe in the first place. Staff were not providing pain medication prior to her receiving therapy and going out for [MEDICAL TREATMENT] even though the care plan directed staff to give pain medication before treatment or cares. Findings include: Surveyors reviewed the facility's Pain-Clinical Protocol, which is labeled "2005 MED-PASS, Inc. Revised August, 2008." It states: Assessment and Recognition: 1. Identify individuals who have pain or who are at risk for having pain. a. This includes a review of known [DIAGNOSES REDACTED]. b. It also includes a review of any treatments that the resident currently is receiving for pain, including complementary (non-pharmacologic) treatments. c. Such assessments should occur on admission to the facility, at each quarterly review, whenever there is a significant change in condition and at any time pain is suspected. 2. Identify the nature and severity of pain including characteristics (location, intensity, frequency, duration, etc.). a. Use a standardized pain assessment instrument appropriate to the resident's cognitive level. b. Evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned or having a wound dressing changed. 3. Evaluate how pain is affecting mood, activities of daily living, sleep, and selected quality of life measures, including complications such as deconditioning, gait disturbances, social isolation, and falls. Treatment/Management: 1. With input from the resident and/or advocate, establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. 2. The physician will order appropriate non-pharmacologic and medication interventions to address the individuals pain. a. Any pain medications should be selected based on pertinent guidelines. 3. Evaluate and report how much and how often the individual asks for PRN pain medication. a. Depending on the severity and location of pain, the physician may start with PRN doses or supplement standing does with PRN doses for breakthrough pain. b. If there are more than occasional [MEDICATION NAME] requests, the physician will consider changing to regular administration of at least one [MEDICATION NAME] with another medication for PRN use, increasing the standing dose of an existing [MEDICATION NAME], or switching to another [MEDICATION NAME]. 4. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. 5. For the individual who is receiving opioid [MEDICATION NAME], the physician will order a regimen to minimize side effects. Monitoring: 1. The staff will reassess the individual's pain and consequences of pain at regular intervals. a. For example, review frequency and intensity of pain, ability to perform activities of daily living (ADL's), sleep pattern, mood, behavior, and participation in activities. 2. Periodically, the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including active conditions that exacerbate pain, consequences or complications of pain, and effectiveness of current interventions for pain. 3. The staff will discuss significant changes in levels of comfort with the Attending Physician who will adjust interventions accordingly. a. This may include adjustments of regular and PRN [MEDICATION NAME] doses to find the best combination of effectiveness and tolerable side effects, or possible addition on non-pharmacologic interventions. 4. The staff and physician will monitor for adverse effects... 5. If the resident's pain is complex or not responding to standard interventions, the attending physician may consider a psychiatric evaluation or referral to a pain clinic or specialist... 1.) Surveyor # reviewed Resident #8's medical record on 1/5/15 to 1/7/15. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8 started receiving hospice services on 12/4/14. The care plan dated 8/19/14 for "The resident has actual pain due to dx (diagnosis) of arthritis, [MEDICAL CONDITIONS], leg ulcers" has interventions which are all dated 8/19/14 of: * "Administer [MEDICATION NAME] as per orders. Give 1/2 hour before treatments or care." * "Anticipate the resident's need for pain relief and respond immediately to any complaint of pain." * "Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid rocking, curled up, thrashing)." * "Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment." * "Provide the resident with reassurance that pain is time limited. Encourage (SPECIFY: resident NAME, me) to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold applications, muscle stimulation, ultra sound." The pain observation tool dated 11/3/14 answers "hurts even more" for face pain response. Location of pain is "bil. (bilateral) knees, hips." Frequency of pain is "frequently." Yes is answered for does pain impact quality of life/functioning? "Sleeping", "day to day activities/ADL's (activities of daily living)" and "limits activities and/or m" are checked under this section. Acceptable level of pain is "0." Under plan of care "Satisfactory pain management/continue with current plan of care" is checked. Review of the physician orders [REDACTED].#8 receives Aspirin 81 mg (milligrams) one time daily and [MEDICATION NAME] 100 mg three times a day for [MEDICAL CONDITION]. PRN (as needed) pain medication include [MEDICATION NAME] 650 mg every four hours as needed for pain/fever, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg one table every six hours as needed for pain, [MEDICATION NAME] sulfate 10 mg every 1 hour as needed for pain/SOB (shortness of breath), and [MEDICATION NAME] sulfate 5 mg every 1 hour as needed for pain/SOB. Review of the December 2014 MAR (Medication administration record) reveals Resident #8 received the following prn pain medication: One dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablet on 12/1/14 & 12/2/14. No other prn pain medications were administered according to the December 2014 MAR. The significant change MDS (minimum data set) signed as completed on 12/18/14 documents that during the past 5 days no is checked for been on a scheduled pain medication regimen, received prn pain medications and received non medication interventions for pain. The Resident pain interview answers yes for pain presence, occasionally is checked for pain frequency, and pain intensity is rated at a "4." The pain CAA (care area assessment) did not trigger. The CNA (Certified Nursing Assistant) report sheets dated 1/5/2015 for Resident #8 documents under the ADL (activities of daily living) section "Complete assist." Under the misc. (miscellaneous) section documents "Prevalon boots in bed. Float heels off pillows. Air mattress. Check & change q (every 2-3 hrs (hours) and prn. Bedpan per resident request. Incontinent brief." There is no direction to the staff as to how to position Resident #8 and interventions to be implemented when she has signs/symptoms of pain. Review of the January 2015 MAR indicated [REDACTED]. As of 1/7/15 no other prn pain medications were administered according to the January 2015 MAR. On 1/5/15 at 1:36 p.m. Surveyor # observed Resident #8 sitting in the wheelchair in the dining room participating in a sheepshead card game activity. On 1/5/15 at 2:12 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-E remove Resident #8 from the activity and wheel Resident #8 down the hallway towards her room. Surveyor # asked CNA-E what she was going to do for Resident #8. CNA-E informed Surveyor # that she was going to change her and then bring her back to the activity. At 2:17 p.m. CNA-E and CNA-C hooked the sling to the hoyer lift and transferred Resident #8 into the bed. As CNA-E and CNA-C were transferring Resident #8 over the bed, Resident #8 was yelling out, "Ow, ow." CNA-C asked Resident #8 if she was "ok" and Resident #8 pointed to her right hip. After the sling was unhooked from the hoyer lift, CNA-C crossed Resident #8's right leg over her left and positioned Resident #8 on her side. When CNA-C crossed Resident #8's right leg, Resident #8 yelled out "ow, ow, ow." CNA-E unfastened the incontinence product and removed the incontinence product. While CNA-E was removing the incontinence product and Resident #8 was being repositioned side to side Resident #8 was yelling out "ow, ow, God have mercy." CNA-C washed and dried Resident #8's frontal perineal area. While CNA-C was washing Resident #8, Resident #8 was yelling "ow, Lord" and rubbing her right hip. CNA-C placed A & D ointment on Resident #8's left upper leg. While applying the A & D ointment, Resident #8 was yelling out, "Oh, Jesus." Resident #8 was positioned on her side, CNA-C washed her buttocks and an incontinence product was placed alongside Resident #8. While CNA-C and CNA-E were positioning Resident #8 on her side, Resident #8 yelled out "ow." CNA-E stated to Resident #8 "lets roll back." As Resident #8 was positioned on her side, she again yelled out, "Ow, ow." CNA-E & CNA-C fastened the incontinence product. At 2:25 p.m. CNA-E asked Resident #8 if she was getting up. Resident #8 stated, "No tell them I'm not coming back, it's too much." As CNA-E & CNA-C positioned Resident #8 on her left side to place a pillow under her right side, Resident #8 yelled out, "Ow, ow." On 1/6/15 at 10:28 a.m. Surveyor # observed morning cares for Resident #8 with RA (Restorative Aide)-I and CNA-G. CNA-G removed pillows under Resident #8's calves. While CNA-G was removing the pillows, Resident #8 stated that her leg was hurting a little. Resident #8 then pointed to her right leg stating, "This is starting to ache." Neither CNA-G or RA-I asked Resident #8 about her leg. CNA-G informed Resident #8 that she was going to wash her face. Resident #8's gown was removed and RA-I washed Resident #8's upper body. RA-I unfastened Resident #8's incontinence product and washed Resident #8 frontal perineal area. Resident #8 was then positioned on her left side. While positioning Resident #8 on her side, Resident #8 yelled out "ow." The incontinence product was removed and RA-I washed Resident #8's buttocks. An incontinence product was placed under Resident #8 and A & D ointment placed on Resident #8's buttocks. As CNA-G was positioning Resident #8 on her back, Resident #8 yelled out "ow, ow." RA-I stated to Resident #8, "Sorry." Resident #8's incontinence product was fastened and RA-I washed Resident #8's legs. While washing Resident #8's leg, Resident #8 was yelling out "ow, ow." Staff informed Resident #8 that she needed A & D on her legs. As RA-I was rubbing A & D on Resident #8's right leg, Resident #8 yelled out, "Ow, you can't do anything without hurting me. Ow, hurts." RA-I informed Resident #8 that she was just trying to grease it. Resident #8 yelled out, "Ow Jesus." CNA-G removed the Prevalon boots and CNA-G & RA-I washed and placed A & D ointment on Resident #8 feet. After washing Resident #8's feet, CNA-G moved Resident #8's right leg. While Resident #8's leg was being moved, Resident #8 was yelling out, "Ow that hurts so bad." Surveyor # observe that Resident #8 had both hands clinched into a fist stating "that hurts so bad." On 1/6/15 at 11:02 a.m. CNA-G entered Resident #8's room with a hoyer lift and sling. CNA-G placed the sling along side Resident #8 and CNA-G & RA-I positioned Resident #8 from side to side to place the sling under Resident #8. CNA-G lifted Resident #8's right leg up a little. Resident #8 informed CNA-G that she was going to holler when it hurts. CNA-G told Resident #8, "You're suppose to." CNA-G & RA-I transferred Resident #8 into the high back wheelchair. CNA-G placed the right foot rest on the wheelchair and then Resident #8's foot on the footrest. While CNA-G was placing Resident #8's right foot on the footrest, Resident #8 was yelling out "ow, ow" and pointing to her right hip area stating, "Right there." CNA-G told Resident #8, "It's alright for you to yell out." CNA-G adjusted Resident's right foot and Resident #8 yelled out, "Oh Lord have mercy. Oh Lord what am I going to do? Ow, it's too high." Resident #8 was rubbing the side of her right leg while CNA-G moved her right foot. On 1/6/15 at 11:19 a.m. Surveyor # asked CNA-G if Resident #8 usually yells out in pain when she is doing her cares. CNA-G replied, "Yes, she yells out all the time. I know we aren't hurting her but when touch her leg in spots it hurts her." On 1/6/15 at 1:40 p.m. Surveyor # asked CNA-E if she usually takes care of Resident #8. CNA-E informed Surveyor # she takes care of Resident #8 when CNA-G is off. Surveyor # informed CNA-E that Surveyor # had observed Resident #8 to be in pain when she and CNA-C were providing cares to her and asked if she usually yells out like that. CNA-E replied, "Not like that." Surveyor # asked CNA-E if she informed the nurse. CNA-E informed Surveyor # that she spoke to LPN (Licensed Practical Nurse)-D. Surveyor # asked when Resident #8 was yelling out why didn't she and CNA-C stop doing cares. CNA-E replied, "Not sure." On 1/6/15 at 1:45 p.m. Surveyor # asked LPN-D if she gave Resident #8 any prn pain medication yesterday. LPN-D informed Surveyor # that she didn't give her anything yesterday. Surveyor # asked LPN-D if CNA-E informed her that Resident #8 was yelling out in pain during afternoon cares. LPN-D replied, "No, just bowel movement but pain no." On 1/7/15 at 10:20 a.m. Surveyor # asked Resident #8 when staff is doing cares for her is she in pain. Resident #8 informed Surveyor # that when staff turns her and then holds her leg "ow it hurts real bad." Resident #8 informed Surveyor # that after staff puts her back on her back the pain eases and then goes away. Resident #8 stated that when she is just laying in bed she is not in pain but when they turn her or puts her in the lift it hurts real bad. Surveyor # asked if it was one side of her body or a certain part of her body was more painful. Resident #8 replied "right side" and rubbed her right hip. Resident #8 stated that the pain "hurts real bad." On 1/7/15 at 2:22 p.m. Surveyor # asked RN (Registered Nurse) Unit Manager-F when a pain assessment would be completed. RN Unit Manager-F informed Surveyor # when a Resident has a change of condition, change in pain medication, when there is a change in in Resident's pain signs & symptoms and that she does the wound care so with a new wound she would do an assessment. Surveyor # informed RN Unit Manager-F that Surveyor # noted that RN Unit Manager-F completed a pain observation tool on 1/5/15 and asked what prompted this. RN Unit Manager-F informed Surveyor # that during Resident #8's coccyx treatment she noted that Resident #8 seemed a little achy so she did an evaluation. Surveyor # inquired if during the week if any CNA's reported that Resident #8 was in pain. RN Unit Manager-F informed Surveyor # that none of the CNA's did but she just started being the unit manager and was the wound nurse before. Surveyor # asked who would the CNA's report a Resident's pain to. RN Unit Manager-F replied that they would go to the nurse who was passing medication, they would do an assessment and then they would report to the charge nurse. On 1/7/15 at 3:34 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. 2.) Resident #5 was admitted to the facility 10/23/14 and discharged to the hospital on [DATE]. Surveyor # reviewed Resident #5's closed medical record in regards to a complaint received that Resident #5's pain was not managed appropriately while she resided at the facility. Resident #5 had [DIAGNOSES REDACTED]. A Pain Observation was completed 10/23/14 for Resident #5. Resident #5 is cognitively intact. The form directs staff to complete "EITHER" Section B (for Cognitively Intact residents) or Section C (for Cognitively Impaired residents). Instead, staff completed parts of Section B and part of Section C. Instead of asking Resident #5 to rate her pain, they used the Wong-Baker pain scale and indicated Resident #5 had no pain based on her facial expression, breathing and body language. Resident #5 indicated a score of 1 on a scale of 0-10 would be acceptable level of pain. The Pain Observation notes Resident #5 receives scheduled and PRN medications including [MEDICATION NAME] and narcotic pain medication. Even though Resident #5 is taking scheduled pain medication, staff do not utilize the Pain Observation form to describe the characteristics of Resident #5's pain (where located, type of pain-burning, aching, dull, stabbing, etc., frequency, etc.) (DON-Director of Nursing-B later stated staff did not describe Resident #5's pain on this form because she was not having any at that time- (per their assessment-not Resident #5's report). This form is just to capture a "snapshot in time", not a comprehensive pain assessment.) The Observation concludes "Satisfactory pain management/continue with current plan of care." Resident #5's Initial MDS (Minimum Data Set) completed 10/30/14 indicates Resident #5 scored 15 of 15 on the Brief Interview for Mental Status. Resident #5 reported over the past five days, she experienced frequent pain of 7 on a scale of 0-10 (10 being worst pain imaginable). Resident #5 received scheduled and PRN (as needed) pain medication. The pain made it hard for her to sleep and she has limited her day-to-day activities because of pain. Resident #5's CAA (Care Area Assessment-which should be a further assessment of the indicated concern-pain) completed 11/4/14 indicates Resident #5 had moisture associated skin damage (MASD) and arthritis that may cause pain. (Staff did not indicate Resident #5 had an unstageable pressure ulcer on her heel, 4.0 x 6.0 cm. (centimeters) on her left heel, dark purple in color. MASD is more like [MEDICAL CONDITION].) The "Characteristics of Pain", "Frequency and Intensity of Pain" and "Non-verbal indicators of pain" are all left blank, even though Resident #5 reported frequent pain of 7 out of 10 over the past five days. "Pain Affect on Function" is noted to be "disturbs sleep, "adversely affects mood", and "limits day-to-day activities." "Immobility" is checked under "Other Considerations". The section for the Resident and/or Family/Representative questions, comments, concerns, preferences and suggestions is blank. The CAA indicates pain will be addressed in the care plan, but when asked "If care planning for this problem, what is the overall objective?" Staff left it blank. Options include: Improvement, slow or minimize decline, avoid complications, maintain current level of functioning, minimize risks, symptom relief or palliative measure. The CAA requires staff to "describe impact of this problem/need on the resident and your rationale for care plan decision. Include complications and risk factor and the need for a referral to other health professionals." Staff also left this section blank. While the above Pain Observation assessment and MDS/CAA assessments do not give much specific information regarding Resident #5's pain, Nurses' Notes during the Assessment Reference Period (timeframe used to complete the MDS-10/23/14 through 10/30/14) include the following: 10/27/14 Resident reports pain 6/10 to tailbone and legs. 10/10/29/14 Complaint of bilateral knee pain 7/10. 10/30/14 7:55 a.m. Complaint of pain 10/10 (does not indicate where pain is). 10/30/14 3:33 p.m. Resident complains of pain to bilateral knees and coccyx after therapy. Rates as 7/10 and describes as achy and sharp pains. 10/30/14 5:02 p.m. Rates pain 7/10 coccyx. 1000 mg. (milligrams) given. 10/30/14 7:54 p.m. Rates pain 6/10 lower back. Surveyor # reviewed Resident #5's Care Plan dated 10/24/14 stating "The Resident has potential acute pain". "Goals" are: -The Resident will verbalize adequate pain relief of pain or ability to cope with incompletely relieved pain through the review day of 12/31/14; -The Resident will not have discomfort related to side effects of [MEDICATION NAME] through the review date of 12/31/14. "Interventions" include: -Administer [MEDICATION NAME] as per orders. Give 1/2 hour before treatments or care. -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. -Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation; restlessness, confusion, hallucinations, dysphasia, nausea, vomiting, dizziness and falls. Report occurrences to physician. -Monitor /record/report to nurse any s/s (signs/symptoms) of non-verbal pain: changes in breathing (noisy, deep, shallow, labored, fast/slow); Vocalizations (grunting, moaning, yelling out, silence); Mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing). -Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. (Note: Resident #5's care plan is not individualized to her specific experiences of pain. Cross reference F279 re: Care Plans.) Resident #5's Admission Physician order [REDACTED]. -[MEDICATION NAME] 300 mg. twice a day for [MEDICAL CONDITION] (nerve pain); -[MEDICATION NAME] 5%, two patches to buttocks, to be applied in the morning and removed in the evening. PRN (as needed) pain medications: [REDACTED] -[MEDICATION NAME] 7.5 mg./[MEDICATION NAME] 325 mg. tablets ([MEDICATION NAME]), two tablets every 6 hours as needed for pain. -Tylenol tabs 325 mg.-give two tablets by mouth every 6 hours as needed for pain rating 1-5 or fever." -[MEDICATION NAME] 25 mg. every 12 hours as needed for pain. The following is a sample of Nurses' Notes after the MDS Assessment Reference Period ended 10/30/14: -11/1/14 11:01 a.m. Pain med given for pain (no further information). -11/3/14 9:03 a.m. Resident had period of right-sided weakness... Labs ordered. Elevated potassium detected. new order for [MEDICATION NAME] and X-rays of bilateral knees. -11/3/14 6:04 p.m. Resident moaning and crying. Stated her tailbone hurting. Resident repositioned. On 11/4/14, Resident #5 was lethargic and sent to the hospital until 11/11/14 for elevated ammonia levels in blood. On 11/6/14, a Permacath was inserted in Resident #5's chest for [MEDICAL TREATMENT]. Resident #5 to have a AVF (arteriovenous fistula) procedure at the hospital on [DATE]. Upon return from the hospital on [DATE], Resident #5's Physician order [REDACTED]. Another "Pain Observation" form was completed upon Resident #5's return from the hospital. Staff again completed part of the Cognitively Intact Pain Section (Section B) and part of the Cognitively Impaired Pain Section (Section C) when the instructions clearly state "choose EITHER (their emphasis) section B or C". Resident #5 is cognitively intact. The Pain Observation states Resident #5 has no pain based on the Wong-Baker Pain Scale/Face Response, breathing, body language and no need to console. Resident #5 did report occasional, intermittent pain, but staff did not select any descriptors (burning, stabbing, dull, tingling, aching, throbbing, etc.). The Pain Observation form asks "Does pain impact quality of life/functioning" and Resident #5 replied "Yes, it impacts sleeping, mood/emotions and limits activity." Resident #5's acceptable level of pain is 3 of 10. When asked what makes pain worse, staff left it blank. "PRN pain pills" reduce the pain. Anxiety is noted to be an additional symptom related to pain. In the section titled "Possible Conditions related to Pain" - staff left it all blank. Under "Pain Management" it is noted Resident #5 receives Tylenol and narcotics, scheduled and PRN medications, and current non-pharmacological interventions include PT/OT (physical and occupational therapy), and distraction. The Observation states "Satisfactory pain management/continue with current plan of care." The Nurses' Notes continue with most of the following notes corresponding with PRN medication administration: -11/13/14 5:14 p.m. Resident complained of pain 8/10 which radiates from back of neck, down back to coccyx and RLE (right lower extremity) post [MEDICAL TREATMENT]. Medication given.-11/14/14 7:36 p.m. Resident complained of pain 7/10 to right shoulder, back and bilateral knees. Medication given. -11/15/14 5:40 p.m. complaint of back pain 7/10. -11/16/14 complaint of back pain 7/10. -11/17/14 4:59 a.m. 9/10 generalized pain. -11/17/14 1:30 p.m. Back pain rated 8/10. Resident up in chair. Will be laying down in few minutes per her request... -11/17/14 2:59 p.m. Social Service Note- ...Resident eagerly participates in therapy... -11/19/14 1:42 p.m. Back and leg pain rated 8/10 post therapy... -11/20/14 5:25 p.m. Complained of pain 8/10 upon return from [MEDICAL TREATMENT] to BLE (bilateral lower extremities) and coccyx... -11/21/14 7:37 p.m. PRN pain medication given... -11/21/14 9:16 p.m. Resident tolerated LUE (left upper extremity) AVF procedure well. Area is still slightly swollen with light purple bruising around incision...New orders received for Tylenol #3 (with [MEDICATION NAME]) PRN ([MEDICATION NAME] 300 mg./[MEDICATION NAME] 30 mg.), 1 or 2 tablets every 4 hours as needed for post operative pain. -11/22/14 5:24 a.m. Complaint of left upper extremity pain 8/10. -11/22/14 Resident complained of pain 10/10 to coccyx upon returning from [MEDICAL TREATMENT]. Resident crying. -11/22/14 New order received for ice and elevation to LUE fistula site due to slight redness and pain... -11/22/14 9:07 p.m. Resident yelling out in pain yelling help. Other PRN medications given, ice packs and repositioning. -/11/23/14 9:52 a.m. Resident complained to pain to buttocks rating pain at 9/10... -11/23/14 3:00 p.m. Resident complaining of pain to right buttocks. Rates pain as 10/10. -11/24/14 back pain 8/10. -11/25/14 9:52 a.m. Leg and back pain 6/10... -11/25/14 9:45 p.m. Resident reported pain 8/10 to buttocks, left shoulder and lower back... Another Pain Observation was completed on 11/25/14, again scoring "0" for pain using section C for Cognitively Impaired (breathing, facial expression, body language, etc.)when Resident #5 is Cognitively intact. While it appears staff did not ask Resident #5 what her pain level was, it is documented that the pain radiates from bilateral buttocks to legs frequently to constantly; the pain is burning, dull, and aching; and it limits her activity. Resident #5 reported her acceptable level of pain if "1". Therapy makes pain worse and PRN Tylenol with [MEDICATION NAME] and PRN [MEDICATION NAME] make the pain better. "Possible conditions related to pain is again left blank. The conclusion is "Plan of Care-Satisfactory pain management/continue with current plan of care". (Even though Resident #5's pain interferes with her daily activities and is way above her goal of acceptable pain daily.) The Nurses' Notes continue: -11/26/14 Resident complained of pain rating 9/10 (doesn't state location); -11/17/14 1:53 p.m. Resident reported pain coccyx 6/10; -11/28/14 Reported coccyx pain 8/10. Resident put to bed. -11/29/14 Resident requested pain med (no further info). -12/1/14 5:00 a.m. 9/10 generalized pain; -12/6/14 8:05 a.m. Resident complained of pain to her tailbone, rating pain 8/10, turned and repositioned, pain patch applied. -12/9/14 5:00 p.m. Resident complained of pain 10/10 left hand from middle finger, index finger and thumb that shoots down wrist and is aggravated with wrist movement...(Nurse Practitioner examined Resident)... -12/12/14 9:26 p.m. Resident reported pain 10/10 to lower back... -12/13/14 4:36 a.m. 8/10 generalized pain. On 12/14/14 Resident #5 was sent to the hospital with low blood sugar, sluggish responses and has not returned to the facility. The above notes show Resident #5 was experiencing severe pain daily, often after returning from [MEDICAL TREATMENT] or therapy. Pain management is more effective if the pain is kept at a more manageable level of pain consistently, instead of allowing the pain to become severe (rating 6-10) and then trying to "catch up" with getting the pain under control. Surveyor # reviewed Resident #5's November and December MARs (Medication Administration Records). The November 2014 MAR indicated [REDACTED]. On the PM shift on 11/2/14 the rating is 7/10 and reported pain rating of 10/10 on 11/3/14. Resident #5 was out to the hospital 11/4/14 to 11/11/14. Upon returning, on 11 of the 19 PM shift through the end of November, Resident #5 reported pain levels of 7 to 10 on a scale of 0-10, indicating she had severe pain about two-thirds of the time on evening shift. Day shift only reported one pain level other than 0; the pain rating on 11/28/14 was rated "5". However, on the page of the MAR indicated [REDACTED]"0" pain ratings for the shift do not appear accurate. The same is true for night shift- the shift pain rating does not always correspond with the rating given prior to PRN administration. Night shift documented all "0"'s except for a 20 (?) on 11/21/14. But the page where the nurses sign out the [MEDICATION NAME] indicate pain ratings of some "9"'s and "10"'s on night shift when the [MEDICATION NAME] is given. The December, 2014 MAR indicated [REDACTED]"5;" again Resident #5 in significant pain about two thirds of the time in the evening. On 12/12/14, Resident #5 received new orders

Based on record review and staff interviews, the facility did not ensure that they provided the necessary care and services to attain or maintain the highest practicable physical well-being to 1 out 1 (Resident # 5) sampled residents who experienced a significant decline in bowel incontinence. Resident #5 experienced an avoidable significant decline in bowel continence when he went from being continent of bowel to frequently incontinent of bowel as noted on his Annual Minimum Data Set, dated dated [DATE]. Resident #5 was not comprehensively assessed and an individual plan of care was not developed to address the change bowel continence. According to the National Digestive Diseases Clearninghouse (NDDIC): Fecal incontinence, also called a bowel control problem, is the accidental passing of solid or liquid stool or mucus from the rectum. Fecal incontinence includes the inability to hold a bowel movement until reaching a toilet as well as passing stool into one's underwear without being aware of it happening. Stool, also called feces, is solid waste that is passed as a bowel movement and includes undigested food, bacteria, mucus, and dead cells. Mucus is a clear liquid that coats and protects tissues in the digestive system. Fecal incontinence can be upsetting and embarrassing. Many people with fecal incontinence feel ashamed and try to hide the problem. Findings include: Resident # 5 was originally admitted to the facility on [DATE]. Resident #5 had [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), dated [DATE], Resident #5 was always continent of bowel. Surveyor # conducted a review of the most recent full/annual MDS, with an assessment reference date of 8/16/14. The MDS states that Resident #5 has a BIMs (Brief Interview for Mental Status) score of 6- severely cognitively impaired. The MDS also states that Resident #5 needs extensive 1 person physical assist to use the toilet and transfer. The MDS also states that Resident #5 is frequently incontinent of bowel (2 or more episodes of bowel incontinence, but at least 1 continent bowel movement). According to the Care Area Assessment (CAA) for ADL (activities of daily living)Function/Rehabilitation Potential, dated 8/20/14, Resident #5 has been incontinent of bowel and bladder. He needs assistance with toileting and frequent reminders. The CAA states that Resident #5 has had a recent decline in ADLs/mobility and that he is alert to self, confused with time and place and needs cues. A review of Resident #5's most current, individual plan of care, does not indicate that Resident #5 is incontinent of bowel, nor does it list any interventions to help maintain/attain bowel continence. It was noted the plan of care states Resident #5 has functional urinary incontinence and to toilet every 2- 3 hours. On 9/16/14 at 11:10 a.m., Surveyor # interviewed Nurse Manager- E in regard to Resident #5's recent decline in bowel continence. RN Manager-E stated she was not aware if there were any changes and would provided Surveyor # with the bowel assessment and a copy of the caretracker information. RN- Manager- E stated that she rely's on the information provided by the CNA's (Certified Nursing Assistants) to complete assessments. On 9/16/14 at 11:20 a.m., Surveyor # interviewed Licensed Practical Nurse (LPN)-AA who works on the unit in which Resident #5 resides. LPN- AA stated that Resident #5's overall condition has declined over the past few months since he was readmitted from the hospital. LPN- AA stated that he came back on an antibiotic and was being monitored for loose stools. LPN- AA stated that the loose stools seem to be much less now, and Resident #5 has been incontinent of bowel now for awhile. He has become more dependent on staff. Surveyor # was provided with an assessment titled "bowel observation" dated 8/20/14 and signed by RN Manager- E. The bowel observation states that Resident #5 is continent of bowel. Surveyor # was also provided with a copy of the caretracker information which is data entered by the CNA staff, by shift. The care tracker information dated 8/1/14 to 8/20/14 states that Resident #5 was incontinent of bowel 15 times. It was noted that the assessment reference period used for the MDS is dated 8/16/14, Resident #5 was incontinent of bowel 10 times during that period. Additional caretracker information reviewed dated 8/19/14 to 9/18/14 which states that Resident #5 was incontinent of bowel 28 times during this time period. Resident #5 has physician orders [REDACTED]. Review of Resident #5's record indicates that this medication was held on 8/16/14, 8/17/14, and 8/31/14. On 9/17/14 at 10:00 a.m., Surveyor # spoke with MDS Coordinator- BB in regard to Resident #5's most recent annual MDS, dated [DATE]. MDS Coordinator- BB stated she uses the information from the caretracker as well as talks with staff when conducting the MDS assessment. MDS Coordinator-BB stated that she will also use information from the bowel and bladder patterning. MDS Coordinator- BB stated she was verbally made aware that there was no patterning available for her to review and she requested the patterning be completed. MDS Coordinator-BB was asked why Resident #5 did not have a plan of care to address the onset of bowel incontinence. MDS Coordinator-BB said that she works on the assessment and plan of care between herself and the nurse manager. On 9/16/14, Surveyor # asked administrative staff for a copy of their bowel management policy/protocol. At 1:00 p.m., Surveyor # was told by Administrator- A that the facility did not have a bowel policy/procedure that addressed the assessment/care planning of bowel incontinence, only a facility guideline for bowel management dealing with residents who have not experienced a bowel movement over a certain period of time. Surveyor # was also provided with a copy of the "Bowel and Bladder Patterning" for Resident #5, dated 8/11/14-8/14/14. It was noted that the patterning was not complete, nor did the patterning provide a summary of the potential patterns identified. On 9/17/14, Surveyor # was provided with a copy of a "bowel observation", dated 9/16/14 at 6:57 p.m. which stated that Resident #5 is occasionally incontinent of bowel and will be in a bowel maintenance program. It was noted that no additional updates the Resident #5's plan of care had been provided. As of the time of exit on 9/17/14, no information had been provided as to why a compressive assessment was not conducted of the significant decline in Resident #5's bowel incontinence. Resident #5 was noted to go from totally continent of bowel to frequently incontinent of bowel, and there was not an accurate patterning conducted, comprehensive assessment or an individual plan of care written to address Resident #5's bowel incontinence. On 9/22/14 the facility submitted additional information to review regarding Resident #5. This information included a summary of weights, skin condition and bowel and bladder patterning; including a summary of all the nursing progress notes showing how the facility tracks the Resident's bowel status. The additional information also included a care plan intervention dated 8/20/14 to toilet Resident #5 every 2-3 hours and a physician recertification indicating to not change the regime for Resident #5. Surveyor # noted that additional information still does not provide a comprehensive explanation why Resident #5 declined in their bowel continence status from an individual who was continent to frequently incontinent. The additional information, while it includes a care plan intervention dated 8/20/14, does not show that the Resident's care plan was modified to create a toileting intervention that was based upon an assessed pattern to specifically reestablish Resident #5's bowel continence status.

Based on observation, record review and interview, the Facility did not ensure that 10 (Resident #8, #7, #6, #19, #20, #12, #15, #5, #9, & #17) of 20 Residents at risk for the development of pressure ulcers, received consistent measures to prevent the development of pressure ulcers. Resident #6 initially developed an pressure ulcer on the left pinky finger on 5/19/14 related to severe contractures. On 6/3/14 the physician ordered a treatment to clean the pressure ulcer with soap & water, pat dry, apply [MEDICATION NAME]/Ag followed by gauze daily until healed. This treatment was not started until 6/23/14. The RN Wound Nurse's wound evaluation flow sheet indicates on 6/4/14 that the treatment was changed to a sponge dressing. There is no order to discontinue the treatment that was ordered on [DATE]. The June 2014 treatment record doesn't reveal any treatment was being completed from 6/3/14 to 6/22/14. On 6/15/14 the left pinky finger was tender to touch and slightly swollen with scant amount of bloody drainage noted there was no RN (Registered Nurse) assessment until 6/23/14. Resident #6's heels were observed not being floated. The example Regarding Resident #6 is identified as being deficient practice at a scope and severity (s/s) of a level 3 "G" (actual harm/isolated). The additional 9 examples are identified as being deficient practice at a severity level 2 (potential for harm). Resident #8 was observed not wearing Prevalon boots according to her plan of care on 9/10/14 and on 9/10/14, 9/11/14, & 9/16/14 was observed without the Duoderm dressing on the coccyx. Resident #7 who is at risk for pressure ulcer development did not have barrier cream applied during continence care on 9/10/14 and her heels were not floated. Resident #19's heels were not floated and is at risk for pressure ulcer development. Resident #20's heels were not floated and is at risk for pressure ulcer development. Resident #12's heels were not floated and is at risk for pressure ulcer development. Resident #15's heels were not floated and is at risk for pressure ulcer development. Resident #5 was observed without a pressure relieving cushion in the wheelchair and is at risk for pressure ulcer development. Resident #9's heels were not floated and is at risk for pressure ulcer development. Resident #17's heels were not floated and is at risk for pressure ulcer development. Findings include: The Skin Management Program not dated documents under the section responsibility documents "2. It is the responsibility of the Charge nurse to ensure that interventions are conducted as per the resident's plan of care." "3. It is the responsibility of the CNA (Certified Nursing Assistant) to ensure that the residents identified receive the appropriate interventions per the resident's individual plan of care." Under procedure #4 documents "Interventions for the prevention of pressure ulcers will be individualized to meet the specific needs of the resident. interventions to be implemented can include, but are not limited to: a. Weekly skin checks b. Support surfaces for wheelchair and beds c. Positioning d. Exercise program e. Nutritional support f. PROM (passive range of motion)/AROM (active range of motion) g Therapy to enhance mobility h. Bathing schedule i. Skin care j. Incontinence care k. Pressure, friction, shear reduction l. Mechanical lift for transfer m. Heel lift needs." 1.) Surveyor # reviewed Resident #6's medical record on 9/10/14 to 9/16/14. Resident #6 has [DIAGNOSES REDACTED]. Resident #6 was placed on hospice on 7/26/2013 and her power of attorney was activated on 1/29/2010. The nurse's note dated 5/19/14 documents "Resident noted to have pressure area to side of left pinky finger, 2.0 cm (centimeters) x (times) 1.0 cm some clear drainage noted and base is pink with slightly red surrounding tissue. Resident does have contractures to fingers and left hand, resident also appears to be having some discomfort to area. Resident given prn (as needed) pain med. (medication)." The nurse's note dated 5/20/14 documents "Situation: Called by floor nurse to view pressure sore on left hand on inside of pink finger. Background: Diabetes, dementia,[MEDICAL CONDITION](hypertension). Assessment: Open area to inside of pinky finger on left hand. Stage III, measures 2 cm x 2cm, yellow slough, no drainage. Skin surrounding area is red. Painful to touch. Response: Message left to update NP (Nurse Practitioner)-JJ. treatment for [REDACTED]." Surveyor # reviewed the May 2014 TAR (treatment administration record) and noted this treatment was completed on the day shift on 5/21/14 and then discontinued. The skin/wound note dated 5/21/14 documents "resident has stage 4 open area to the inside of left pinky. area measures 1.0 x 1.5 x 0.1 cm scant amount of drainage noted to old dressing, redness is noted to surrounding skin. residents hand is contracted and resident showed signs of pain during assessment. Placed gauze between finger to keep from rubbing together." The telephone order dated 5/21/14 documents "Discontinue treatment to pinky finger, place gauze between fingers to help fingers from rubbing." Surveyor # reviewed the May 2014 TAR (treatment administration record) and noted gauze was placed daily on 5/22/14 to 5/31/14. The June 2014 TAR reveals that gauze was placed daily on 6/1/14 & 6/2/14 and was then discontinued on 6/3/14. The nurse's note dated 5/24/14 documents "O/A (open area) remains on lt. (left) pinky finger drsg (dressing) changed per this shift, yellow drainage noted on bandage foul odor noted." The physician telephone order dated 6/3/14 documents "Start treatment to (L) (left) hand pinky finger cleanse w/ (with) H2O (water) & soap pat dry apply [MEDICATION NAME]/Ag f/b (followed by) gauze daily until healed." Review of the June TAR reveals that there was no treatment for [REDACTED]. The treatment of [REDACTED]. The skin/wound note dated 6/4/14 documents "Resident has stage 4 open area to the inside of left pinky. area measures 1.0 x 1.5 x 0.1 cm scant amount of drainage noted to old dressing, redness is noted to surround skin. Residents hand is contracted and resident showed signs of pain during assessment. Placed sponge between finger to keep from rubbing together. Abrasion to right lower glut area is healed." The wound evaluation flow sheet dated 6/4/14 documents under current treatment "changed to sponge dressing". There is no physician order for [REDACTED]. The nurses note's dated 6/5/14, 6/6/14, 6/7/14, 6/8/14, 6/9/14, 6/10/14, 6/11/14, & 6/12/14 document that the left pinky finger dressing is dry and intact. There is no documentation that a treatment was completed. The skin/wound note dated 6/13/14 documents "Resident has stage 4 open area to the inside of left pinky. area measures 1.0 x 1.5 x 0.1 cm scant amount of drainage noted to old dressing, a scab is beginning to form to area. residents hand is contracted and resident showed signs of pain during assessment. 3 steristrips were applied to keep area closed. Gauze is placed between fingers to keep from rubbing together." The nurse's note dated 6/15/14 documents "Tx (treatment) performed to (L) pinky finger. Area tender to touch and slightly swollen. Scant amount of bloody drainage noted. Medicated with scheduled [MEDICATION NAME]. Charge nurse informed. Will continue to monitor." The nurse's note dated 6/15/14 documents "Wound nurse notified of slight swelling and will assess." The nurse's note dated 6/18/14 documents "Resident has foul smelling drainage noted, resident has swelling and lots of drainage coming from left pinky finger dressing change and resident given schedule pain pill." The nurse's note dated 6/19/14 documents "Resident left pinky finger remains swollen and drainage continues, resident dressing clean dry and intact. resident given schedule pain med." The nurse's note dated 6/21/14 documents "Dressing to L (left) pinky saturated with yellowish-brownish serosanguinous drainage. Some pus present. Pink swollen and tender during dressing change. Hand slightly warmer than other hand. T (temperature): 98.9." The nurse's note dated 6/22/14 documents "Resident left pinky finger remains swollen and foul smelling drainage noted, resident given prn (as needed) pain med for general discomfort and staff continue to monitor." The nurse's note dated 6/22/14 documents "L pinky still swollen. Sanguineous drainage noted. Culture taken. Tx. (treatment) performed. Patient yelled out during dressing change. Patient was pre-medicated with pain medicine before dressing change." The nurse's note dated 6/22/14 documents "Writer changed bandage noted bloody drainage on dressing. Cleaned pinky with n/s (normal saline) and applied prescribed cream f/b (followed by) clean dressing. Resident was very uncomfortable during procedure. Resident had been previously medicated." The skin/wound note dated 6/23/14 documents "open area to left pink measures 3.0 x 1.0 serosanguinous drainage noted to old dressing, red wound bed, with yellowish green pus noted at 9 o ' clock. new treatment orders were received yesterday. will continue to monitor. received verbal orders from hospice that wound doctor can see resident when doctor comes in next week." The skin/wound note dated 6/26/14 documents "open area to left pinky - serosanguinous drainage noted to old dressing, red wound bed, with yellowish green pus noted at 9 o'clock. resident was started on ABT (antibiotic) for infection. will continue to monitor. Hospice nurse was present during dressing change." The skin/wound note dated 6/30/14 documents "dressing to finger changed, hospice nurse present, bloody drainage noted to old dressing. no odor. finger still swollen. resident verbal during treatment. will continue to monitor." The annual MDS (minimum data set) with an assessment reference date of 7/8/14 documents that Resident #6 has short and long term memory problems, is severely impaired for cognitive skills for daily decision making, rarely makes self understood and rarely understands others. Resident #6 does not ambulate, is dependent upon staff for her ADL's (activities of daily living), and is always incontinent of bowel & bladder. Resident #6 is at risk for developing pressure ulcers and during this assessment had a Stage 4 pressure ulcer. The pressure ulcer CAA (care area assessment) dated 7/11/14 documents under analysis of findings "Patient has a stage four pressure ulcer on her finger; goal is for pts (patient) pressure ulcer to heal without complications by next review date; pt is being seen by the wound nurse and treatments are being done as ordered by nurses; pt is at risk for further breakdown r/t (related to) her incontinence and requiring total dependency for ADLs and mobility; staff to provide thorough incontinence care and pressure relief; will address in care plan." The skin/wound note dated 7/9/14 documents "open area to left pinky measures 2.0 x 1.0 scab has formed to area. some yelling during assessment. treatment continues will continue to monitor." The nurse's note dated 7/15/14 documents "resident left pinky finger has pink scar tissue, finger continues to have swelling and is contracted. resident does not appear to be having any discomfort and does take scheduled pain medication." Treatment to Resident #6's left pink pressure ulcer was discontinued on 8/4/14 as the area had healed. Resident #6's Heels: The quarterly MDS with an assessment reference date of 9/3/14 documents Resident #6 has short and long term memory problems, is severely impaired for cognitive skills for daily decision making, rarely makes self understood and rarely understands others. Resident #6 does not ambulate, is dependent upon staff for her ADL's, and is always incontinent of bowel & bladder. Resident #6 is at risk for developing pressure ulcers and during this assessment does not have a pressure ulcer. The CNA (Certified Nursing Assistant) Report Sheets dated 9/10/14 for Resident #6 documents under the miscellaneous section "Encourage to float heels." On 9/11/14 at 12:57 p.m. Surveyor # observed CNA-G wheel Resident #6 into her room. CNA-G and CNA-I washed their hands and placed gloves on. Resident #6 was transferred from the Broda chair into bed via mechanical lift. CNA-I removed Resident #6's pants and shoes. CNA-I unfastened Resident #6's incontinence product and Surveyor # observed there was BM (bowel movement) up Resident #6's frontal perineal area. CNA-I informed Resident #6 that she was going to clean her up and washed Resident #6's lower abdomen to remove the BM. CNA-I placed soiled towels in bag, removed her gloves, & placed new gloves on. CNA-G and CNA-I positioned Resident #6 on her side, CNA-G removed the soiled incontinence product and washed Resident #6's rectal area & buttocks. CNA-I placed a product under Resident #6 and then applied A & D ointment to the buttock. CNA-I and CNA-G fastened the incontinence product and changed the sheets on Resident #6's bed. Resident #6 was positioned on her back, covered with a blanket, and the call light was clipped to the bedding. CNA-I and CNA-G did not float Resident #6's heels. On 9/11/14 at 3:52 p.m. Surveyor # observed that Resident #6 continues to be in bed on her back. Resident #6's heels are not floating and are resting directly on the mattress. On 9/15/14 at 2:15 p.m. Surveyor # observed Resident #6 in bed on her back. Resident #6's heels are not floating and are resting directly on the mattress. On 9/16/14 at 8:45 a.m. Surveyor # asked RN (Registered Nurse) Manager-E on 6/15/14 when she wrote the note that the wound nurse was notified of slight swelling and will assess, did she assess Resident #6's pressure ulcer. RN Manager-E replied, "No." Surveyor # asked RN Manager-E why she didn't assess the area. RN Manager-E informed Surveyor # that she was the charge nurse for the building, it was a very busy day and so she just notified the wound nurse. On 9/16/14 at 12:55 p.m. Surveyor # asked RN Wound Nurse-H why she didn't assess Resident #6's pressure ulcer until 6/23/14 when there was a note on 6/15/14 written by RN Manager-E notifying her of a change in the pressure ulcer. RN Wound Nurse-H informed Surveyor # that she can't say for sure that she was updated. Surveyor # asked RN Wound Nurse-H should staff inform her when there is a change. RN Wound Nurse-H replied, "Yes they should." Surveyor # asked RN Wound Nurse-H what were the treatments for the pressure ulcer. RN Wound Nurse-H informed Surveyor # that a nurse contacted the doctor and had an order for [REDACTED]. On 9/16/14 at 1:33 p.m. Surveyor # asked LPN (Licensed Practical Nurse)-F if she ever did the treatment for [REDACTED]. LPN-F informed Surveyor # that RN Wound Nurse-H did the treatment and that she never did. Surveyor # asked if a treatment was scheduled for the day shift would RN Wound Nurse-H do the treatments. LPN-F replied, "Yes." On 9/16/14 at 1:57 p.m. Surveyor # informed RN Manager-E of the observations of Resident #6's heels not being floated. Surveyor # asked RN Manager-E who would have done the treatment for [REDACTED]. RN Manager-E informed Surveyor # that the nurses on the floor do the treatment for [REDACTED]. On 9/16/14 at 2:42 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. On 9/17/14 at 9:18 a.m. Surveyor # asked RN Wound Nurse-H if she had any information regarding Resident #6's treatments. RN Wound Nurse-H informed Surveyor # that she had been speaking to the nurses and when she has gathered everything she will get back to Surveyor # . Surveyor # asked RN Wound Nurse-H if she did Resident #6's treatment daily. RN Wound Nurse-H replied, "No, just once a week." On 9/17/14 at approximately 1:00 p.m. RN Wound Nurse-H provided Surveyor # with four staff statements regarding Resident #6's June treatments. Two of the statements provided indicate that they didn't remember what the treatment was, one indicated that it was wrapped up with gauze, and the fourth from RN-KK indicated normal saline, sponge, wrapped with gauze. On 9/17/14 at 1:34 p.m. Surveyor # spoke with RN-KK via the telephone. Surveyor # asked RN-KK if she ever did a treatment for [REDACTED]. RN-KK informed Surveyor # that she did and the treatment was normal saline and wrap with gauze. Surveyor # asked if it was dry gauze. RN-KK replied, "Yes." Surveyor # asked RN-KK if she ever did a treatment with sponge dressing. RN-KK replied, "No." 2.) Surveyor # reviewed Resident #8's medical record on 9/11/14 to 9/16/14. Resident #8 has a [DIAGNOSES REDACTED]. The potential for alteration in skin integrity dated 11/18/13 includes an intervention dated 6/23/12 "pressure reducing Prevalon boots @ (at) all times may remove for cares and skin assessments." The quarterly MDS (minimum data set) with an assessment reference date of 7/15/14 documents that Resident #8 has short and long term memory problems is severely impaired for cognitive skills for daily decision making. Resident #8 is dependent upon staff for her ADL's (activities of daily living), and is always incontinent of bowel and bladder. Resident #8 is checked as at risk for pressure ulcers and has a pressure ulcer, one Stage 3. This pressure ulcer healed on 8/2/14. The Braden scale for predicting pressure sore risk dated 8/4/14 has a total score of "11" which indicates high risk. The telephone order dated 8/5/14 documents "(1) Discontinue treatment to coccyx area healed. (2) Place Duoderm to coccyx q (every) 3 days for protection." The monthly physician orders signed on 9/13/14 document "Place Duoderm to coccyx q (every) 3 days for protection in the morning every 3 day(s)" and "Prevalon boots to bilateral lower extremities." On 9/10/14 at 12:21 p.m. Surveyor # observed Resident #8 on her back with a pillow between her knees. Surveyor # observed that Resident #8 was not wearing Prevalon boots and her heels were resting directly on the mattress. On 9/10/14 at 12:33 p.m. Surveyor # observed RA (Restorative Aide)-EE and CNA (Certified Nursing Assistant)-DD reposition Resident #8 onto her right side. Surveyor # observed that Resident #8's heels were resting directly on the mattress and she was not wearing Prevalon boots. On 9/10/14 at 1:32 p.m. Surveyor # observed Resident #8 continues to be on her right side and is not wearing Prevalon boots. On 9/10/14 at 2:21 p.m. Surveyor # observed CNA-DD and CNA-FF reposition Resident #8 onto her left side. Surveyor # observed that Resident #8 was not wearing Prevalon boots according to her plan of care. On 9/10/14 at 2:53 p.m. Surveyor # observed continence cares for Resident #8 with CNA-GG and CNA-HH. CNA-GG and CNA-HH washed their hands and placed gloves on. CNA-GG filled a wash basin and removed the pillow from between Resident #8's knees. Surveyor # observed that Resident #8 was not wearing Prevalon boots. CNA-GG and CNA-HH unfastened Resident #8's incontinence product and washed Resident #8's frontal perineal area. CNA-GG and CNA-HH positioned Resident #8 on her side and CNA-HH washed Resident #8's rectal area and buttocks to remove the BM (bowel movement). CNA-HH removed the soiled incontinence product, rewashed Resident #8's buttocks, placed an incontinence product under Resident #8, removed her gloves and washed her hands. CNA-HH placed A & D ointment on Resident #8's buttocks and CNA-GG & CNA-HH fastened the incontinence product. Surveyor # did not observe a Duoderm dressing on the coccyx nor was there a dressing in the incontinence product. CNA-GG & CNA-HH removed their gloves ,washed their hands, and placed gloves on. CNA-GG & CNA-HH repositioned Resident #8 from side to side to place a draw sheet under Resident #8. Resident #8 was positioned on her right side. CNA-GG placed a pillow under Resident #8's right foot and between her knees. Resident #8 was covered with bedding, the head of the bed was raised, the call light placed within reach and the bed was placed in the lowest position. CNA-GG & CNA-HH removed their gloves and washed their hands. Surveyor # observed that CNA-GG and CNA-HH did not place Prevalon boots on Resident #8. On 9/11/14 at 10:10 a.m. Surveyor # observed continence cares for Resident #8 with CNA-DD & RA-EE. RA-EE cleansed her hands and placed gloves on. CNA-DD washed her hands, placed gloves on and informed Resident #8 that she was going to put her head down, change, and turn her. RA-EE removed the pillow from between Resident #8's knees and staff unfastened the incontinence product. CNA-DD washed Resident #8's frontal perineal area and Resident #8 was positioned on her right side. CNA-DD washed Resident #8's buttocks, removed the incontinence product, and placed an incontinence product under Resident #8. Surveyor # did not observe a Duoderm dressing on Resident #8's coccyx nor was there a dressing in the incontinence product. Surveyor # observed that Resident #8 was wearing Prevalon boots. CNA-DD removed her gloves, washed her hands, and placed gloves on. The incontinence product was fastened and Resident #8 was positioned on her right side with a pillow under her back on the left side and between her knees. Resident #8 was covered with bedding, the head of the bed was raised and the height of the bed was lowered. CNA-DD and RA-EE removed their gloves and washed their hands. On 9/15/14 at 7:26 a.m. Surveyor # observed Resident #8 on her left side in bed. Surveyor # did not observe Prevalon boots on Resident #8 and noted that there was a pair of boots next to the TV and another pair of boots on top of Resident #8's knee splints. On 9/15/14 at 8:40 a.m. Surveyor # observed Resident #8 in bed wearing Prevalon boots. On 9/16/14 at 12:19 p.m. Surveyor # observed CNA-DD and RA-EE transfer Resident #8 from the Broda chair into bed using a mechanical lift. After transferring Resident #8 into bed, CNA-DD removed her gloves & washed her hands and RA-EE removed her gloves and cleansed her hands. Staff re-gloved and lowered Resident #8's pants. CNA-DD unfastened Resident #8's incontinence product and washed her frontal perineal area. Resident #8 was positioned on her right side and CNA-DD washed Resident #8's buttocks. Surveyor # did not observe a Duoderm dressing on Resident #8's coccyx nor was the dressing in the incontinence product. Surveyor # asked CNA-DD if Resident #8 ever had a pressure ulcer. CNA-DD showed Surveyor # where Resident #8 had a pressure ulcer stating that Resident #8 had one on her tailbone but it was healed. Surveyor # asked CNA-DD if Resident #8 has a dressing on that area now. CNA-DD replied, "No." Staff placed an incontinence product under Resident #8, fastened the incontinence product and pulled up Resident #8's pants. Resident #8 was positioned on her right side, with a pillow under her back on the left side and between her knees. Resident #8 was covered with bedding, the call light was placed within reach, and the bed was lowered down. CNA-DD and RA-EE removed their gloves and washed their hands. On 9/16/14 at 1:42 p.m. Surveyor # asked RN (Registered Nurse) Manager-E if Resident #8 should be wearing Prevalon boots when she is in bed. RN Manager-E replied, "At all times, yes." Surveyor # informed RN Manager-E of the observations of Resident #8 not wearing Prevalon boots. Surveyor # informed RN Manager-E that Surveyor # had noted on the physician orders that Resident #8 should have a Duoderm dressing on her coccyx. Surveyor # informed RN Manager-E during continence cares for Resident #8 Surveyor # did not observe the dressing on 9/10/14, 9/11/14, and today. On 9/16/14 at 2:42 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. No additional information was provided to Surveyor # . 3.) Surveyor # reviewed Resident #7's medical record on 9/10/14 to 9/16/14. Resident #7 has a [DIAGNOSES REDACTED]. The at risk for pressure ulcers care plan dated 1/23/12 includes an intervention also dated 1/23/12 of "provide thorough skin care after incontinent episodes and apply barrier cream." The quarterly MDS (minimum data set) with an assessment reference date of 7/10/14 documents that Resident #7 has short and long term memory problems is severely impaired for cognitive skills for daily decision making. Resident #7 is dependent upon staff for her ADL's (activities of daily living), and is always incontinent of bowel and bladder. Resident #7 is checked as at risk for pressure ulcers and currently does not have a pressure ulcer. The CNA (Certified Nursing Assistant) Report Sheet dated 9/10/14 under the miscellaneous section documents "Encourage to float heels, check & change q (every) 2-3 hrs (hours), pull up, barrier cream to buttocks every shift." On 9/10/14 at 1:13 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-II inform Resident #7 she was going to lay her down for a nap. CNA-II placed the sit to stand lift in front of the wheelchair, placed the sling around Resident #7 and hooked the sling to the lift. CNA-II asked Resident #7 if she was ready and transferred Resident #7 into bed. CNA-II filled a wash basin and removed Resident #7's shoes. Surveyor # observed that Resident #7 was not wearing any socks. CNA-II positioned Resident #7 from side to side to lower her pants and then unfastened the incontinence product. Surveyor # observed urine in the product. CNA-II washed Resident #7's frontal perineal area, positioned Resident #7 on her side and washed Resident #7's buttocks. CNA-II placed a product under Resident #7 and fastened the product. Surveyor # did not observe CNA-II place any barrier cream on Resident #7's buttocks. CNA-II pulled up Resident #7's pants, Resident #7 was positioned on her back, and CNA-II covered Resident #7 with a sheet. CNA-II placed the call light within reach, lowered the bed, removed her gloves and washed her hands. Surveyor # observed that CNA-II did not ask Resident #7 about floating her heels nor did she float Resident #7's heels. On 9/10/13 at 2:20 p.m. Surveyor # observed that Resident #7 continues to be in bed on her back. Surveyor # observed that Resident #7's heels are not being floated and are resting directly on the mattress. On 9/11/14 at 7:22 a.m. Surveyor # observed Resident #7 asleep in bed on her back. Surveyor # observed that Resident #7's heels are not being floated and are resting directly on the mattress. On 9/11/14 at 12:39 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-G and CNA-I wash their hands, place gloves on, place a sling around Resident #7 and hook the sling to the sit to stand lift. Resident #7 was raised up off the wheelchair, CNA-I lowered Resident #7's pants and Resident #7 was transferred into bed. CNA-G and CNA-I removed the sling & CNA-G removed Resident #7's shoes. Surveyor # observed that Resident #7 was not wearing socks. CNA-I filled a wash basin, unfastened Resident #7's incontinence product stating "time to go to bed now." CNA-I washed Resident #7's frontal perineal area and staff positioned Resident #7 on her left side. CNA-G wiped the BM (bowel movement) with the product while CNA-I held onto Resident #7's leg. CNA-G washed Resident #7's rectal area and buttocks, dried the area, and removed the soiled incontinence product. CNA-G placed an incontinence product under Resident #7 and applied A & D ointment on the buttocks. CNA-G and CNA-I positioned Resident #7 on her back and CNA-G placed A & D ointment under the abdominal fold. CNA-G and CNA-I fastened the incontinence product, and Resident #7's pants were pulled up. CNA-G and CNA-I positioned Resident #7 in the middle of the bed. CNA-G covered Resident #7 with bedding, clipped the call light to the bedding, and lowered the bed down. CNA-G and CNA-I removed their gloves and washed their hands. Surveyor # observed that CNA-G or CNA-I did not ask Resident #7 about floating her heels nor did staff float Resident #7's heels. On 9/15/14 at 1:01 p.m. Surveyor # observed Resident #7 in bed on her back. Surveyor # observed that Resident #7's heels are not being floated and are resting directly on the mattress. On 9/15/14 at 2:13 p.m. Surveyor # observed Resident #7 in bed on her back. Surveyor # observed that Resident #7's heels are not being floated and are resting directly on the mattress. On 9/15/14 at 3:37 p.m. Surveyor # observed Resident #7 in bed on her back. Surveyor # observed that Resident #7's heels are not being floated and are resting directly on the mattress. On 9/16/14 at 1:35 p.m. Surveyor # observed Resident #7 in bed on her back. Surveyor # observed that Resident #7's heels are not being floated and are resting directly on the mattress. On 9/16/14 at 1:45 p.m. Surveyor # informed RN (Registered Nurse) Manager-E of the observations of Resident #7 not having her heels floated. RN Manager-E informed Surveyor # that not every one has an order to float heels. Surveyor # informed RN Manager-E that the CNA report sheets indicates that On 9/16/14 at 2:42 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. 4.) Surveyor # reviewed Resident #19's medical record on 9/16/14. The annual MDS (minimum data set) signed as completed on 6/16/14 documents a BIMS (brief interview mental status) total score of "1"which indicates severe impairment, does not ambulate, and requires total dependence with one staff physical assist for bed mobility. Resident #19 does not currently have any pressure ulcer and is checked "Yes" for the question "Is this resident at risk of developing pressure ulcers?" The CNA (Certified Nursing Assistant) Report Sheets dated 9/10/2014 documents under the section Misc. (miscellaneous) "Encourage to float heels." On 9/15/14 at 1:06 p.m. Surveyor # observed Resident #19 in bed on her right side. Surveyor # observed that Resident #19's heels were not floated. On 9/15/14 at 1:56 p.m. Surveyor # observed Resident #19 continues to be in bed on her right side. Surveyor # observed that Resident #19's heels were not floated. On 9/15/14 at 3:48 p.m. Surveyor # observed Resident #19 continues to be in bed on her right side. Surveyor # observed that Resident #19's heels were not floated. On 9/16/14 at 12:39 p.m. Surveyor # observed Resident #19 in bed on her back with her heels resting directly on the mattress. On 9/16/14 at 1:31 p.m. Surveyor # observed Resident #19 continues to be in bed on her back with her heels resting directly on the mattress. On 9/16/14 at 2:05 p.m. Surveyor # informed RN (Registered Nurse) Manager-E of the observations of Resident #19's heels not being floated according to her plan of care. On 9/16/14 at 2:42 p.m. during the daily exit conference Surveyor # informed the Administrator and Director of Nursing of the observations of Resident #19's heels not being floated. 5.) Surveyor # reviewed Resident #20's medical record on 9/15/14 & 9/16/14. The quarterly MDS (minimum data set) signed as completed on 7/3/14 documents that Resident #20 has short and long term memory problems, is severely impaired for cogniti

Based on observation, interviews and record reviews the facility did not assess 1 of 6 Residents (#5) reviewed with a Foley catheter to justify the use of the catheter. The facility did not assess and develop individualized care plans to assure appropriate treatments for 3 of 14 Residents (#13, #4 and #22) reviewed who were incontinent of urine. 1. Resident #13 was admitted to the facility on [DATE]. The facility initiated a care plan on 1/25/11 related to Resident #13 bladder incontinence. The care plan was not based on a comprehensive assessment as the facility did not complete the bladder assessment until 3/31/11. The 6/15/11 quarterly MDS (Minimum Data Set) for Resident #13 showed a decline in bladder status. The facility did not assess Resident #13's bladder status or update the care plan after this decline. 2) Resident #4 was admitted to the facility on [DATE]. The facility did not complete Resident #4's comprehensive bladder assessments until 7/7/11. Resident #4 did not have an individualized care plan related to bladder incontinence. 3) Resident #5 was admitted to the facility on [DATE] with a Foley catheter. The facility did not assess the justification for use of the Foley catheter. Resident #5 did not have an individualized care plan related to bladder function 4) The facility did not complete a bladder assessment for Resident #22. Resident #22 did not have an individualized care plan related to urinary incontinence. Findings Include: Cross Reference F272 and F279 1) On 7/6/11 at 11:45 AM Resident #13 told Surveyor # that she needs staff to assist with toileting. Resident #13 indicated that staff are usually good about helping with toileting when asked. Resident #13 stated that she can't always make it to the bathroom in time and has been more incontinent lately. On 7/6/11 at 1:30 PM Surveyor # observed staff assisting Resident #13 to the bathroom. On 7/7/11 at 1:30 PM Surveyor # observed staff assisting Resident #13 to the bathroom. On 7/6-7/8/11 Surveyor # reviewed Resident #13 medical record that revealed the following: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13's admission MDS dated [DATE] indicated that she was occasionally incontinent of bladder. A comprehensive assessment of Resident #13's bladder status was not completed. The facility initiated a care plan dated 1/25/11 related to Alteration in elimination of bladder, Resident is occasionally incontinent of bladder The goals include: I will improve my current level of continence. Interventions include: -check and change -encourage fluids -Evaluate timing of medications which may cause increased urination -Evaluate frequency/timing of incontinence episodes -Monitor and report changes in ability to toilet or continence status The facility did not begin the 3 day incontinence tracking form used to complete a comprehensive bladder until 2/2/11. The bladder assessment form which is partially based on the 3 day tracking forms was not completed until 3/31/11. The assessment indicates that Resident #13 has [DIAGNOSES REDACTED]. Resident #13 reported stress incontinence with movement, coughing and laughing and unable to hold urine. Resident #13 indicated that urine leaks on the way to the bathroom and is able to control bladder at times. The assessment indicates that Resident #13 us able to make toileting needs known and is receiving rehab to improve strength/endurance. Upon completion of the assessment Resident #13's physician ordered [MEDICATION NAME] LA which is used for overactive bladder in patients with symptoms of urinary frequency, urgency or urge incontinence-taken from the Nursing 2011 Drug Manual published by Wolters Kluwer/Lippincott page 986-987. The care plan was then updated to include for staff to offer toileting every 2-3 hours and as needed, rehab and [MEDICATION NAME] as ordered. No individualized approaches were added to the plan of care. The facility completed a quarterly MDS on 6/15/11 which indicated that Resident #13 had a decline and was now frequently incontinent bladder. The facility did not do any further assessment of Resident #13's bladder decline to identify what may have contributed to the decline and update the care plan based on the findings to attempt to restore/maintain as much bladder function as possible. On 7/8/11 at 3:00 PM Surveyor # informed Nursing Home Administrator A and DON(Director of Nursing) B of the above findings. On 7/11/11 at 9:30 AM DON B provided Surveyor # a copy of the bladder assessment forms. These forms include areas that need to be assessed, indication of the type of incontinence and and area to summarize the findings and program placement decisions (development of an individualized care plan). DON B told surveyor # that the bladder assessments should be completed on admission, annually, with significant change in condition or removal of a Foley Catheter and care plans updated accordingly. No additional information was provided. 2.) On 7/6/11, 7/7/11, & 7/8/11 Surveyor # reviewed Resident #4's medical record. Resident #4 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CNA (Certified Nursing Assistant) Assignment family group 1 1A front not dated and provided by the Director of Nursing on 7/6/11 at 9:05 a.m. documents for Resident #4 under toilet "offer bed pan, check & change q (every) 3-4 hrs (hours)." The admission MDS (minimum data set) signed as being completed on 5/30/11 documents Resident #4 has short and long term memory problems. Is always incontinent of bladder and requires extensive assistance with one person physical assist. The alteration in elimination of bowel and bladder care plan initiated 6/3/11 has interventions with the same date of "Bowel medication as ordered. Monitor use and effectiveness; Call bell within and reminders to use call bell as needed; Check and change; Encourage fluids; Encourage foods high in fiber; Evaluate frequency/timing of incontinence episodes; Labs as ordered; Monitor and report changes in ability to toilet or continence status; Provide easy access to clothing; Rehab services per physician order; Scheduled toileting plan of staff to offer toileting to resident q (every) 2-3 hrs. (hours) and prn (as needed). assist to toilet using bed pan; and Use of briefs/pads for incontinence protection." On 7/6/11 at 12:30 p.m. Surveyor # observed CNA-D and CNA-I transfer Resident #4 from her wheelchair into bed using a sit to stand mechanical lift. CNA-D informed Resident #4 that she was going to check her incontinence product, lowered Resident #4's slacks, positioned Resident #4 on her left side, and checked the product stating "ok your good." On 7/7/11 at 9:04 a.m. Surveyor # observed CNA-D check Resident #4 who had received a suppository earlier to see if Resident #4 had moved her bowels. CNA-D unfastened Resident #4's incontinence product. Surveyor # observed Resident #4 had large bowel movement and urine was also observed in the incontinence product. During Resident #4's medical record review Surveyor # was unable to locate a bladder assessment since Resident #4 was admitted on [DATE]. On 7/7/11 at 12:44 p.m. Surveyor # met with ADON (Assistant Director of Nursing)-F and RN (Register Nurse)-E and informed them that Surveyor # was unable to locate a bladder assessment for Resident #4. Surveyor # was informed that ADON-F would look for the assessment. On 7/7/11 at 2:19 p.m. ADON-F showed Surveyor # a bladder assessment for Resident #4 dated 7/7/11. Surveyor # requested a copy of the bladder assessment. On 7/7/11 at 3:08 p.m. during the daily exit conference Surveyor # requested Resident #4's bladder assessment. On 7/8/11 at 7:20 a.m. Surveyor # was provided a copy of Resident #4's bladder assessment dated [DATE]. Along with the bladder assessment Surveyor # noted a three day incontinence tracking diary dated 6/22/11, 6/23/11, and 6/24/11. Surveyor # noted the diary indicated there were periods when Resident #4 was not incontinent of urine. On 7/8/11 at 3:11 p.m. the Administrator and Director of Nursing were informed of the above. 3.) On 7/7/11 and 7/8/11 Surveyor # reviewed Resident #5's medical record. Resident #5 is an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CNA (Certified Nursing Assistant) assignment sheet family group 1A front not dated and provided to Surveyor # by the Director of Nursing on 7/6/11 at 9:05 a.m. under the section toilet documents "Foley, check & chg. (change) q (every) 2-3 hrs. (hours)." The clinical health status dated 4/1/11 documents that Resident #5 was admitted with a Stage 2 pressure ulcer on her right and left buttocks, Stage 2 pressure ulcer on her right heel and an unstageable pressure ulcer on her left heel. Under the section urinary incontinence "yes" is checked for indwelling catheter. The admission MDS (minimum data set) signed as complete on 4/14/11 is checked "yes" for indwelling catheter. "No" is checked for [MEDICAL CONDITION] bladder and [MEDICAL CONDITION]. The alteration in elimination of bowel and bladder care plan initiated 4/18/11 documents interventions dated 4/18/11 of "Anchor catheter, avoid excessive tugging on the catheter during transfer and delivery of care; Bowel medication as ordered. Monitor use and effectiveness; Call bell within and reminders to use call bell as needed; Change catheter bag per order; Change Foley catheter per order; Check catheter tubing for proper drainage and positioning; Encourage fluids; Encourage foods high in fiber; Indwelling catheter care every shift and as needed; Monitor and report changes in ability to toilet or continence status; Monitor and report S & S (signs and symptoms) of UTI (urinary tract infection): changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain; Monitor bowel status frequency; and Use of briefs/pads for incontinence protection." physician progress notes [REDACTED]. The nurses note dated 6/29/11 documents "Wound charting (R) (right) + (L) (left) butt area 100% pink scar tissue, No drainage or odor noted. Surrounding warm dry and intact. Denies any pain or discomfort at this time. Has APP mattress in bed and uses a broda chair when up repositioned q 2 hrs (hours) (L) side to back to (R) side by staff has a Foley cath (catheter) for wound healing and prevention R/T (related to) incont (incontinence) and decreased mobility." On 7/7/11 at 12:28 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-D and CNA-M transfer Resident #5 from the broda chair into bed. Resident #5 was positioned from side to side and Resident #5's slacks & incontinence product were removed. Resident #5 was positioned on her right side and CNA-D sprayed peri wash on her buttocks and wiped her buttocks. Staff placed an incontinence product and slacks on Resident #5. Surveyor # did not observe any open areas on Resident #5's buttocks. CNA-D emptied the urine from the drainage bag into a cylinder and emptied the urine. CNA-D removed her gloves and washed her hands. CNA-D lowered the bed, covered Resident #5 with a blanket, and placed the call light in reach. On 7/7/11 at 12:41 p.m. Surveyor # met with ADON (Assistant Director of Nursing)-F and RN (Registered Nurse)-E to inquire why Resident #5 has a Foley catheter and was unable to locate a bladder assessment. Surveyor # informed ADON-F and RN-E that during Resident #5's record review Surveyor # was unable to locate medical justification and during care observations no open areas were observed. ADON-F informed Surveyor # that Resident #5 was admitted from the hospital with the Foley and had an excoriated bottom. RN-E informed Surveyor # that she will contact the doctor and see if they can get the Foley discontinued. ADON-F informed Surveyor # that she will look for the bladder assessment. On 7/7/11 at 3:08 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above and Surveyor # requested a bowel and bladder assessment for Resident #5. The nurses note dated 7/7/11 documents "Physician-Q called. Made aware that Foley catheter was in to promote healing of buttocks, which are now healed. Order rec'd (received) to dc (discontinue) catheter. On 7/8/11 at 7:20 a.m. Surveyor # was provided with a bowel assessment dated [DATE] but was not provided with a bladder assessment. On 7/8/11 at 8:40 a.m. Surveyor # observed Resident #5 sitting in a broda chair in the hall way. Surveyor # noted that Resident #5 did not have a Foley catheter. 4.) On 7/8/11 Surveyor # reviewed Resident #22 medical record. Resident #22 was admitted to the facility on [DATE] with the following diagnoses, Type II diabetes, hypertension, [MEDICAL CONDITION] and depression. The Admission MDS dated [DATE] indicated Resident #22 is occasionally incontinent of bladder. The 30 day MDS dated [DATE] indicate the resident is frequently incontinent. The CAA (Care Assessment Area) dated 5/13/11 indicates Resident #22 is "non ambulatory, staff transfer with 2 assist and stand pivot with gait belt." It also indicates the resident is "continent of bowel and occasionally incontinent of bladder." The Alteration in Elimination bladder care plan dated 6/9/11 indicate Resident #22 is on a "scheduled toileting plan" "staff also offer toileting to resident Q(every) 2-3 hours and as resident request""use of briefs/pad for incontinent protection." Surveyor # was unable to find a bladder assessment or a bladder patterning that would indicate a toileting schedule for Resident #22 in the medical record. On 7/8/11, during the daily exit meeting with the facility, Surveyor # requested to see Resident #22 bladder assessment. On 7/11/11 at 9:55 a.m., Surveyor # spoke with DON B. DON B states a bladder assessment was not completed for Resident #22.

Based on observation, interviews and record reviews the facility did not ensure that residents at high risk for falls received the necessary supervision and assistance to prevent accidents for 3 of 14 residents reviewed. Resident #10 has a history of falls and has a chair alarm; Resident #10 was left unattended in the bathroom. Resident #10 stood up to self transfer onto the toilet when she fell and as a result fractured her left ankle. Resident #4 has a history of falls and was observed in bed for a period of time and the bed alarm was not on. Resident #6 has a history of falls and was observed in bed without a mat on the floor by his bed. Findings include: 1. On 7/7/11, Surveyor # reviewed Resident's #10 medical record. Resident #10 was admitted to the facility on [DATE]. Resident #10's [DIAGNOSES REDACTED]. On 7/6/11 at 11:48 a.m., Surveyor # observed Resident #10 in the dining room. Resident #10 had a black, boot splint on her left foot. The Clinical Health Status form dated 1/17/11 indicates the resident is at risk for falls. The MDS (Minimum Data Set) dated 4/9/11 indicates Resident #10 requires extensive assistance of one staff for transfers, dressing and toileting. The care plan dated 3/1/11 indicates staff should stay in the bathroom with the resident or right outside the door for privacy. The care plan dated 3/28/11 also indicates the resident is to have a "bed alarm to alert staff to resident doing any unassisted transfers from bed." It also indicates staff should "frequent safety checks offer assistance." The progress note dated 3/25/11 indicates the resident was found sitting on the floor in the bathroom. The progress note dated 4/3/11 indicates Resident #10 needs extensive assistance with cares and has long and short term memory impairment. The progress note dated 5/4/11 indicates the resident slid out of her wheelchair onto her buttocks with no injuries noted. It also indicates, "encourage resident to call for assistance and stop turning off her w/c (wheelchair) alarm." The care plan dated 5/4/11 indicates that a wheelchair alarm was placed to "alert staff to unassisted transfers." The progress note dated 5/8/11 indicates the resident was trying to self transfer and fell which resulted in a hematoma to the back of head. It also indicated the resident complained of pain to her left lower extremity. The facility received an order to send the resident to the emergency department. The progress note dated 5/9/11 indicates Resident #10 returned to the facility with a left lower leg splint due to a "torus Fx (fracture) of left ankle." On 7/7/11 during the daily exit meeting with the facility, Surveyor # requested more information regarding the falls that occurred on 3/25/11, 5/4/11 and 5/8/11. On 7/8/11 at 8:10 a.m., Surveyor # interviewed Director of Nursing (DON) B regarding the above falls. DON B states that the chair alarm was instituted on 5/3/11 because staff caught resident self transferring to the toilet. The resident was also observed by the staff to be "shaky and unsteady." Surveyor # asked DON B what occurred on 5/8/11 when Resident #10 fell and fractured her left ankle. DON B states that Certified Nursing Assistant (CNA) R was going to toilet the resident. The resident was in her wheelchair and CNA R transported the resident into the bathroom when she realized that the bathroom didn't have gloves or periwipes. So CNA R left the resident in the bathroom to search for gloves and periwipes. Per the investigation dated 5/8/11, while CNA R was searching for gloves and periwipes, the resident stood up which triggered the alarm. CNA R heard the alarm and went back to the resident's bathroom and found her on the floor, the resident's left side against the wall and the resident's pants were down. Surveyor # asked DON B what is the facility's expectation regarding leaving Resident #10, who has a history of falls and had alarms due to safety concerns, unattended in the bathroom. DON B states the facility would expect the staff to either put the call light on for assistance or take the resident with them when gathering supplies. DON B states that CNA R was very new and had just completed her orientation. On 7/8/11 at 11:29 a.m. Surveyor # interviewed Alzheimer care unit (ACU) Director C regarding Resident #10. ACU Director C states Resident #10 needed assistance for toileting and was a "stand by assist" prior to the left fractured ankle on 5/8/11. ACU Director C indicated Resident #10 is now a sit to stand transfer. ACU Director C states that Resident #10 needed assistance with ambulation prior to the fracture but now does not ambulate. On 7/8/11 during the daily exit meeting the NHA A and DON B were informed of the above. 2. On 7/6/11, 7/7/11, & 7/8/11 Surveyor # reviewed Resident #4's medical record. Resident #4 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CNA (Certified Nursing Assistant) Assignment family group 1 1A front not dated and provided by the Director of Nursing on 7/6/11 at 9:05 a.m. documents for Resident #4 under alarm "Bed/W/C (wheelchair)." The clinical health status form dated 5/17/11 for section risk for falls documents a total score of "11" (total score of 10 or above deems resident at risk). On 5/18/11 Resident #4 had a fall from her wheelchair which resulted in a fracture of her right ankle. The at risk for falls care plan initiated 6/3/11 includes an intervention of "Bed/w/c alarms to alert staff of unassisted transfers." On 7/6/11 at 12:30 p.m. Surveyor # observed CNA-D and CNA-I transfer Resident #4 from her wheelchair into bed using a sit to stand mechanical lift. CNA-D informed Resident #4 that she was going to check her incontinence product, lowered Resident #4's slacks, positioned Resident #4 on her left side, and checked the product stating "ok you're good." CNA-D removed Resident #4's slacks, covered her with a sheet, lowered the bed, placed the call light within reach, and inquired if Resident #4 wanted the tv on or off. CNA-D removed her gloves, washed her hands and left the room. Surveyor # observed the alarm box on the right hand side of the bed frame but did not note any light on or flashing. On 7/6/11 at 1:21 p.m. Surveyor # observed Resident #4 sit up in bed and then lay back down. On 7/6/11 at 1:22 p.m. Surveyor # checked the alarm box and noted the alarm was in the off position. On 7/6/11 at 1:44 p.m. Surveyor # observed Resident #4 sitting on the edge of the bed with her back towards the door. The bed alarm was not sounding. Surveyor # observed CNA-I and CNA-H walking down the hallway towards Resident #4's room and asked if they could come to Resident #4's room. CNA-I asked Surveyor # if Resident #4 was trying to get up. Surveyor # informed CNA-I that Resident #4 was sitting on the edge of the bed and the alarm was not sounding. Surveyor # entered Resident #4's room with CNA-I and CNA-H. CNA-I checked the bed alarm and turned on the alarm. Surveyor # asked CNA-I if the alarm was off. CNA-I responded "yes." CNA-H assisted Resident #4 with laying back in bed. On 7/8/11 at 3:11 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. 3. On 7/7/11, & 7/8/11 Surveyor # reviewed Resident #6's medical record. Resident #6 is a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 is dependent upon staff for his ADL's (activities of daily living) and is non verbal. The CNA (Certified Nursing Assistant) Assignment family group 2 1A front split list not dated and provided by the Director of Nursing on 7/6/11 at 9:05 a.m. for Resident #6 under matt "yes" is documented. The at risk for falls care plan initiated 12/22/10 has an intervention dated 3/24/11 which documents "double floor pads at bed side." The clinical health status form dated 4/29/11 for section risk for falls documents a total score of "14" (total score of 10 or above deems resident at risk). The physician orders [REDACTED]." On 7/6/11 at 11:10 a.m. Surveyor # observed Resident #6 in bed. Surveyor # did not observe a mat on the floor. On 7/6/11 at 12:06 p.m. Surveyor # observed Resident #6 in bed positioned on his back. Surveyor # did not observe a mat on the floor. On 7/6/11 from 1:32 p.m. to 1:41 p.m. Surveyor # observed cares for Resident #6 with CNA-I and CNA-K. Surveyor # did not observe a mat on the floor and after cares were completed staff did not place a mat on the floor. On 7/6/11 at 3:31 p.m. Surveyor # observed Resident #6 on his right side in bed. Surveyor # did not observe a mat on the floor. On 7/7/11 at 7:29 a.m. Surveyor # observed Resident #6 asleep in bed on his left side. Surveyor # did not observe a mat on the floor. On 7/7/11 at 7:53 a.m. Surveyor # observed CNA-L check Resident #6's incontinence product. Surveyor # did not observe a mat on the floor upon entering Resident #6's room and CNA-L did not place a mat on the floor before she left. On 7/7/11 from 9:35 a.m. to 10:20 a.m. Surveyor # observed morning cares for Resident #6 while he was in bed with CNA-K and CNA-M. Upon entering the room Surveyor # did not observe a mat on the floor. Before CNA-K and CNA-M left Resident #6's room a mat was not placed on the floor. On 7/7/11 at 2:27 p.m. Surveyor # observed Resident #6 in bed on his left side. Surveyor # did not observe a mat on the floor. On 7/7/11 at 3:18 p.m. Surveyor # observed Resident #6 in bed on his left side Surveyor # did not observe a mat on the floor. On 7/8/11 at 8:45 a.m. Surveyor # observed Resident #6 in bed on his back. Surveyor # did not observe a mat on the floor. On 7/8/11 at 10:59 a.m. Surveyor # informed LPN (Licensed Practical Nurse)-J that Surveyor # had noted during Resident #6's record review and on his CNA assignment sheet Resident #6 is supposed to have a mat by his bed. Surveyor # informed LPN-J that Surveyor # has not observed a mat on the floor and inquired if he is supposed to have one. LPN-J reviewed the record and informed Surveyor # that if it says he's supposed to have a mat he should have one. At 11:04 a.m. Surveyor # accompanied LPN-J to Resident #6's room. LPN-J verified there was not a floor mat in Resident #6's room. On 7/8/11 at 1:09 p.m. Surveyor # observed Resident #6 in bed on his left side. Surveyor # observed there is now a mat on the floor. On 7/8/11 at 3:11 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above.