Every finding on record at Brookside Care Center

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 6 (R26, R96, R133, R67, R55, and R106) of 28 residents reviewed for Infection control practices. *Staff did not implement Enhanced Barrier Precautions (EPB) for R26, R96, and R133 despite each meeting the criteria to require such precautions. *R67 was observed during wound care to the sacrum to have stool present at the rectum and was not provided with incontinence care prior to completing the treatment creating an unsanitary environment.*Staff were observed to handle R55, and R106's medications with bare hands. Findings include: The facility's policy titled, Enhanced Barrier Precautions with a last review date of 1/26/2026 indicates when a resident is admitted or found to be infected or colonized with a Novel or targeted Multidrug Resistant Organism (MDRO), indwelling devices, chronic wound (wound that is non healing greater than 12 weeks, etc. will have an isolation kit with gowns, gloves, alcohol sanitizer will be placed on resident's door with signage that says Enhanced Barrier Precautions, which clearly indicated high contact resident care activities (dressing, transferring, providing hygiene, changing briefs, toileting, etc. 1) R26 was admitted to the facility on [DATE], with diagnoses including urinary retention. R26's admission Minimum Data Set (MDS), dated [DATE], indicates they have an indwelling urinary catheter. On 06/15/26, at 9:23 AM, Surveyor observed no PPE (Personal Protective Equipment) available in or outside of R26's room. On 06/15/26, at 9:53 AM, Surveyor observed Certified Nursing Assistant (CNA)-X and CNA-Y transfer R26 from the bed to the wheelchair. Surveyor noted, neither CNA had gowns on, and began assisting R26 with clothing adjustments, sitting up at the edge of the bed and transferring, using a mechanical lift. 2) R96 was admitted to the facility on [DATE] with diagnoses including urethral stricture, overactive bladder, and crossing vessel and stricture of ureter. R96's Significant Change Minimum Data Set (MDS), dated [DATE] indicates they have an indwelling urinary catheter. On 06/15/26, at 11:09 AM, Surveyor observed no PPE available in or outside of R26's room. On 06/15/26, at 11:13 AM, Surveyor observed CNA-Z in R96's room with no PPE. R96 was sitting in their wheelchair and CNA-Z sat on R96's bed, facing R96 and began assisting R96 with putting on stockings and shoes. On 06/17/26, at 9:44 AM, Surveyor interviewed Infection Preventionist (IP)-C regarding EBP. IP-C indicated EBP are required for anyone with any tube feedings, midline, drains, foley, suprapubic or chronic wounds. IP-C informed surveyor that anyone with an indwelling urinary catheter should be on EBP and is unsure why they were not. IP-C expects staff to wear EBP PPE when performing direct care and transfers. 3) R133 was admitted to the facility on [DATE]. On 5/27/26, R133 developed moisture associated skin damage that evolved on 6/1/2026 into a pressure injury. On 6/16/26 at 9:01 AM, Surveyor accompanied Registered Nurse (RN)-M and Nurse Practitioner (NP)-N to do R133's treatment to the coccyx pressure injury. Surveyor noted R133 did not have a sign posted on the door for Enhanced Barrier Precautions (EBP) or gowns and gloves available outside of the room. RN-M and NP-N proceeded into R133's room and completed the wound treatment without wearing gowns. Surveyor asked RN-M and NP-N why R133 did not have EBP with the presence of a pressure injury. NP-N stated they were wondering the same thing. RN-M stated R133's wound was new and would find out and clarify about the need for EBP. On 6/16/26 at 12:46 PM, RN-M provided Surveyor with a policy and procedure documenting EBP are not implemented for a wound that is non healing greater than 12 weeks. RN-M stated R133 has only had the wound since May 2026, so it is not at the 12 week time frame. On 6/16/2026 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Assistant DON (ADON)-K the concern R133 was not in EBP with a pressure injury. Surveyor shared the concern the policy and procedure provided was not the standard of practice for EBP; the wound should be protected from potential multidrug resistant organisms with the use of gown and gloves, and a pressure injury is considered a chronic wound unlike a skin tear or abrasion. On 6/17/2026 at 7:51 AM, NHA-A stated the nursing administrative staff looked at what Surveyor had presented the day before regarding EBP and they are currently revising their policy and procedure. NHA-A agreed with what was said about pressure injuries being chronic wounds and any resident with a chronic wound should be in EBP. 4) R67 was admitted to the facility on [DATE]. R67 was admitted with pressure injuries to the buttocks as well as moisture associated skin damage with open areas. On 6/16/26 at 8:37 AM, Surveyor accompanied RN-M and NP-N to complete R67's treatment to the sacral pressure injury. RN-M assisted R67 to roll onto the left side and NP-N exposed R67's bottom to access the sacral area. R67 had visible stool at the rectum and R67 stated they had to have a bowel movement. NP-N cleaned the wound pushing the fecal matter down towards the rectum away from the wound. NP-N did not allow R67 to have a bowel movement at that time and did not clean the stool from the rectum. NP-N continued with the dressing change and placed a dressing over the wound, leaving the stool in place and notifying floor staff that R67 had to complete having a bowel movement and then would need assistance cleaning up. Surveyor asked NP-N why they did not clean R67 of the stool prior to completing the dressing change. NP-N stated R67 was still going so it did not make sense to clean it at that time. On 6/18/26 at 11:51 AM, Surveyor spoke with DON-B about the observation. DON-B stated NP-N had talked to DON-B about the dressing change and that R67 had started to go when they rolled R67 over. DON-B stated NP-N said R67 would have to be cleaned up and probably change the dressing that had just been put on. The Facility Policy titled Medication Administration, Oral, dated 11/21/2017, documents (in part):Policy: It is the policy of Brookside Care Center to accurately prepare, administer and document oral medications.Interpretive Guides. Do not touch medications with bare hands. Pour medications directly from the package into a medication cup, use the container cap for non-unit dose medications, or wear gloves when handling medications. 5) On 6/16/26, at 9:00AM, Surveyor observed LPN-D (Licensed Practical Nurse) prepare R139's medications for administration. LPN-D punched medications from two cards directly into bare hand then placed the medication into the medication cup. LPN-D punched a pill out of another card and the pill fell unto the medication cart. LPN-D picked up the pill off the cart with bare hand and put it into the medication cup. These medications were administered to R139. On 06/16/26, at 12:45 PM, Surveyor interviewed LPN-D regarding touching the pills with bare hands. LPN-D admitted touching the medications was an infection risk and should not have done that. On 06/16/26, at 12:51 PM, Surveyor interviewed IP-C regarding expectation for medication administration. Surveyor shared the observation of LPN-D. IP-C agreed this was not a good infection prevention method. 6) On 6/16/26, at 9:20AM, Surveyor observed LPN-E finishing preparations for R55 to receive their medications. Surveyor observed LPN-E take a pill out of R55's medication cup and break it in half with bare hands and place the two pieces into the medication cup. The cup was then taken into R55's room and administered. 7) On 6/16/26, at 9:34AM, Surveyor observed LPN-E prepare medications for R106. After the medications were put into the medication cup LPN-E picked the Florastor out of the cup, with bare hands, and opened the capsule to add just the medication powder to the cup. On 06/16/2026, at 12:48 PM, Surveyor interviewed LPN-E about the observations. LPN-E stated they feel bad for doing that and they have been off for an extended period and trying to get their groove back. On 06/16/26, at 12:51 PM, Surveyor interviewed IP-C regarding expectation for medication administration. Surveyor shared the observations of LPN-E. IP-C agreed this was not a good infection prevention method.

Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (R67 and R133) of 4 residents reviewed for pressure injuries.*R67's pressure injuries were not assess upon admission or upon 2 subsequent readmissions. In addition, multiple open areas were measured as one wound with no characteristics documented of what the wound looked like. *R133 had moisture associated skin damage to the coccyx that developed into an Unstageable pressure injury. The wound was documented as scattered full-thickness wounds with no documentation of how many wounds or how big the wounds were. Findings include: The facility policy and procedure titled Wound/Pressure Ulcer Documentation dated 12/14/22, and reviewed 3/17/25, includes, .Each wound/PU/PI will be identified by a number and location. Ex. Area 1 Left heel; Area 2 Left lateral malleolus, etc .Each wound/decubitus will be measured in cm using disposable measuring tools found in each cart or med room. The length, width and depth should always be documented. Input these measurements into (the charting system) to obtain the PUSH score. Document any undermining/tunneling/sinus tracts .Describe any exudate - type, amount, or odor .Describe the wound bed (various types of tissue in the wound) .Amount - Describe in percent (Example: 50% wound bed covered with soft yellow slough, 50% beefy red granulation tissue) .When a new wound, including wounds on admission, is identified the following needs to take place: 1. Assessment of wound with measurement 2. Any appropriate interventions put into place, such [sic] air mattress, heel lift 3. Call to MD to request a treatment and (facility) wound care team to eval and treat 4. Notify Dietician for nutritional intervention 5. Care plan updated 6. Notification to POA, if there is one 7. All the above documented in (the charting system) 8. Set up weekly assessment 9. Email wound care team 10. Always date and initial dressings PLEASE OBTAIN A TREATMENT RIGHT AWAY, THE WOUND CARE TEAM WILL ASSESS AS SOON AS POSSIBLE .A note regarding wound/pressure injury status must also be made at the time of summary charting or Medicare charting. Information regarding the presence of a wound/pressure injury must be transferred to the care plan by the nurse first identifying the wound. This must be done as soon as it is identified. 1) R67 was admitted to the facility on [DATE]. R67's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documents R67 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and was dependent for toileting, bed mobility, and transfers. R67 had an indwelling urinary catheter. R67 had an activated Power of Attorney (POA). The hospital Inpatient Wound Consult dated 1/26/26 documented R67 had a pressure injury of deep tissue of the right buttock which was nonblanchable, deep purple discoloration with scattered open areas, some covered with slough, and a pressure injury of deep tissue of the left buttock which was nonblanchable, deep purple discoloration with scattered open areas, some covered with slough. Treatments were ordered for the left and right buttock pressure injuries on the discharge summary. In addition to the left and right buttock pressure injuries, the active problem list included a Stage 2 decubitus ulcer of the sacral region. On 1/29/26, R67 had a treatment order for the right buttock: cleanse with Vashe, then Aquacel AG, cover with sacral Mepilex every other day or as needed if soiled. Surveyor noted this was the order from the hospital discharge summary. No order was entered for the left buttock wound. On 1/29/26, the admission Observation form documented R67 had an open area to the coccyx, an open area to the right buttock, and excoriation to bilateral buttocks. There was no comprehensive assessment that would include measurements, wound descriptors, or type of wounds were documented. No treatment was obtained for the open area to the coccyx. On 2/4/26 on the Wound Documentation form, Wound Registered Nurse (WRN)-W documented R67 had moisture associated skin damage (MASD) to bilateral buttocks and coccyx measuring 8 cm x 12 cm with granulation tissue. WRN-W documented the wound was to the entire buttocks area and the treatment in place was calcium alginate. Surveyor noted the treatment to R67's right buttock was not calcium alginate, and the documentation did not give a percentage of granulation tissue in the wound bed or depth measurement of the wound. On 2/9/2026 on the Wound Documentation form, WRN-W documented R67 had MASD to bilateral buttocks measuring 7 cm x 10 cm with granulation tissue. Surveyor noted WRN-W did not document the percentage of granulation tissue or depth of the wound. On 2/10/26, Wound Nurse Practitioner (WNP)-N made an initial assessment of R67's skin. WNP-N documented R67's MASD of the gluteal cleft had scattered full-thickness wounds that measured 5 cm x 5 cm x 0.1 cm with about 20% granulation tissue and 80% moisture damaged epithelial tissue. Surveyor noted WNP-N did not document the number or size of the open areas within the wound to get a full picture of how the wound presented. On 2/17/26, WNP-N documented R67's MASD to the gluteal cleft healed. On 3/25/26 on the Bath Day Skin/Feet Assessment form, nursing documented a R67 had excoriation to the buttocks and an order for barrier cream with zinc was obtained. No measurements of the wound were documented. On 3/31/26, R67 was transferred to the hospital for complaints of difficulty breathing and chest pain. R67 was admitted to the hospital for sepsis. On 4/9/26, R67 was readmitted to the facility. On 4/9/26 on the admission Observation form, nursing documented, R67's left inner thigh had an open blister, the right heel had unblanchable redness measuring 2.2 cm x 3.6 cm, the sacrum/coccyx and buttocks had multiple small open areas, and the right buttock had two open areas that measured 1.5 cm x 2 cm and 1 cm x 1 cm. There was no comprehensive assessment that would include the type of wounds present, no depths were measured, and no description was documented of the wound beds. On 4/14/26 on the Wound Documentation form, WRN-M documented R67 had a Stage 2 pressure injury to the right buttock that was present on readmission measuring 1 cm x 1 cm with granulation tissue being treated with Medihoney, a Stage 2 pressure injury to the inner right buttock that was present on readmission measuring 0.5 cm x 0.5 cm with granulation tissue being treated with zinc barrier cream, and a Stage 2 pressure injury to the left buttock measuring 3.2 cm x 0.5 cm with epithelial tissue being treated with zinc barrier cream. No depths were documented. No documentation was found of the left inner thigh blister or the right heel unblanchable area. On 4/20/26, R67 was transferred to the hospital and admitted with pneumonia. On 4/27/26, R67 was readmitted to the facility. On 4/27/26 on the admission Observation form, nursing documented in the skin section of the form, R67's right heel has a dark area, and the bottom area is red with multiple open areas: left buttock wound measuring 0.5 cm x 0.6 cm, inner left buttock wound measuring 1.9 cm x 0.7 cm, right buttock wound measuring 1 cm x 1 cm, and right buttock wound measuring 0.6 cm x 0.6 cm. On 4/27/26, R67 was assessed by WNP-N (Wound Nurse Practitioner). WNP-N documented R67 returned from a brief hospitalization with a pressure injury to the sacrum. The sacrum Stage 3 pressure injury had scattered full-thickness wounds measuring approximately 7 cm x7 cm x 0.1 cm with 40% granulation tissue and 60% hyperpigmented blanchable epithelial tissue. WNP-N did not describe or measure the individual full-thickness wounds within the area or how many open areas there were to give a complete picture of how the wound presented. On 4/28/26 on the Wound Documentation form, WRN-M documented R67's sacrum Stage 3 pressure injury measured 7 cm x 7 cm with 40% granulation and 60% epithelialization and the right heel deep tissue injury measured 1.6 cm x 1.6 cm that was nonblanchable with epithelial tissue to an open area measuring 0.6 cm x 0.6 cm. Surveyor noted a deep tissue injury does not have the characteristics of an open area and would be classified as a staged pressure injury. On 5/5/26 on the Wound Documentation form, WRN-M documented the right heel deep tissue injury healed. On 5/5/26, WNP-N documented R67's sacrum Stage 3 pressure injury had scattered full-thickness wounds measuring approximately 5 cm x 4 cm x 0.1 cm with 20% granulation and 80% hyperpigmented blanchable epithelial tissue. WNP-N did not describe or measure the individual full-thickness wounds within the area or how many open areas there were to give a complete picture of how the wound presented. On 5/12/26, WNP-N documented R67's sacrococcygeal Stage 3 pressure injury full-thickness wound measured approximately 1.6 cm x 0.4 cm x 0.1 cm with 100%. Surveyor noted WNP-N did not document what type of tissue was in the wound bed. WNP-N documented R67 had MASD with scattered full thickness open areas to the bilateral gluteal cleft measuring 6 cm x 6 cm x 0.1 cm with 60% epithelial tissue and 40% granular tissue. WNP-N did not describe or measure the individual full-thickness wounds within the area or how many open areas there were to give a complete picture of how the wound presented. On 5/18/26 on the Wound Documentation form, WRN-W documented R67's sacrum Stage 3 pressure injury measured 1.5 cm x 0.7 cm with 100% granulation. No depth was documented. On 5/25/26 on the Wound Documentation form, an RN documented R67 had two open areas and excoriation to the buttocks measuring 6.27 cm x 7.02 cm with granulation tissue. The two open areas were not measured, no depth was documented, and the percentage of granulation tissue was not documented. On 5/27/26 on the Wound Documentation form, WRN-W documented R67's healing Stage 3 pressure injury measured 6 cm x 3 cm with non-granular tissue with two small open areas measuring 0.3 cm x 2 cm to the right inner gluteal cleft and 0.2 cm x 0.2 cm to the coccyx with smooth pink non granular tissue to both areas. No depth was documented. On 6/1/26 on the Wound Documentation form, WRN-W documented R67's buttocks Stage 3 pressure injury measured 1.5 cm x 0.6 cm with epithelial tissue and a thin scab to the right buttock and was almost healed. Surveyor noted the location of the pressure injury changed and the location of the open areas could not be determined from previous assessments. On 6/8/26 on the Wound Documentation form, an RN documented R67's coccyx had an open area that measured 12 cm x 4 cm with epithelial tissue. No staging, depth, or percentage of tissue type was documented. On 6/11/26 on the Wound Documentation form, WRN-W documented R67's right buttock/coccyx Stage 3 pressure injury had scabbed over and healed. WRN-W documented R67 had MASD to bilateral buttocks measuring 9 cm x 9 cm with non-granulation tissue. On 6/15/26 on the Wound Documentation form, WRN-W documented the coccyx MASD measured 5 cm x 2.5 cm with epithelial tissue. On 6/16/2026, WNP-N documented R67's sacrococcygeal Stage 3 pressure injury with scattered full-thickness wounds measured approximately 4.3 cm x 2 cm x 0.1 cm with 80% blanchable epithelial and 20% granular tissue and bilateral gluteal cleft MASD had healed. Surveyor noted WRN-W had resolved the pressure injury and continued the MASD while WNP-N resolved the MASD and continued the Stage 3 pressure injury. Surveyor noted confusion between the facility and WNP-N with labeling of areas and descriptions of the wounds. On 6/16/26 at 8:37 AM, Surveyor observed WNP-N and WRN-M complete wound care with R67. R67 had an air mattress in place and heel boots on. WRN-M assisted R67 to roll onto the left side and held R67 in place while WNP-N measured and treated the wounds. WNP-N stated the MASD had healed and the Stage 3 pressure injury to the coccyx measured approximately 4.3 cm x 2 cm. Surveyor observed a small open area on the inner right buttock and the coccyx that were actively bleeding after WNP-N removed the zinc barrier cream from the area. Surveyor asked WNP-N how many open areas were present. WNP-N stated there were three wounds. WNP-N showed Surveyor the additional wound to the inner left buttock. Surveyor asked WNP-N why the individual open areas were not measured. WNP-N stated R67 was admitted with one wound that had healed in the middle making it now three smaller wounds and did not want to document that R67 now had three wounds. On 6/17/26 at 1:42 PM, Surveyor spoke with DON-B. DON-B stated they were aware WNP-N measures the whole area for MASD. Surveyor shared with DON-B that WNP-N does the same for pressure injuries and does not describe what the entire area looks like. DON-B stated each wound should be measured separately. 2) R133 was admitted to the facility on [DATE]. R133's Significant Change MDS assessment dated [DATE] documented R133 did not have any pressure injuries at the time of the assessment and had elected hospice services. R133 had an activated Power of Attorney (POA). On 5/13/226 at 2:01 PM in the progress notes, nursing documented R133 had a blanchable redness to the coccyx. Hospice was notified and an order for Calmoseptine twice daily was obtained. On 5/27/26 at 12:18 AM in the progress notes, a Licensed Practical Nurse (LPN) documented R133 had two open areas; the coccyx wound measured 1.5 cm x 1 cm and the right buttocks wound measured 1 cm x 0.5 cm. The hospice agency was notified and ordered to continue with the scheduled Calmoseptine cream and apply a protective dressing. The hospice nurse would follow up in the morning. On 5/27/2026 on the Wound Documentation form, Wound Registered Nurse (WRN)-W documented R133 had moisture associated skin damage (MASD) to the coccyx measuring 5 cm x 1 cm with non-granulation tissue. No depth was documented and did not indicate there were any open areas as noted in the progress note on 5/27/2026 at 12:18 AM. On 6/1/26 on the Wound Documentation form, WRN-W documented the wound to the coccyx started as MASD and was now an Unstageable pressure injury measuring 6 cm x 1.5 cm with necrotic tissue. No depth or percentage of necrotic tissue was documented. The original note documented 2 separate open areas, however, this note only documents 1. On 6/2/26, R133 was initially assessed by WNP-N. WNP-N documented R33's coccyx unstageable pressure injury had scattered full-thickness wounds measuring approximately 4 cm x 5 cm x unable to determine with 5% smooth pink tissue, 10% slough, 5% non-blanching erythema, and 80% blanchable epithelial tissue. No description of the scattered full thickness wounds was documented, including number, appearance, and locations. Surveyor noted that 10% slough would not cover the entire wound bed and therefore the wound should be staged according to the characteristics of the wound. On 6/9/26, WNP-N documented R133's coccyx unstageable scattered full-thickness pressure injury measured approximately 3 cm x 3.5 cm x unable to be determined with 20% slough and 80% epithelial tissue. No description of the scattered full thickness wounds was documented, including number, appearance, and locations. On 6/15/26 on the Wound Documentation form, WRN-W documented R133's coccyx unstageable pressure injury measured 1.1 cm x 1.5 cm with slough. No depth or percentage of slough was documented. On 6/16/26 at 9:01 AM, Surveyor observed WNP-N and WRN-M complete wound care with R133. WP-N measured and treated the wound. The wound had defined edges measuring approximately 1.5 cm x 1.5 cm x 0.2 cm with 100% slough. The surrounding skin did not look macerated or broken down. On 6/16/26, WNP-N documented R133's coccyx unstageable full-thickness pressure injury measured 1.3 cm x 1.3 cm x unable to determine with 100% thin layer of slough. On 6/18/26 at 9:28 AM, Surveyor shared with DON-B the concerns with documentation of R133's wounds by not being comprehensive and measuring large areas with multiple scattered open areas and no description or measurements of those areas. DON-B stated they were aware WNP-N measures the whole area for MASD. DON-B stated each wound should be measured separately. On 6/18/26 at 11:30 AM, Surveyor spoke with WRN-M and asked what the facility's process was for newly admitted residents with an open area. WRN-M stated the nurse on the floor will do the body check and the wound observation. WRN-M stated the wound care team comes in to assess wounds; on Monday and Wednesday WRN-W assesses wounds and on Tuesday and Thursday WRN-M assesses wounds. They do not have any wound rounds on Friday, Saturday, or Sunday, but WRN-M and WRN-W work alternate weekends so staff will find them, and they will look at wounds even though that is not what they are at work to do. Surveyor asked WRN-M how quickly the wound team will come to assess a resident with a wound. WRN-M stated they will come and look at it right away, but WNP-N comes in only on Tuesdays. Surveyor asked WRN-M if open areas are measured as one area or individual wounds. WRN-M stated they know WNP-N will measure the area as one wound if open areas are close together and the tissue in between is not good. Surveyor shared with WRN-M the concern R67's admission assessment on 1/29/26 had wounds present and they were not comprehensively assessed until 2/4/26. WRN-M stated they should have been assessed right away.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 6 residents (R90) reviewed for falls.R90 was care planned to have a floor mat alongside the bed. Observations were made of R90 lying in bed without the floor mat in place. Findings include: 2) R90 was admitted to the facility on [DATE] with diagnoses including Dementia, orthostatic hypotension, hemiplegia, and hemiparesis affecting right dominate side. R90's Comprehensive MDS, dated [DATE], indicates severe cognitive impairment, no impairment in upper or lower extremities and dependent for transfers from bed to chair. R90's Care Plan indicates R90 is at risk for falls with the following interventions:-Assessment and treatment for postural/orthostatic hypotension.-Call light within reach at all times.-Floor mat next to bed while in bed.-Exercise program that targets strength, gait and balance.-Increased staff supervision with tensity based on need.-Comprehensive medication review by pharmacist.-Provide individual toileting interventions on needs/pattern. On 06/16/26, at 7:03 AM, Surveyor observed R90 in their bed with both legs hanging off the side of the bed. Surveyor observed R90 attempting to get out of bed and appeared to be close to sliding out of bed. Surveyor noted there was no fall mat on the floor next to R90's bed and there were no staff readily available. Surveyor intervened by going to get a staff member. Certified Nursing Assistant (CNA)-O was found and assisted R90 get situated back in bed. On 06/17/2026, at 7:29 AM, Surveyor observed R90 in bed with no fall mat on the floor next to R90's bed. At 7:34 AM, Surveyor asked Licensed Practical Nurse (LPN)-P to come to R90's room with Surveyor. Surveyor asked LPN-P what fall interventions R90 should have in place. After LPN-P reviewed R90's care plan, Surveyor asked LPN-P if R90 has a fall mat in place. LPN indicated no and looked around R90's room for a fall mat but could not locate one. LPN-P informed Surveyor that she is unsure why a fall mat is not in place but is should be due to R90 being at an increased risk for falls and would get a fall mat for R90. On 06/17/2026, at 11:12 AM, Surveyor informed Registered Nurse (RN) Supervisor-Q, RN Educator-R and Director of Nursing (DON)-B of Surveyors observations of R90. RN Supervisor-Q informed Surveyor that R90 should have a fall mat in place. RN Supervisor-Q indicated she was informed this morning about R90 not having a fall mat in and a fall mat has now been provided to R90.

Based on interview and record review, the facility did not ensure the attending physician addressed the identified irregularity noted by the pharmacist for 1 (R5) of 5 residents reviewed for unnecessary medications.*R5 had an order for olanzapine, an antipsychotic medication, that was ordered for skin picking disorder/excoriation. The pharmacist documented that was not an approved diagnosis for the use of the medication. The physician did not address the diagnosis for use. Findings include: R5 was admitted to the facility on [DATE]. R5's Significant Change Minimum Data Set (MDS) assessment dated 5/19026 documents R5 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. R5 was seen on 12/16/25 by a psychiatric Nurse Practitioner (NP) who documented R5 had previously been diagnosed with major depressive disorder, generalized anxiety disorder, insomnia, and was diagnosed on that visit with excoriation (skin-picking) disorder. The excoriation disorder was based on repetitive skin picking observed at the nose and arms, as reported by R5, R5's spouse, and facility staff. A new medication of olanzapine 2.5 mg daily was ordered to treat the disorder. On 2/6/26, the pharmacist identified and documented an irregularity during R5's medication review. The Note to Attending Physician/Prescriber completed by the pharmacist documented R5 was receiving the antipsychotic agent Zyprexa (olanzapine) but lacks an allowable diagnosis to support its use. The pharmacist provided a list of appropriate diagnoses for the physician. The document had a hand-written note by Director of Nursing (DON)-B stating as of 12/16/25, olanzapine was started for skin picking (excoriation) disorder with a diagnostic code of F42.4 as diagnosed by the psych NP. The physician initialed the document, but no changes were made to R5's diagnosis connected to the olanzapine. On 5/11/26, the pharmacist again identified and documented the same irregularity during R5's medication review. The Note to Attending Physician/Prescriber was the same information as given to the facility on 2/6/26. No changes were made to the diagnosis for the use of olanzapine. On 6/18/26 at 10:06 AM, Surveyor spoke with Assistant Director of Nursing (ADON)-K about R5's pharmacy review and that the irregularities were not addressed. ADON-K indicated they were not aware of the recommendation and would get more information. On 6/18/26 at 10:13 AM, Surveyor spoke with the Medical Director (MD)-U and DON-B about the diagnosis for R5's use of olanzapine. MD-U stated the diagnosis should be dementia with behaviors and has to be treated pharmacologically because the skin is a big area and R5 picks the face and arms until they bleed. Surveyor shared with Director of Nursing (DON)-B the list provided by the pharmacist for appropriate diagnosis for the use of olanzapine.

Based on interview and record review, the facility did not provide a notice of discharge to the Office of the State Long-Term Care Ombudsman for 2 of 4 residents (R1 and R67) reviewed for discharge from the facility. R1 was transferred to the hospital 6 times between 2/7/26 and 5/17/26. No notice was provided to the Ombudsman. R67 was transferred to the hospital 2 times between 3/31/26 and 4/20/26. No notice was provided to the Ombudsman. Findings include: 1) R1 was admitted to the facility on [DATE]. R1 was transferred to the hospital on 2/7/26, 2/11/26, 3/20/26, 4/2/26, 4/23/26, and 5/17/26. On 6/16/26 at 3:00 PM, Surveyor asked Nursing Home Administrator (NHA)-A who sends notification to the Ombudsman of resident transfers. NHA-A stated Social Worker (SW)-V sends a monthly email to the Ombudsman with all the names of the residents that were discharged for that month. Surveyor requested to see the list of names SW-V had sent to the Ombudsman for the last six months. On 6/17/26, NHA-A provided the monthly list of residents that were discharged and sent to the Ombudsman. R1 was not included on the list of residents. On 6/17/26 at 9:39 AM, Surveyor asked SW-V how the discharged resident list was determined. SW-V stated they pull a report from the electronic charting system, and it comes up with a list of residents that were discharged to home. SW-V stated they did not know the Ombudsman list needed to include any resident that sent to the hospital. 2) R67 was admitted to the facility on [DATE]. R67 was transferred to the hospital on 3/31/26 and 4/20/26. On 6/17/26, NHA-A provided the monthly list of residents that were discharged and sent to the Ombudsman. R67 was not included on the list of residents. In an interview on 6/17/2026 at 9:39 AM, Surveyor asked SW-V how the discharged resident list was determined. SW-V stated they pull a report from the electronic charting system, and it comes up with a list of residents that were discharged to home. SW-V stated they did not know the Ombudsman list needed to include any resident that discharged to the hospital. NHA-A provided a document to Surveyor on 6/17/26 from the Long Term Care Community Coalition that documents: As of November 2016, federal regulations have required that nursing homes provide a notice of discharge to the state LTC Ombudsman Program (LTCOP) when a resident is discharged or transferred from a facility. NHA-A stated the same document had been provided to SW-V.

Based on interview and record review, the facility did not ensure 1 (R14) of 3 residents received treatment and care in accordance with professional standards of practice.R14 returned to the facility on 4/9/26. There is no evidence a skin assessment, including R14's vascular wounds, was completed. Findings Include:The Facility policy titled, Skin care management, initiated 12/21/26 documented: policy: each resident will have a skin assessment and treatment plan for the maintenance of skin integrity and wound management if required .R14's significant change minimum data set (MDS) completed on 4/22/26 documented R14 has 3 venous and arterial ulcers present at the time of the MDS assessment.On 4/3/26, R14 was sent to the hospital and returned on 4/9/26. R14's electronic medical record (EMR) did not include a skin assessment when R14 readmitted to the facility on [DATE].R14 has a physician order dated 4/9/26 to apply betadine to R14's left lateral foot, left great toe tip, and left 2nd toe daily. May cover for protection. The treatment end date was 6/10/26.On 6/18/26, at 11:31 AM, Surveyor interviewed Wound Care Nurse (WCN)-M regarding the procedure of when wounds are assessed. WCN-M stated the body assessments are completed on admission or readmission to the facility. The nurse completing the admission is responsible for documenting the assessment of any wounds or skin concerns found at the time of admission. The nurse then emails the wound team so the wound team can assess and treat the wound. The nurse can either get an order to treat the skin concern from the physician or the wound team.On 6/18/26, at 12:42 PM, Surveyor interviewed Director of Nursing (DON)-B regarding expectations for skin assessments. DON-B stated nurses are expected to complete skin assessments on admission and when skin issues are found when skin checks are completed. Skin checks are completed weekly on resident bath days. Surveyor asked DON-B if a skin assessment for R14 was completed when they readmitted to the facility on [DATE]. DON-B said they were not sure if one was completed and that they would look into it.On 6/18/26, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R14's missing admission skin assessment from 4/9/26. NHA-A stated that it is expected a skin assessment is completed on admission. The admission skin assessment includes all skin alterations present at that time. NHA-A stated they would investigate the matter.

Based on observation, record review, interview, document review and facility policy review, the facility failed to ensure one of four residents reviewed for medication administration (Resident (R)1) out of eight sampled residents was free from significant medication errors when R1 was administered R8’s medications which included amiodarone (cardiac antiarrhythmic), bumetanide (diuretic), carvedilol (blood pressure), clozapine (antipsychotic), divalproex (anticonvulsant), Jardiance (diabetic), and lamotrigine (anticonvulsant). This failure resulted in the R1’s becoming lethargic, requiring hospitalization. Findings include: Review of the facility's policy titled, Medication Administration dated 11/21/17 provided by the facility revealed, Administer to the patient after verifying the resident’s identity. Follow the six rights . right patient, right medication, right dose, right time, right route, and right documentation. Identify residents by their photo in the computer. Ask his/her name. If unsure of either step listed above, verify with another staff member. Review of R1's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus with diabetic chronic kidney disease, acute respiratory failure with hypoxia, sepsis, iron deficiency anemia, metabolic encephalopathy, chronic kidney disease, dysphagia, peripheral vascular disease, personal history of transient ischemic attack (TIA), and cerebral infarction. Review of R1’s quarterly “Minimum Data Set (MDS)” located under the “MDS” tab of the EMR with an Assessment Reference Date (ARD) of 04/17/25 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderate cognitive impairment. Review of R1’s “Progress notes” located under the “Prog Notes” tab of the EMR dated 05/11/25 at 9:00 AM, documented, wrong medications were given to [R1]. The resident was able to follow directions by squeezing fingers but was very lethargic and could not follow any other commands, unable to respond verbally to any questions, could not open eyes and drool running out of his mouth with deep, slow shallow respirations. Resident’s vital signs were 141/79, pulse 100, O2 Sat 95% RA, Resp 12 and BS 299. Immediately called 911 after assessment and reviewing medications given. Ambulance arrived at 0916 [9:16AM] and resident was transported to hospital. POA [Power of Attorney] called and updated on wrong medications given….On call doctor notified and gave orders to send to the hospital Review of R8’s Medication Administration Record (MAR) dated 05/11/25 located under the Reports tab of the EMR revealed R8 was to be administered amiodarone (cardiac antiarrhythmic) 200 milligram (mg), bumetanide (diuretic) 0.5 mg, carvedilol (blood pressure) 3.125 mg, clozapine (antipsychotic) 25 mg, divalproex (anticonvulsant) 125 mg, Jardiance (diabetic) 10 mg, and lamotrigine (anticonvulsant) 150 mg in the morning. Review of a written statement by Licensed Practical Nurse (LPN) 2 dated 05/13/25 stated, “On 05/11/25, I was working on the 700 unit for AM [morning] shift. I was preparing to give [R8]’s medications, the aid was getting him dressed. I went into [another resident’s] room and came out. A patient wheeled up to the cart asked if I had something for him. I said yes I do. Let me take your BP [R8] and he gave me his arm to get is vitals. I asked him about how unique his name and how he looked like the actor. He said he got that before. He said he was really ready to get to breakfast. I said ok. I have your meds ready. I gave who I thought to be [R8] his meds. I said have a good day, see you later, enjoy breakfast [R8]. He proceeded to breakfast. I continued my med pass and about an hour later the aid wheeled who I knew to be [R8] back to the unit and asked if I could check him. He wasn’t himself, very sleepy. I rubbed his chest, called him [R8] 2x and the aid asked what did you call him. I said [R8]. [The aid] said that’s not [R8], that’s [R1]. I immediately opened my med drawer to see and make sure I didn’t give him [R8]’s med and I discovered I had. I took his vital signs and blood sugar, took him to the nurses’ station, kept talking to him, not calling him [R8], but [R1]. Called for [another nurse] to help me and she told me what unit the supervisor was on to call her too and she would be right over. I called the supervisor, explained what happened. She told me to contact the doctor, and she would send another registered nurse to help me and call the family too. [We] felt because of [R1] condition changes and vital signed calling 911 to send him to the hospital was best not to wait for the doctor to call back. I normally would not give patients meds that wheel up to me.” Review of hospital records revealed R1 was hospitalized from [DATE] to 05/13/25. Review of LPN2’s employee record revealed she had been suspended pending the investigation and resigned from her position. During an observation on 07/11/25 at 11:50 AM, R1’s room was located across the hall from R8’s room. During an interview on 07/11/25 at 11:50 AM, R1 introduced himself. When asked if he received the wrong medications a month or two ago, he at first replied, “No, I got some wrong medications at the hospital.” Then he said, “I got 14 wrong medications and had to go to the hospital because I was unconscious for a while. I was there for a week. I’m okay now.” During an interview on 07/11/25 at 2:10 PM, the Director of Nursing (DON) stated, “Medication errors are taken very seriously, and the resident was hospitalized . Nurses are expected to follow the six rights of medication administration and verify the resident’s identity.”

Based on interview and record review the facility did not report 1 (R12) of 3 reportable incidents to the State survey agency and/or Law Enforcement within the required timeframe. *On 02/12/2025, The facility was made aware of R12's missing narcotic medication. The facility did not notify the State Agency at any point, and did not notify Law Enforcement until 02/28/2025. Findings: The facility Policy, titled ABUSE, NEGLECT, MISAPPROPRIATION, EXPLOITATION, MISTREATMENT, dated 10/26/2016, documents the following, Policy: . It is the policy of this facility that all allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property are reported per Federal and State Law. or not later than 24 hours if the events that cause the allegations do not involve abuse and no not result in serious bodily injury, to the Administrator of the facility and to other state officials in accordance with Federal and Wisconsin Law, through established procedures. 7. Reporting: Employees must always report an abuse or suspicion of abuse IMMEDIATELY to the Supervisor on duty . B. The Supervisor on duty will notify the Administrator of the allegation. The Administrator will involve key leadership personnel as necessary to assist with the reporting, investigating and follow up. C. If an incident is considered reportable. The Administrator or designee will make an initial (immediate within 24 hours) report to the Division of Quality Assurance Office of Care Giver Quality. E. Law Enforcement will be notified immediately but no later than two hours if there is suspicion of a crime / or alleged sexual abuse as required by the Elder Justice Act. Surveyor reviewed a complaint sent into the State Agency regarding allegations of narcotic/medication diversions had occurred at the facility in February 2025. Surveyor, along with a team of Surveyors, entered the facility on 03/10/2025 to complete a complaint and verification survey. Surveyor requested facility Investigations from 12/2024 to current. The facility provided two facility reported investigations, Surveyor noted neither were related to medication diversion. On 03/10/2025, at 10:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E, on the 400 unit, regarding the procedures for Narcotic medications. LPN-E indicated all narcotic medications are kept in a [NAME] box on the medication cart. LPN-E indicated that 2 nurses will now perform the narcotic medication count in the medication room in front of the camera. Surveyor asked LPN-E if narcotic medication count in the medication room was a newly implemented procedure. LPN-E indicated being unsure if the procedure is new, but indicated an email was sent out last month (February) indicating to ensure medication counts are done in the medication room in front of the camera. Surveyor preformed a narcotic medication count with LPN-E. Surveyor noted, no discrepancies identified with the narcotic medication count. On 03/10/2025, at 11:04 AM, Surveyor interviewed LPN-K, on the 500 unit, regarding the procedures for Narcotic medications. LPN-K indicated that Narcotic medications are kept in the [NAME] box of the medication cart. LPN-K indicated counts are down with 2 nurses and the beginning and end of each shift. LPN-K indicated that the Narcotic medication counts were not always preformed in the medication room and indicated that in February of 2025, on this unit (500 unit), there was an incident where a Narcotic medications were missing. LPN-K indicated the facility was aware and after the incident, staff are now to count Narcotic medications in the medication room in front of the camera. LPN-K indicated there was training and re-education provided by the facility following the incident. LPN-K indicated destruction of unused Narcotic medications are destroyed in the medication room, with 2 nurses. LPN-K indicated 2 nurses sign off on the medication and the medication is put into a container labeled Drug Buster.LPN-K indicated that the paper work is then put into the out box in the nurses station. Surveyor preformed a narcotic medication count with LPN-E. Surveyor noted, no discrepancies identified with the narcotic medication count. On 03/10/2025, at 03:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked NHA-A and DON-B if the facility has had any concerns or issues with drug diversion. DON-B indicated that yes, in February around the 9th through the 11th, an incident occurred resulting in the facility initiating an Investigation. NHA-A indicated they are still in the midst of investigation the allegation. Surveyor inquired as to why the facility did not report the allegation to the State Agency. DON-B indicated the State Agency was not notified because DON-B did not know if the Narcotic medication (oxycodone) was actually missing and indicated the facility is still investigating the allegation. DON-B indicated the nurse who normally works that unit was out for about a week and upon return indicated there was a missing Narcotic medication card. On 03/11/2025, at 08:34 AM, Surveyor received the facility investigation for the missing Narcotic medication. Within the Investigation report, Surveyor noted a document which indicated the narcotic medication was last given on 02/06/2025, a card of 20 oxycodone was delivered on 01/31/2025 and was signed in to the facility. The document indicates the last oxycodone from the prior card that was deliver on 01/21/2025 contained 20 pills and was given on 02/02/2025. From 02/02/2025 there was a total of 8 oxycodone given to R12 and indicated R12 should still have 12 remaining. The card and sign out sheet were discovered missing on 02/12/2025. HR notified. Drug urine will be requested to be done on all staff that worked between time frame. All were negative. Surveyor noted written in pen 2/28/25-Sheriff notified. On 03/11/2025, at 10:55 AM, DON-B indicated to Surveyor that the facility notified Law Enforcement of the allegation after the facility Corporate [NAME] suggested to notify police on 02/28/2025. On 03/11/2025, at 12:41 PM, Surveyor shared concerns with NHA-A, DON-B, Assistant Director of Nursing (ADON)-I, and Nursing Supervisor (NS)-C regarding the facility not reporting R12's missing narcotic medication to the State Agency and the delay reporting the misappropriation to law enforcement. No additional information was provided at time of write up.

Based in interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R8) of 4 residents reviewed. * On 12/4/2025 at 9:00 AM R8 did not have a comprehensive assessment completed when R8 yelled and cried out stated stated R8's foot hurt. Licensed practical nurse (LPN) assessed R8's leg instead of R8's foot and noted no pain. There was no documentation of an assessment or pain assessment completed at that time for R8. On 12/4/2025 in the evening R8 was noted to have pain in the left foot, LPN noted R8 left toes were swollen and painful to touch. An order for x-ray was obtained and R8 was noted to have a 3rd, 4th, and 5th, metatarsal (toe) fractures on the left foot. R8 was sent to the hospital for further evaluation and readmitted to the facility with a half open cast and Ace wrap to R8's left lower extremity. Findings include: The facility policy titled Change of Condition Assessment and Reporting Requirements revised February 1, 2019, documents: Purpose: 1. To identify individuals at risk for an acute change of condition (ACOC). 2. To systemically collect and document data when the resident experiences an ACOC. 3. To systemically collect and document data to monitor the resident's condition in response to treatment. 7. To ensure that any chance in condition or incident is reported in accordance with State and Federal guidelines. Procedure: Step 1- Identify individuals at risk for ACOC's. - All interdisciplinary team (IDT) members are expected to report findings that may represent and [sic] ACOC. (this includes CNA's .) Step 2- Describe and document symptoms and/or condition changes accurately and completely . When assessing a resident with signs and symptoms that may indicate an ACOC the minimum to be done includes: - Regardless of cognitive level, ask the resident how he/she is feeling or how the symptoms developed. Absence of a response should be documented. - Take vital signs. - Assess overall condition, . and function. Step 3- Document the nature, extent and severity of symptoms, abnormalities and condition changes clearly and in detail to help distinguish potential causes and consequences and to determine whether the symptoms are problematic or simply normal expected variants. - Observation, documentation and description of symptoms must be distinguished from interpretation. Complete head to toe assessment of resident (neurological, . skin, behavior, musculoskeletal, pain, .). - Imprecise descriptions of the problem or incorrect interpretation of the symptoms may lead to erroneous diagnosis and inappropriate treatment. - Document assessment on situation, background, assessment, recommendation (SBAR) form and file in the chart. Be sure to enter that an SBAR was completed in the medical record. Documentation/ Follow-up Guidelines: -Monitor progress: all staff are responsible for reporting any findings that may represent ACOC's. - Frequency of assessment must be determined by the registered nurse (RN) according to stability of condition but must be completed at least one time per shift for all residents on report for ACOC. - To facilitate communication, resident should be placed on the To Do list . for follow-up charting for 72 hours after the change. - Review all progress notes at least daily including summary of overall condition and a comparison of actual progress with expected progress as noted in the care plan. 1.) R8 was admitted to the facility on [DATE] and has diagnoses that include Multiple Sclerosis, Dementia with behavioral disturbance, major depressive disorder, Pseudobulbar affect, right foot drop, polyneuropathy, memory deficit and severe osteopenia. R8's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicating that R8 has moderately impaired cognition. The MDS documents that R8 needs total assist with 1 staff member for toileting and personal hygiene, lower body dressing, putting on and off footwear, and repositioning. R8 was incontinent of bowel and bladder and wore protective briefs and required a Hoyer lift with 2 staff members for transfers. R8's pain MDS assessment documented R8 denied pain, does not receive scheduled pain medication, did not receive as needed (PRN) pain medication or other interventions for pain in the last 5 days of the assessment on 9/24/2024. R8's annual MDS dated [DATE] did not trigger a pain care area assessment (CAA). R8's pain care plan was initiated on 8/5/2021 and last reviewed/revised on 1/17/2025 with the following interventions: Problem: I (R8) may experience pain. I like to keep my pain at a minimum. I have neuropathic pain and right foot drop and utilize Gabapentin daily at bedtime to promote comfort. - I need my aides to --- be extra gentle with me; ask me if I hurt; tell the nurse if I hurt; help me get dressed; be patient with me; keep my chair comfortable; make my bed comfortable; help me to change position. - I need my nurse to --- ask me if I hurt; be patient with me; help me mover around if I need it; Help me to change position. On 12/4/2024, at 2018 (8:18 PM), in the progress notes, nursing documented R8 complained of left foot pain when up for supper. Later when CNA was going to give R8 a shower, R8 complained of left foot pain. The CNA notified nursing a that time. Nursing noted some swelling, no bruising or redness, and painful to touch. Nurse supervisor notified and new orders x-ray. R8's progress note dated 12/4/2024, at 2206 (10:06 PM) documented R8 going to hospital for further evaluation. (R8's x-ray) positive for mild fracture to left 3rd, 4th, and 5th metatarsals (toe). R8's progress note dated 12/5/2024, at 0409 (4:09 AM), documented R8 returned to facility with half open cast with ACE wrap to left lower extremity. The Facility submitted a Facility Self Report on 12/5/2024 at 3:06 PM for an injury of unknown origin for R8. The summary of incident documents: . - On December 4th, 2024, R8 was found to have a displaced fracture of the left 3rd, 4th, and 5th metatarsals. R8 first reported pain to the day shift CNA-D at approximately 0900 (9:00 AM) during cares. R8 did not report pain again until PM shift on December 4th at approximately 1600 (4:00 PM) to CNA-G and another CNA who was assisting CNA-G. R8 again reported pain at shower time that evening. LPN-H assessed and noted slight swelling to the left foot, no redness but R8 was having pain. X-rays were obtained and confirmed the fractures. R8 has sever cognitive impairment 2nd to Dementia. R8 is unable to state how this injury happened but stated R8 feels safe in the environment. - Describe the Effect: (R8) expressed pain with cares, putting on and taking off pants and socks. There are no identified witnesses. Time of injury unknown. (R8) has immobilizer in place and has not been reporting pain. Surveyor reviewed the staff statements that were documented: - CNA-D's statement documented: CNA-D was assigned R8 morning of incident. CNA-D was washing up and getting R8 dressed for the morning. R8 complained of bad pain in R8's foot. CNA-D covered R8 up and went to report situation to the nurse. The nurse went to check R8. - LPN-E's statement documented: LPN-E was the nurse working with R8 on 12/4/2024. LPN-E was called into R8's room for R8 complaining of leg pain. LPN-E documented after assessment (word assessment is crossed out in error with LPN-E initials) clinical data obtained, R8 no complaints of pain at this time. Range of motion (ROM) within normal limits at that time. Surveyor noted that CNA-D documented R8 had bad foot pain, but LPN-E documented looking at R8's leg. Neither statement document if it was R8's left or right foot or leg. - CNA-G's statement documented CNA-G was the assigned CNA for R8 on 12/4/2024 PM shift. CNA-G and another CNA went to get R8 up, R8 complained of foot pain so CNA-G went to get nurse. Surveyor noted that CNA-G's statement documents one time of R8 complaining of pain and getting the nurse. CNA-G statement does not indicate a time the nurse was notified. LPN-H's statement documented R8 complained of left foot pain when up for supper, then later when CNA was going to give R8 a shower R8 complained of left foot pain and toes. That is when CNA notified LPN-H. R8 had pain to the touch of foot and toes, some swelling noted, no redness or bruising noted. R8 unable to say what happened. Supervisor and medical provider notified. On 3/11/2025 at 8:40 AM, Surveyor called and left voice message with return phone number for CNA-G to call back Surveyor. Surveyor never received a return phone call from CNA-G. On 3/11/2025, at 9:07 AM, Surveyor called and left a message with return phone number for LPN-H to call back Surveyor. Surveyor never received a return phone call from LPN-H. On 3/10/2025, at 10:05 AM, Surveyor observed R8 sitting in a Broda wheelchair watching TV. R8 was wearing black Velcro tennis shoes. R8 did not recall a time when she had problems with her feet and denied pain at that time when talking with Surveyor. R8 stated she felt safe at the facility and did not have any concerns. Surveyor reviewed R8's medical record and noted there were no progress notes documenting R8's complaint of pain to the foot, no comprehensive assessment was documented, and no pain assessment completed for R8's complaint of foot pain in the morning on 12/4/2024. Surveyor noted a pain assessment completed on 12/4/2024, at 1939 (7:38 PM) and R8 was given two Tylenol 325 mg (totaling 650 mg) for verbal pain rating of 6/10 per order. On 3/10/2024, at 1:12 PM, Surveyor interviewed CNA-D who stated CNA-D usually gets R8 up and ready between 8:00 AM and 9:00 AM. CNA-D stated that R8 was lying in bed and CNA-D went to put R8's sock on and R8 yelled out about her foot and started crying. CNA-D stated she did not see anything wrong with R8's foot, but R8 was crying and never complains of pain. CNA-D covered R8 up and went to get LPN-E to look at R8. Surveyor asked if R8 had pain in the leg at all or was it just R8's foot, and what foot/leg did R8 complain about. CNA-D stated that it was definitely R8's foot that was the concern, but R8 complained of the opposite foot than what had fractures at that time. Surveyor confirmed with CNA-D that R8 has complaints of pain in the right foot. CNA-D stated yes and that is what was relayed to LPN-E. Surveyor asked if CNA-D was in the room when LPN-E checked on R8. CNA-D stated no CNA-D did not go with LPN-E. CNA-D went to help another resident and when was finished with that resident CNA-D asked LPN-E if R8 could get up and LPN-E stated that LPN-E did not see anything and R8 was good to continue getting ready for the day. Surveyor asked CNA-D if R8 had any more complaints of pain throughout the day. CNA-D stated R8 had no further complaints. Surveyor asked CNA-D if it was reported to the upcoming shift that R8 had complaints of pain in R8's foot. CNA-D could not recall if CNA-D passed it on in shift report if R8 had pain in the foot in the morning. On 3/11/2025, at 8:47 AM, Surveyor interviewed LPN-E who stated CNA-D came up and stated R8's leg hurt. LPN-E stated went into room pretty quickly because R8 never complains about pain. LPN-E stated LPN-E looked at R8's left leg. LPN-E stated R8 denied having pain and was not crying. LPN-E stated that LPN-E did not look at R8's foot or toes because CNA-D stated it was R8's leg. LPN-E stated R8's socks were on and did not remove them to look at R8's foot or toes. LPN-E stated that LPN-E held R8's heel and middle of foot to bed R8's leg to assess ROM and R8 did not indicate any pain at that time. Surveyor asked LPN-E what the Facility process or procedure is when a resident complains of pain or an acute change. LPN-E stated the nurse supervisor would be notified to come do an assessment on the resident and medical provider notified for further directions. Surveyor asked if the nurse supervisor was notified. LPN-E stated that LPN-E did not notify the nurse supervisor because R8 did not have complaints of pain and LPN-E did not see anything on R8's left leg. Surveyor asked LPN-E how LPN-E knew what leg to look at. LPN-E stated it must have been what CNA-D told LPN-E. Surveyor asked how often residents are assessed for pain and where is documentation located. LPN-E stated that LPN-E asks each resident at least once when LPN-E is working. LPN-E stated that LPN-E usually does not document pain unless resident indicated they have pain and then an assessment with any medication is given for pain and the reassessed if interventions worked. Surveyor asked if R8 wrote a progress note or passed on in shift report that R8 experienced pain. LPN-E stated did not write a progress note because R8 did not express having pain when LPN-E went to look at R8. LPN-E could not recall if R8's pain was passed on in shift report or if it was documented on the 24 hour board. LPN-E state in hindsight, maybe should have written something or told the nurse supervisor, but at the time R8 did not have pain. LPN-E stated that if R8 did express pain, LPN-E would have notified the nurse supervisor, and documented R8's pain and made a progress note. On 3/11/2025, at 9:19 AM, Surveyor interviewed Nursing Supervisor (NS)-C who stated nursing gather information if a resident is expressing pain such as: what happened, do ROM, ask if anybody hurt them. NS-C stated that if someone is experiencing pain it should be assessed and documented. Surveyor asked NS-C if NS-C was notified that R8 was having pain. NS-C was not notified and stated since it was an acute pain for R8, NS-C would have expected to be notified even if R8 rated no pain at the time so a full assessment could be completed. NS-C stated that it should have been documented in the progress notes and a pain rating obtained even though R8 did not stated R8 was having pain at that time. NS-C stated that the nursing staff had education about a year ago going over how to correctly chart a pain assessment. Surveyor asked how often pain assessments are completed and documented on residents. NS-C stated that residents should be asked each shift and if it is a new pain, a pain event should be documented that describes where the pain is located if an injury had occurred, and then fills out a pain assessment. NS-C could not find that that was done for R8 the morning of 12/4/2024. On 3/11/2025, at 9:47 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Assistant DON (ADON)-I and NS-C were also present during the interview. Surveyor asked what the expectation is when assessing a resident that indicated they had pain. DON-B stated that the nurse would do a pain assessment and then look at the resident's orders and see what is available or call the medical provider if necessary. Surveyor brought concern up regarding R8 not being comprehensively assessed when R8 complained of pain on 12/4/2024. NHA-A and DON-B stated that when LPN-E assessed R8, R8 indicated there was no pain. Surveyor stated that LPN-E looked at R8's left leg and did not look at R8's left foot or toes. Surveyor also stated that CNA-D originally stated that R8 was complaining of the right foot hurting and that CNA-D did tell LPN-E that R8's foot was hurting. NHA-A stated that at the time R8 did not complain of any pain, so no further assessment was needed. Surveyor stated that it was told to Surveyor that even though R8 did not complain at the time LPN-E looked at R8, it was still a change for R8 who never complained of pain and that R8's pain should have been comprehensively assessed and documented even though R8 was stating there was no pain at the time. DON-B and NHA-A stated that a new pain is not considered a change in condition and did not see concern due to R8 not indicating R8 had pain at the time. Surveyor requested a policy a procedure for assessing a resident when residents have a complaint. Surveyor shared concerns that R8 was not comprehensively assessed after CNA-D notified LPN-E that R8 was having foot pain. R8's leg was assessed instead of R8's foot. R8 complained of foot pain in the evening and an x-ray indicated R8 had fractures of the 3rd, 4th, and 5th metatarsals on R8's left foot. On 3/11/2025, at 12:08 PM, DON-B brought the policy and procedure for Change of Condition Assessment and Reporting Requirements. Surveyor reviewed and is documented above in the cite write up. On 3/11/2025, at 12:30 PM, Surveyor shared with NHA-A, DON-B, ADON-I, and NS-C that Surveyors concern that R8 was not comprehensively assessed when first indicated foot pain, that the leg was assessed rather than the foot, R8 had no documentation in progress notes or a pain assessment completed, and later in the evening on 12/4/2024 R8 complained of pain and a X-ray showed R8 had toe fractures on the left foot. No additional information was provided as to why R8 did not receive treatment and care in accordance with professional standards of practice for R8's foot pain.

Based on interview and record review the facility did not ensure that 2 (R9, R12) of 3 allegations of mistreatment involving residents were investigated or thoroughly investigated timely. * R9 reported her engagement and wedding ring as missing, and the facility completed a self-report. There was no documentation of other residents on R9's unit being interviewed for missing items. R9's family reported to the facility that they suspected a newer staff member to be involved, and the facility did not submit this to the state agency nor complete an addendum to the original facility self-report. * The facility was made aware by staff that R12 had missing medications, and did not submit the allegations of potential misappropriation to the state agency. Findings include: The facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation, Mistreatment dated: 10/26/2016 states under the policy: . 6. Investigation: A. The investigation is the process used to try and determine what happened. The designated facility personnel will begin the investigation immediately. If abuse injury of unknown origin suspicious injury misappropriation involuntary seclusion any violation of resident rights or exploitation, is suspected or alleged the administrator (designee) must be notified immediately. 1.) R9 was admitted to the facility on [DATE] with a diagnosis of dementia, psychotic disturbance, mood disturbance, and anxiety and obesity. R9's Quarterly Minimum Data Set (MDS) dated [DATE], documents a brief interview for mental status (BIMS) score of 13, indicating that R9 is cognitively intact. The MDS documents under section B, that R9 is understood and understands. Under section E (behavioral symptoms it documents that R9 does not exhibit any behaviors. R9's medical records nursing note, dated 12/4/2024 at: 3:03 AM, documents that a CNA informed the floor nurse of a missing wedding ring, and floor nurse in turn, updated the night shift RN supervisor of the missing ring. On 3/10/2025, at 11:06 AM, Surveyor asked Nursing Home Administrator (NHA)-A for a police report from the reported misappropriation. NHA-A indicated NHA-A made repeat attempts to receive the report through sheriff's office via phone calls and emails with no response back. NHA-A stated that NHA-A will attempt again. On 3/10/2025, at 11:27 AM, Surveyor interviewed via phone, CNA-J who stated that R9 reported missing rings at around 2:00 AM. CNA-J stated the nurse then reported to supervisor at around 2:40 AM. On 3/10/2025, at 11:40 AM, Surveyor received the sheriff's report from NHA-A, The sheriff report dated,12/5/2024 at 9:37 AM, documents: I contacted [Family member name] (Family)-L and conducted an interview via telephone. [Family member name] Family-L stated that she was told that her mother said she gave the rings to 1 of her daughters, to be cleaned. [Family member name] Family-L believes that an employee has convinced [Residents name] R9 somehow, to give them the rings. [Family member name] Family-L stated that she was told by a nurse's aide, that a different nurse's aide, had heard that the patient next door had lost a wedding ring as well. [Family member name] Family-L was unable to provide any names of any nurse's aides. [Family member name] Family-L spoke highly of the facilities staff but believed a newly hired staff member was likely involved in the disappearance of the rings. On 3/10/2025, at 1:55 PM, DON-B stated that R9 and one other resident were asked about missing items. DON-B indicated that the other resident that was questioned, claimed things are missing a lot and random items like a car but no mention of a missing ring when questioned. DON-B indicated this resident was picked because of statements from R9's family that this resident was also missing rings. DON-B stated 2 other residents were asked if everything was alright, but not about missing items. DON-B indicated not wanting to put thoughts in the resident's heads that it was unsafe at the facility. DON-B indicated having no documentation of other residents being interviewed but that second shift supervisor might have additional documentation. On 3/10/2025, at 3:33 PM, Surveyor informed NHA-A, DON-B and Assistant Director of Nursing (ADON)-I of concerns with R9's family reporting that the new hire CNA was involved in the misappropriation. DON-B indicated knowing which CNA R9's family was referring to as there was only one new hire at that time. DON-B indicated there was not a new report started or an addendum to the self-report as this CNA was already interviewed. NHA-A indicated that the new hire CNA was not interviewed again. NHA-A stated: you don't finger point someone out like that, that's jacked up. NHA-A indicated believing this was being brought up because this was a new employee. On 3/10/2025, during the end of the day meeting, Surveyor explained concern that R9's family reported concern that this new hire CNA was involved in misappropriation. Surveyor explained there was no documentation of other residents on the unit being interviewed for missing items. Surveyor explained that the facility became aware of which CNA R9's family was reporting, as there was only one new CNA hired during that time, but didn't include these findings in the reported misappropriation. On 3/10/2025, at 4:10 PM, Surveyor interviewed Registered Nurse (RN)-M who stated that RN-M is the second shift supervisor, and that RN-M did assist DON-B with R9's investigation of misappropriation. RN-M indicated that with investigations or interviews like R9's misappropriation allegation that RN-M would take notes and have documents. RN-M stated he was not the main person doing this interview, and that DON-B would have the notes or documents that pertain to this investigation. No additional information was provided. 49845 2.) Surveyor reviewed a complaint sent into the State Agency regarding allegations of narcotic/medication diversions had occurred at the facility in February 2025. Surveyor, along with a team of Surveyors, entered the facility on 03/10/2025 to execute a complaint and verification survey. Surveyor requested facility Investigations from 12/2024 to current. The facility provided 2 facility Reported Investigations, Surveyor noted neither were related to medication diversion. On 03/10/2025, at 10:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E, on the 400 unit, regarding the procedures for Narcotic medications. LPN-E indicated all narcotic medications are kept in a [NAME] box on the medication cart. LPN-E indicated that 2 nurses will now perform the narcotic medication count in the medication room in front of the camera. Surveyor asked LPN-E if narcotic medication counts in the medication room is a newly implemented procedure. LPN-E indicated being unsure if the procedure is new, but indicated an email was sent out last month (February) indicating to ensure medication counts are done in the medication room in front of the camera. Surveyor preformed a narcotic medication count with LPN-E. Surveyor noted, no discrepancies identified with the narcotic medication count. On 03/10/2025, at 11:04 AM, Surveyor interviewed LPN-K, on the 500 unit, regarding the procedures for Narcotic medications. LPN-K indicated that Narcotic medications are kept in the [NAME] box of the medication cart. LPN-K indicated counts are down with 2 nurses and the beginning and end of each shift. LPN-K indicated that the Narcotic medication counts were not always preformed in the medication room and indicated that in February of 2025, on this unit (500 unit), there was an incident where Narcotic medications were missing. LPN-K indicated the facility was aware and after the incident, staff are now to count Narcotic medications in the medication room in front of the camera. LPN-K indicated there was training and re-education provided by the facility following the incident. LPN-K indicated destruction of unused Narcotic medications are destroyed in the medication room, with 2 nurses. LPN-K indicated 2 nurses sign off on the medication and the medication is put into a container labeled Drug Buster. Surveyor preformed a narcotic medication count with LPN-E. Surveyor noted, no discrepancies identified with the narcotic medication count. On 03/10/2025, at 03:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked NHA-A and DON-B if the facility has had any concerns or issues with drug diversion. DON-B indicated that yes, in February around the 9th through the 11th, an incident occurred resulting in the facility initiating an Investigation. NHA-A indicated they are still in the midst of investigating the allegation. Surveyor inquired as to why the facility did not report the allegation to the State Agency. DON-B indicated the State Agency was not notified because DON-B did not know if the Narcotic medication (oxycodone) was actually missing and indicated the facility is still investigating the allegation. DON-B indicated the nurse who normally works that unit was out for about a week and upon return indicated there was a missing Narcotic medication card. On 03/11/2025, at 08:34 AM, Surveyor received the facility investigation for the missing Narcotic medication. Within the Investigation report, Surveyor noted a document which indicated the narcotic medication was last given on 02/06/2025, a card of 20 oxycodone was delivered on 01/31/2025 and was signed in to the facility. The document indicates the last oxycodone from the prior card that was deliver on 01/21/2025 contained 20 pills and was given on 02/02/2025. From 02/02/2025 there was a total of 8 oxycodone given to R12 and indicated R12 should still have 12 remaining. The card and sign out sheet were discovered missing on 02/12/2025. Human Resources (HR) notified. Drug urine will be requested to be done on all staff that worked between time frame. All were negative. Surveyor noted written in pen 2/28/25-Sheriff notified. On 03/11/2025, at 10:55 AM, DON-B indicated to Surveyor that the facility notified Law Enforcement of the allegation after the facility Corporate [NAME] suggested to notify police on 02/28/2025. On 03/11/2025, at 12:41 PM, Surveyor shared concerns with NHA-A, DON-B, Assistant Director of Nursing (ADON)-I, and Nursing Supervisor ( NS)-C regarding the facility not submitting R12's missing Narcotic medication Investigation to the State Agency within 5 working days. No additional information was provided at time of write up.

Based on interviews, record review, and review of facility policy, the facility failed to ensure that one of three residents (Resident (R)1) reviewed for pressure ulcers out of a total sample of five did not develop a pressure ulcer, unless their clinical condition showed that it was unavoidable. R1, who entered the facility without any skin issues to his right heel, developed a facility-acquired deep tissue injury (DTI) pressure ulcer that deteriorated to an unstageable ulcer. There was no documentation the facility monitored R1's skin and implemented interventions as ordered by the physician and identified in the resident's plan of care. Findings include: Review of the facility's policy titled Prevention of Pressure Ulcers dated 01/06/23, revealed, . The care plan should address the potential for skin breakdown for residents who are at risk. At risk residents will have appropriate pressure-reducing devices on their wheelchair. The resident who is unable to change position on their own will be repositioned frequently according to their individual needs. Resident will be repositioned using appropriate lifting techniques or equipment (ex. Lift sheet) to prevent friction and shearing. Pillows or other devices will be used as needed to prevent pressure between the knees, ankles, etc. When in bed, the immobile resident will have their heels elevated off the bed so that they are 'floating.' Any sign of pressure ulcer formation will be identified, and treatment will be initiated in a timely manner to prevent further tissue damage . Review of R1's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, indicated the resident was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included fracture of the left acetabulum (pelvic region); multiple fractures of ribs, wedge compression fractures of the first, second, and third vertebra; and benign prostatic hyperplasia (enlarged prostate). Review of R1's admission Minimum Data Set (MDS), located in the EMR under the MDS tab, revealed R1 had a Brief Interview of Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. It was recorded that R1 required extensive assistance of two staff members for bed mobility, transfers, locomotion off/on unit, dressing, toilet use, and personal hygiene. It was recorded that R1 had a urinary catheter and was occasionally incontinent of bowels. It was recorded R1 was admitted with one unhealed stage II pressure ulcer to the sacrum and was assessed as being at risk for further pressure ulcer development. It was recorded that skin treatments/interventions included pressure reducing devices for the bed, pressure ulcer/injury care, surgical wound care, and applications of ointments/medications. Review of R1's Care Plan, initially dated 08/17/23 and located in the EMR under the Care Plan tab, revealed the resident had the potential for pressure ulcer development related to decreased mobility/generalized weakness following hospitalization due to pelvic fracture. The short term goal was, . will have intact skin free of redness, blisters, or discoloration . Approaches included, . check my skin during cares; complete a full body checks weekly and document, reduce pressure/friction between myself and my bed/chair, evaluate my skin under tubing or other devices that are in direct contact with my skin, reposition and assist me with bed/chair mobility frequently to prevent pressure to my skin, reposition and assist me with bed/chair mobility frequently to prevent pressure to my skin, provide incontinence care as needed to keep my skin clean and dry, and elevate my heels when I'm in bed. Monitor my nutrition and hydration status, follow facility protocols for prevention of skin breakdown. Review of R1's Admission Assessment, dated 08/17/23 at 2:00 PM and located in the EMR under the Progress Notes tab, indicated the resident had excoriation to the coccyx and a dark purple bruise to the right buttock, measuring 1.5 centimeters(cm) by 0.8 cm. Skin and Ulcer/Injury Treatments indicated applications of a non-surgical dressing and application of an ointment/medication. There was no documentation of any pressure ulcers to the resident's heels. Review of R1's Observation Detail List Report: Braden Scale, dated 08/17/23 at 6:41 PM and located in the EMR under Observation tab, revealed R1's Braden scale score was a 16, which indicated the resident was a mild risk for the development of pressure ulcers. Review of R1's EMR, dated 08/17/23 through 10/03/23, revealed no documented evidence that R1's heels were floated as per the care plan interventions, that skin checks were performed during care, or that the resident was repositioned frequently. Review of R1's Progress Note, dated 10/04/23 at 10:18 PM and located under the Progress Notes tab of the EMR, revealed . called to room re: blister 5 x 5.5 cm to right heel, skin prepped area and heel lift placed under legs to elevate heels. Updated Hospice re: new area and re: skin tear to left buttock as there were no orders for treatment. Treatment orders in place for border gauze to left buttock and skin prep to right heel. Hospice nurse will evaluate right heel in am . Review of R1's Care Plan, located under the Care Plan tab of the EMR and dated 10/04/23, revealed the resident's Care Plan was updated to include, . Pressure Ulcer/Injury I have a blister/DTI [deep tissue injury] to my right heel and need a heel riser to help protect it when in bed HEEL BOOT ON AT ALL TIMES . Interventions included, . apply treatment as ordered by MD. Chartable Task in POC [Point of Care]: unchecked [,] Care Needs Sign-off in POC: unchecked [,] Include on Profile: unchecked . Review of a hospice Nursing Visit Note, dated 10/05/23 at 1:45 PM, revealed, . new DTI to right heel. Writer took off shoe and assessed right heel. New orders obtained for treatment to include skin prep bid and off-loading boot on right foot at all times . new order for tubi grips [a tubular bandage that provides support for the treatment of soft tissue injuries] . Review of R1's Progress Note, dated 10/05/23 at 2:27 PM and located under the Progress Notes tab of the EMR, revealed, . Hospice in this afternoon to see resident. Verbal orders were given to keep heel boot on right foot at all times to help offload pressure to DTI [deep tissue injury], tubi-grips on in AM [morning], and off HS [bedtime] . Review of R1's Progress Note dated 10/09/23 at 10:34 AM and located under the Progress Notes tab of the EMR, revealed . Received order from MD [medical doctor] 1. Apply tubi grips on in a.m., off HS, 2. Keep off loading boot on at all times right foot DTI. 3. Skin prep right BID for DTI . Review of a hospice Nursing Visit Note, dated 10/09/23 at 9:00 AM, revealed, . Teaching provided during visit . instructed to make sure to be [sic] grips are cut to length of his legs and heel boot is too [sic] right heel at all times, and to not wear shoes . reported his right heel was hurting. Writer propped foot up on pillows to view heel. Skin to deep tissue injury head [sic] come off and blood was noted to heal [sic] . RNCM [RN Case Manager] called and made aware area was now open. New wound care orders obtained. Xeroform and calcium alginate applied and dry clean dressing . Writer then assisted [R1] with tubi grips to legs . Facility staff instructed to keep shoe off of right foot and to make sure to be [sic] grips are cut to length . RN was going to give PRN medication due to pain in right heel . Review of R1's Progress Note, dated 10/09/23 at 12:00 PM and located under the Progress Notes tab of the EMR, revealed, . right heel [dressing] will be changing . Right heal [sic] scab is off hospice nurse applied foam dressing to have boot on as much as possible . Will have order for xerofoam CA [calcium] alginate and bordered dressing to heal [sic] . Review of R1's Care Plan, located under the Care Plan tab of the EMR, revealed no documented evidence the resident's Care Plan was updated to include the deterioration of the resident's pressure ulcer from a DTI to an unstageable pressure ulcer or any new interventions were identified or implemented. Review of the Skilled Nursing Facility (SNF) Progress Note: Wound Care Assessment, dated 10/28/23 and located in the EMR under the Resident Documents tab, revealed interventions in place as, . pressure reduction devices, bed, cushion per facility protocol, nursing and wound care, nutritional support, and heel offloading boot in place at all times. Physical Examination: Unstageable pressure injury of right heel, full thickness wound measuring 5.5 cm x 6.0 cm x UTD. Scant serosanguineous drainage around the edges of the eschar . Status: improved . Assessment . Heel boot in place at all times except transfers . Review of R1's Point of Care (POC) documentation (documentation of CNA activities for the resident) for 08/17/23 through 10/30/23, located in the EMR under the POC tab, revealed no documentation R1 was repositioned frequently, that his heels were elevated, that skin checks were performed with care, or that the right heel boot was used as ordered. During an interview on 01/31/25 at 1:08 PM, Certified Nurse Aide (CNA)1 was asked if he remembered R1. CNA1 stated he did not recall the resident. CNA1 was asked what the process was for resident's pressure ulcers. CNA1 stated that the CNAs perform body checks on admission, and skin checks during care. During an interview on 01/31/25 at 1:47 PM, Registered Nurse (RN)1, RN1 was asked if he recalled identifying R1's heel ulcer. RN1 stated he did not recall the resident, but that he was part of the wound care team at that time. RN1 added, We (the facility staff) try to do everything we can to help residents to not develop pressure ulcers. During a telephone interview conducted with CNA2 on 01/31/25 at 1:58 PM, CNA2 was asked if he remembered providing care to R1. CNA2 stated he did not recall the resident, family, or any of the care he may have provided to the resident. An attempt to contact RN2 was made on 01/31/25 at 2:02 PM, and a message was left to return phone call. RN2 was the nurse who initially documented the resident had a deep tissue injury (DTI). During an interview with the Director of Nursing (DON) on 01/31/25 at 3:45 PM, and again at 4:45 PM, the DON was asked if there was any documented evidence that R1 was repositioned frequently, that skin checks were being completed with care, that the resident's heels were elevated, and that the tubi grips and heel boot were applied as ordered. No documentation was provided by the end of the survey.

Based on interviews, personnel files review, and policy review the facility failed to ensure a performance review was completed for three of five Certified Nurse Aides (CNA) 4, CNA1, and CNA 5) once every 12 months. Findings include: Review of the Nursing Staff Competency Policy, dated 03/02/22 revealed The facility will complete a performance review of every certified nursing assistant at least once every 12 months. 1. Review of CNA 4's personnel file revealed CNA 4 had a start date of 09/24/21. The KCDHS (Kenosha County Department of Human Services) Performance Feedback Form Represented Employees revealed her last review date was 09/23. During an interview on 11/14/24 at 9:51 PM, the Director of Nursing (DON) said CNA4's annual performance review had not been completed timely. She said CNA 4's hire date was 09/24/21 and the evaluation should have been completed no later than 09/24/24. 2. Review of CNA 1's personnel file revealed CNA 1 had a start date of 02/03/19. The KCDHS (Kenosha County Department of Human Services) Performance Feedback Form Represented Employees revealed her last review date was 02/28/23. The document was signed by the employee, the supervisor, and the DON on 05/07/24. 3. Review of CNA 5's personnel file revealed CNA 5 had a start date of 02/11/16. The KCDHS Performance Feedback Form Represented Employees revealed her last review date was 02/26/23. The document was signed by the employee, the supervisor and the ADON on 05/07/24. During an interview on 11/13/24 at 4:27 PM, the DON, Assistant DON (ADON) and the Administrator agreed that completing annual performance reviews timely for CNAs was very important.

Based on interview, record review, and facility policy review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility and failed to ensure a medication was administered on dialysis days for one of one residents (Resident (R) 5) reviewed for dialysis out of a sample of 32. Findings include: Review of R5's Face Sheet, found in the Resident Report tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnosis including end stage renal disease, type two diabetes mellitus, and dependence on renal dialysis. Review of R5's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 10/21/24, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. R5 was documented to receive dialysis while a resident. Review of R5's EMR under the Resident Orders tab under the Resident Reports revealed an order dated 08/11/21, for the resident to attend dialysis Tuesday, Thursday, and Saturday. Review of R5's EMR under the Resident Orders tab under the Resident Reports revealed an order, dated 02/15/24, for calcium acetate tablet 667 milligram (mg) .one capsule, oral once a day. Give 30 minutes before, up to 30 minutes after lunch .diagnosis chronic kidney disease. Review of R5's EMR under the Resident Orders tab under the Resident Reports revealed an order, dated 02/15/24, for calcium acetate tablet 667 mg (milligram) .one capsule, oral once a day. Give 30 minutes before, up to 30 minutes after lunch .diagnosis chronic kidney disease. The medication was scheduled to be administered 11:00 AM through 12:00 PM once a day. Review of R5's Medication Administration Record (MAR) of the EMR under the Resident Orders tab for September 2024, revealed calcium acetate tablet 667 mg was not administered on 12 of 12 opportunities, (09/03/24, 09/05/24, 09/07/24, 09/10/24, 09/12/14, 09/14/24, 09/17/24, 09/19/24, 09/21/24, 09/24/24, 09/26/24, and 09/28/24) and was coded by nursing staff as out of the facility on scheduled dialysis dates. Review of R5's MAR of the EMR under the Resident Orders tab for October 2024, revealed calcium acetate tablet 667 mg was not administered on 14 of 14 opportunities, (10/01/24, 10/03/24, 10/05/24, 10/08/24, 10/10/24, 10/12/24, 10/15/24, 10/17/24, 10/19/24, 10/22/24, 10/24/24, 10/26/24, 10/29/24, and 10/31/24) and was coded by nursing staff as out of the facility on scheduled dialysis dates. Review of R5's MAR of the EMR under the Resident Orders tab for November 2024, revealed calcium acetate tablet 667 mg was not administered on six of six opportunities, (11/02/24, 11/05/24, 11/07/24, 11/09/24, 11/12/24, and 11/14/24.) and was coded by nursing staff as out of the facility on scheduled dialysis dates. Review of R5's Blood Pressure Trends documentation, provided by the facility, revealed a date range of 09/13/24 through 11/13/24 and included pre and post weights, blood pressures, pulse, and ultrafiltration rate. The facility received the documentation from the dialysis center on 11/13/24 at 11:51 AM. This information was not in R5's EMR prior to the facility's request from the dialysis center. During an interview on 11/14/24 at 12:33 PM, Licensed Practical Nurse (LPN)1 said that she would take the vitals of R5 before she went out to dialysis and would send the resident with a Continuity of Care Document (CCD) folder. LPN1 said that the facility staff only documented the vitals before the resident left the facility. She said that the dialysis center could write a progress note in the folder, but the dialysis center often did not write one in the folder. She stated that R5 received calcium acetate at breakfast and at dinner. She said the resident also received it at lunch, but on dialysis days the facility nurse would hold the medication. LPN1 confirmed there was no physician order to hold the medication for the times the resident was at dialysis. During an interview on 11/14/24 at 2:18 PM, Registered Nurse Supervisor (RNS) stated that she was made aware that R5 was not receiving the calcium acetate at lunchtime on dialysis days. RNS confirmed R5 was not receiving the medication as ordered on dialysis days. During a concurrent interview on 11/14/24 at 3:18 PM, the Director of Nursing and the Assistant Director of Nursing (ADON) stated that R5's vitals were supposed to be documented by the nurse prior to her going to dialysis. They stated the information should be documented in the EMR and the information would go with the resident to dialysis. They agreed that dialysis should send documentation back to the facility after each visit, which they both confirmed did not always happen. They confirmed they had to request information from R5's dialysis center during the survey. The Director of Nursing stated that she believed the nurse should check vitals when the resident returns. She said the EMR should be correctly documented to show why the resident was not receiving the calcium acetate on days of dialysis. During an interview on 11/14/24 at 4:04 PM, the Assistant Director of Nursing (ADON) stated that the facility always printed out the CCD when R5 went to the dialysis center. She confirmed that the CCD should show all of the vital information needed to go with them. The ADON said that the facility monitored the fistula on the EMR in the medication administration record. Review of the facility's policy titled, Dialysis Policy, dated 02/23/22, documented .will work collaboratively with residents' dialysis center to ensure a unified coordination of services .Information relevant to the resident's care will be shared with the dialysis center as needed. This information may include but is not limited to assessments of the resident's access site .fluid status .vascular status .vital signs .weights .laboratory data .dietary assessments and overall nutritional health. Monitor and provide diet and medications as prescribed by the dialysis staff/nephrologist's. Monitor fistula and catheter site for signs/symptoms of infection, dislodging, or clotting .Communicate any abnormal findings or changes in condition to the resident's physician, dialysis center and the resident's representative.

Based on record review, and interview, the facility failed to ensure two of two sampled discharged residents (R)393 and R140) had discharge summaries completed prior to discharge to ensure continuity of care. Findings include: 1. Review of R393's Progress Notes under the progress notes tab of the electronic medical record (EMR) revealed on 10/30/23 at 12:08 PM Discharge orders and med [medications]list sent to PA [Physician Assistant]. On 10/30/23 at 12:58 PM Received signed discharge order and signed paperwork from [name] PA. On 10/30/2023 at 12:59 PM a note by the Rehab Care Coordinator Discharge instructions explained to resident and POA [Power of Attorney]. All residents' meds and belongings were sent with the resident. All questions have been answered. Residents discharged via family setup. Review of R393's EMR under the forms and miscellaneous tabs revealed no evidence of a discharge summary that had been provided to R393 or his representative. 2. Review of R140's Face Sheet, located under Resident tab in the EMR indicated that R140 was admitted to the facility on [DATE] with a diagnosis of fracture of second lumbar vertebra. Further review indicates that R140 was discharged on [DATE]. Review of R140's Social Service Progress Notes, dated 08/12/24, indicated, .R140 will be discharged either 08/14/24 or 08/15/24. R140 will discharge with daughter .go back to [name of the Assisted Living Facility]. Review of R140's Nurses Notes, dated August 2024, indicated no evidence that there was a discharge note written by nursing on the date of discharge. Interview on 11/13/24 at 3:45 PM, the Director of Nursing (DON) confirmed no discharge nursing note and stated that she would expect to have a discharge note written when a resident is discharged . Interview on 11/14/24 at 2:22 PM, Registered Nurse (RN) 2 confirmed that she did not write a discharge note for R140 on the date of discharge. RN2 indicates that the nurses are responsible for having the resident and/or resident representative (RP) sign discharge paperwork before a resident is discharged from the facility and that the nurse is responsible for writing a discharge note. Review of R140's facility provided Resident Discharge Instructions, dated 08/15/24, indicated no evidence of a recapitulation of R140's stay at the facility. During an interview on 11/14/24 at 11:20 AM, the Social Services Director (SSD) revealed a formal Discharge Summary was not completed when a resident was discharged . The instructions given to the resident and/or their representative would have only included a list of their current medications, Home Health information, and any appointments scheduled. Interview on 11/14/24 at 2:30 PM, the Director of Nursing (DON) stated that on the date of discharge the nurse will have the resident and/or RP (resident representative) sign the discharge instructions along with a list of medications. The DON indicated that the nurse who discharges the resident, is responsible for writing a discharge note in the medical record. Interview on 11/14/24 at 3:02 PM, the Rehab Care Coordinator (RCC) indicated that R140 did not have a discharge summary, which includes a recapitulation of the resident's stay and said that the facility does not complete discharge summaries. 51678

Based on interview and record review, the facility did not provide necessary treatment and services to promote healing for 1 (R10) of 4 residents reviewed for pressure injuries. R10 developed a facility acquired Stage 2 pressure injury to the sacrum. The Facility was not consistently assessing R10's pressure injury and the care plan was not revised. Findings include: The Facility's Prevention Of Pressure Ulcers policy, undated, states the following (in part): .Any sign of pressure ulcer formation will be identified and treatment will be initiated in a timely manner to prevent further tissue damage. R10 was admitted to the facility on [DATE]. R10's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's quarterly MDS (Minimum Data Set) with an assessment reference date of 11/2/21, documents: R10 has a BIMS (Brief Interview Mental Status) score of 14, indicating R10 is cognitively intact for daily decision making. R10 requires extensive assistance from staff for bed mobility, transfers, dressing and toileting. R10 has a urinary catheter. R10's MDS indicates R10 is at risk for development of pressure injuries and is assessed as having no pressure injury. On 1/11/22, R10's CAA (Care Area Assessment) worksheet was completed for pressure ulcer/injury. The analysis of findings section indicates [Resident name] triggered Pressure due to assisted mobility and skin care as part of his individualized and specialized senior lifestyle. The Care Plan addresses ongoing assistance, assessment and prevention strategies to promote safety and well-being. R10's pressure ulcer care plan, initiated on 7/15/21 and last reviewed/revised date of 1/11/22, documents the following: I need to reposition frequently and (need) extra protection to prevent skin injury because I can't move around as well on my own. My right side is weak and I have damp skin in vulnerable areas, including the tip of my penis (catheter entry point). I receive special daily skin care to avoid complications. The care plan interventions, dated 7/15/21, include: -Check my skin with cares and assess perineal area - apply antifungal treatment as necessary and treat any excoriation noted - reduce pressure and friction between myself and my bed or chair - limit the head of my bed being elevated to 30 degrees and encourage me to use a 30 degree side lying position when in bed - monitor my nutrition or hydration intake - suggest repositioning with every encounter; -Discuss my nutrition needs with me; -Help me with hygiene and general skin care, avoid using hot water for washing and use moisturizer on my skin, help me stay clean and dry, elevate my head 30 degrees and elevate my heels in bed, reduce pressure and friction between myself and my bed or chair, suggest repositioning often, please ensure my catheter is not strapped tight; -Make sure I change positions frequently and report any changes to my nurse; -Promote safe activity. Surveyor noted no revisions to the pressure ulcer care plan after 1/11/22. On 1/11/22, the facility completed a Braden Scale for Predicting Pressure Sore Risk observation form which documents a score of 14, indicating a moderate risk for developing a pressure injury. On 4/3/22, at 9:40 AM, a clinical observation report was completed and documents skin status as dry and warm. No other skin observations noted. On 4/4/22, at 10:17 AM, a progress note documents Call placed to Doctor [Name of Doctor]. Request for PRN (as needed) foley flush orders for blockage and report open area to right buttock/sacrum. Message left, awaiting return call. Already have order for happy butt, OK to apply bordered foam. Change daily. Surveyor noted no further progress notes regarding the open area to right buttock/sacrum. On 4/4/22, at 12:42 PM, a wound management detail report was created by LPN (Licensed Practical Nurse)-D for R10. LPN-D indicated: Length 2 cm (centimeters), width 2 cm, no depth can be measured, exudate amount none, no odor, no tunneling, no undermining, tissue type granulation tissue. Comments: resident receiving comfort care and has not been eating. On 4/4/22, at 2:15 PM, a wound management detail report was created by DON (Director of Nursing)-B. DON-B indicated: Length 2 cm, width 2 cm, yes depth can be measured, light exudate, serosanguineous exudate color and consistency, no odor, no undermining, no tunneling, tissue type epithelial tissue, 100% epithelialization tissue, 0% granulation tissue, 0% slough, 0% eschar, well defined wound edges, pink/normal surrounding skin, no wound vac, wound healing status stable. Comments: New open wound is superficial. Very light drainage. Wound bed is pink. Residents with no reports of pain. Cooperative with repositioning. Created date and time: 4/12/22 3:16 PM. Surveyor noted the tissue type was different with the two wound observations on 4/4/22. Surveyor noted there was no staging documented on these initial wound reports. On 4/5/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/22, at 11:18 AM, a wound management detail report was created by LPN-E. LPN-E indicated: Length 2 cm, width 2 cm, yes depth can be measured, no exudate, no wound, Stage II, no undermining, no tunneling, tissue type granulation tissue, no wound vac, stable wound healing status. Created date and time: 4/13/22 2:23 PM. Surveyor noted the tissue type is different from the DON-B's wound observation on 4/4/22. On 04/11/22, at 2:37 PM, Surveyor interviewed R10. R10 stated there is a sore on his bottom that gets taken care of daily. R10 was not sure of the stage the pressure injury was, but there was no pain. R10 stated he did not think the facility was doing anything new to help his pressure injury except the treatment. On 4/13/22, at 8:45 AM, Surveyor observed R10's sacrum pressure injury treatment with LPN-D and DON-B. Surveyor observed this treatment was performed according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/13/22, at 3:39 PM, Surveyor interviewed DON-B. DON-B stated she meets with the other wound nurse in the facility everyday they are both at work to review all of the wounds and complete an audit sheet. DON-B indicated R10 is on the audit worksheet as a Stage 2 pressure injury. DON-B said either DON-B or the other wound nurse will do the initial assessment and then try to assess all the wounds at the facility every 7 days based on their last assessment. On 04/14/22, at 8:44 AM, Surveyor interviewed LPN-D. LPN-D indicated a CNA (Certified Nursing Assistant) told her the morning of 4/4/22 that R10 had a new wound on his buttock. LPN-D went to assess the wound and notified the doctor, family and emailed the wound team right away. LPN-D stated DON-B came shortly after notification to assess the wound. LPN-D stated she did not stage the wound and really was not sure of the tissue type, but knew the wound team would put in the right data in their assessment. LPN-D said there is some training, but LPN-D was not wound certified and not comfortable determining the tissue types of wounds therefore relies on the wound team. LPN-D said DON-B recommended a treatment and the doctor confirmed the treatment. On 4/14/22, at 9:01 AM, Surveyor interviewed DON-B. DON-B said she is wound certified. DON-B stated R10's wound is a stage 2 with epithelial tissue not granulation tissue. DON-B indicated LPN-D and LPN-E were unsure of the tissue type and are not wound certified. DON-B stated training has been limited to computer training during COVID and would be getting more wound training soon. DON-B stated 3 of the other wound certified nurses just recently left so there are just two of them trying to review all the wounds. DON-B said R10's wound has not changed since the first assessment which was a Stage 2 wound and saw it during wound treatment yesterday. DON-B indicated the documentation will be updated to correct the tissue type. DON-B confirmed the care plan has not been updated or revised with the current pressure ulcer. On 04/14/22, at 10:56 AM, Surveyor met with NHA (Nursing Home Administrator)- A to share the concern of the inconsistent documentation and lack of care plan revision for R10's sacrum pressure injury. NHA-A had no further information for Surveyor.

Based on observation, record review, and interview, the facility did not ensure residents received adequate supervision and assistance devices with revisions to care plans as indicated to prevent falls for 2 (R2 and R3) of 3 residents reviewed for falls. R2 had multiple falls that were not comprehensively assessed with revision to the Falls Care Plan addressing the root cause of the fall or implemented in a timely manner. R3 had two falls that were not comprehensively assessed with revision to the Falls Care Plan addressing the root cause of the fall or implemented in a timely manner. Findings: The facility policy and procedure entitled Fall Prevention Program dated 9/19/2019 states: 3. The C.N.A. (Certified Nursing Assistant) care card will be updated to reflect any and all interventions put into place for this resident. 4. When a resident has a fall at [the facility] a fall report will be completed promptly by a licensed nurse. The fall scene investigation form will be used to help determine the reason for the fall. The form will be completed by the nurse and kept in the residents chart. Notification of the fall will be made to the resident's primary care physician and to the resident's primary contact. 5. A post fall assessment is to be completed by the nurse to evaluate factors associated with the fall, to aid in identifying the cause of the fall. Root cause analysis will be used to identify and implement measures to avoid further falls. 4. [sic] All falls will be reviewed by an Interdisciplinary fall team. A. The incident report and post fall assessment will be reviewed by the team. Determining factors will be sought through evaluation of the post fall assessment, examples may include, but are not limited to: health care changes, environmental changes, etc. Prior risks will be reviewed, and any new health concerns will be considered. A Medication review will be performed. If a concern is determined regarding a medication, the physician will be notified. Additional measures to prevent further falls may be recommended based on this review. 1. R2 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, history of urinary tract infections, [CONDITION(S)], depression, and diabetes. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R2 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 with an activated Power of Attorney, and needed extensive assistance with bed mobility and transfers. The facility was transitioning from one computer charting system to another from 6/2021 through 8/2021 per facility administration. R2's falls were reviewed starting from 8/2021. R2's Falls Care Plan was initiated in the new system on 8/3/2021 and had the following interventions in place on 9/23/2021: -explain needs to others -transfer with assist of 1 or 2 for safety and a stand-up lift with verbal cues -Hoyer transfers with 2 assist (Contradicts the use of stand-up lift.) -review safety strategies during encounters and offer further assistance to reduce risk before departing resident -keep bed low to the ground and keep the wheels locked -gripper socks on at all times when in bed/non-skid footwear to prevent slipping; remind to use -check in whenever possible and assess condition and needs -remind to use call light for all transfers and when reaching for things -make sure all personal/important items are within reach -remind frequently to ask for assistance due to poor safety awareness -make sure urinal is within reach at all times and have room rearranged as needed to maintain safety and comfort -report signs of pain to nurse -Call, Don't Fall sign written in Spanish in room to remind to call for help, remind of sign during cares -air mattress with bolsters with assist handles -bed against the wall to enhance security -keep call light at hand and remind to use; tends to forget to use call light -R2 has reacher to use -Dycem in place on the wheelchair seat to prevent from sliding off the chair -check on R2 frequently when in bed and remind to use call light when ready to get out of bed -check on R2 frequently when alone in the bathroom at the sink performing personal care -notify staff if there is a change in ability -R2 transfers independently despite reminders from staff; R2 is forgetful, impulsive and has poor safety awareness -anticipate needs due to dementia; part of Memory Care Community and safety is closely monitored -assure rounding during report, change of shift to assess well-being, anticipate needs -involve whole care team in continuing to redirect R2, frequently check on safety. 1.1 On 9/24/2021 at 9:19 AM in the progress notes, nursing charted R2 had been sent to the emergency roiagnom on [DATE] at 8:30 PM for evaluation and treatment after an unwitnessed fall. The CT scan and x-rays were normal. Surveyor reviewed the Event Report for the fall on 9/23/2021 at 6:26 PM. The unwitnessed fall had no apparent injuries. R2 had been sitting in a wheelchair watching TV in the resident room and, per R2, attempted to get clothes out of the wardrobe. The nurse determined R2 had stood up independently and fell . The Interventions section of the report indicated the Immediate measure taken was a bed alarm was applied and the outcome of the intervention indicated No Interventions Used. Orders initiated on 9/23/2021 were to initiate Fall Prevention Program and a Physical Therapy consult. Surveyor reviewed the Falls Investigation Report for the fall on 9/23/2021 at 6:26 PM. The Interdisciplinary Team (IDT) reviewed the fall on 9/28/2021. The Interventions section of the form indicated R2 was difficult to re-educate due to poor cognition and poor safety awareness and staff should continue frequent safety checks and remind/redirect R2 frequently due to poor cognition and poor safety awareness. The Interventions implemented per the report were to initiate the [CONDITION(S)] protocol and place a stop sign. The form does not indicate where a stop sign should be placed. The IDT reviewed the fall five days after the fall had occurred. Review of R2's medical record showed a [CONDITION(S)] protocol was initiated on 9/24/2021. 1.2 R2 had an unwitnessed fall on 10/31/2021 at 1:20 PM. Surveyor reviewed the Event Report. R2 had been in resident room and slid from the wheelchair causing a bruise to the lower nose. Ice was applied to the area. An order initiated on 11/1/2021 was to initiate Fall Prevention Program. Surveyor reviewed the Falls Investigation Report for the fall on 10/31/2021 at 1:20 PM. The IDT reviewed the fall on 11/1/2021. R2 had been reaching for a piece of paper on the floor and slid from the wheelchair. The Interventions section of the form indicated R2 was difficult to re-educate due to poor cognition and poor safety awareness and staff should continue frequent safety checks, remind/redirect R2 frequently due to poor cognition and poor safety awareness, and remind R2 to call for assistance or use provided reacher to pick up items off the floor. R2's Falls Care Plan was revised on 11/1/2021 with the following interventions: -provide with a reacher and remind to use reacher at all times for picking things up off the floor. (This intervention was in the Fall Care Plan on 8/3/2021 when Fall Care Plan was initiated.) -use stand-up lift for all transfers. (This intervention was in the Fall Care Plan on 8/3/2021 when Fall Care Plan was initiated.) 1.3 R2 had an unwitnessed fall on 11/11/2021 at 5:42 PM. Surveyor reviewed the Event Report. R2 had been in the bathroom leaning forward to brush teeth and fell out of wheelchair. When asked why they fell , R2 stated because no shoes were on. R2 had been barefoot. Per the Fall Care Plan, R2 should have had either gripper socks on or non-skid footwear. Measures to be taken to prevent further falls was to ensure non-skid footwear was in place. An order initiated on 11/15/2021 was to initiate Fall Prevention Program, four days after the fall had occurred. Surveyor reviewed the Falls Investigation Report for the fall on 11/11/2021 at 5:42 PM. The IDT reviewed the fall on 11/15/2021. The Interventions section of the form indicated R2 was difficult to re-educate due to moderately impaired cognition and poor safety awareness due to a BIMS (Brief Interview for Mental Status) of 8-12 and R2 is impulsive at times. Interventions implemented were frequent redirection/reminders due to low BIMS and behaviors and assist R2 to sink after meals for oral cares. The IDT reviewed the fall four days after the fall had occurred. R2's Activities of Daily Living (ADL) Care Plan was revised on 11/15/2021 with the following intervention: -please assist to the sink after meals and set up so R2 can complete oral hygiene as R2 tends to forget to ask for assistance. This intervention was added to the care plan four days after the fall. 1.4 R2 had a witnessed fall on 12/26/2021 at 5:45 PM. Surveyor reviewed the Event Report. A Certified Nursing Assistant (CNA) was passing R2's room and saw R2 bending forward and slid from the wheelchair. When asked why they fell , R2 pointed to the bed. R2 had non-skid footwear on at the time of the fall and was incontinent of urine. R2 was taking antibiotics for a urinary tract infection ([CONDITION(S)]) at the time of the fall and the intervention to prevent further falls was to initiate frequent toilet offering every three hours and R2 uses urinal at times. An order initiated on 12/26/2021 was to assess need for toileting, offer urinal appliance as needed, change brief when soiled, offer toileting via stand up lift as needed, check every three hours while awake, and R2 is at high risk for falls related to [CONDITION(S)] and toileting needs. The intervention to toilet every three hours and the use of a urinal was in R2's ADL care plan on 8/3/2021 so this was not a new intervention. Surveyor reviewed the Falls Investigation Report for the fall on 12/26/2021 at 5:45 PM. The IDT reviewed the fall on 12/29/2021. The Interventions section of the form indicated R2 was difficult to re-educate due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12 so staff need to remind/redirect frequently due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12. Interventions implemented were obtaining orders for physical and occupational therapy, will continue to monitor for antibiotic use, and encourage R2 to use call light and wait for assistance for all transfers. The IDT reviewed the fall three days after the fall had occurred. Review of R2's Fall Care Plan did not show any revisions were made to address the fall to prevent future falls. 1.5 R2 had an unwitnessed fall on 12/30/2021 at 4:00 AM. Surveyor reviewed the Event Report. R2 was found on the floor in the room after falling out of bed. When asked why they fell , R2 stated R2 was looking for the urinal. Incontinent product had been last changed at 1:30 AM. R2 sustained an abrasion to the left knee. Measures taken after the fall was to keep urinal within reach and offer when awake every two hours and frequent monitoring of R2. Surveyor reviewed the Falls Investigation Report for the fall on 12/30/2021 at 4:00 AM. The IDT reviewed the fall on 1/5/2022. The Interventions section of the form indicated R2 was difficult to re-educate due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12 so staff need to remind/redirect frequently due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12. Interventions implemented were frequent redirection/reminders with low BIMS and/or behaviors, will continue to monitor for antibiotic use which was completed on 1/2/2022, and keep the urinal within reach when in bed. The IDT reviewed the fall six days after the fall had occurred. R2's Falls Care Plan was revised on 1/5/2022 with the following intervention: -make sure urinal is within reach when in bed at all times. (This intervention was added to the Fall Care Plan on 8/19/2021.) 1.6 R2 had an unwitnessed fall on 1/21/2022 at 2:45 PM. Surveyor reviewed the Event Report. R2 was found sitting on the bedroom floor next to the window. When asked why they fell , R2 stated R2 self-transferred to shut the window blinds. R2 had shoes on and was last toileted at 2:00 PM. A urinalysis was requested due to R2 appearing more confused. An order initiated on 1/21/2022 was to initiate Fall Prevention Program. Surveyor reviewed the Falls Investigation Report for the fall on 1/21/2022 at 2:45 PM. The IDT reviewed the fall on 1/25/2022. The Interventions section of the form indicated R2 was difficult to re-educate due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12 so staff need to remind/redirect frequently due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12, encourage R2 to use call light and wait for assistance for all transfers, and to ask R2 when R2 want the blinds closed. Interventions implemented were to ask R2 when R2 wants the blinds closed and assist in closing the blinds. The IDT reviewed the fall four days after the fall had occurred. R2's Falls Care Plan was revised on 1/25/2022, four days after the fall had occurred, with the following intervention: -ask if R2 wants window blinds closed and assist as needed. 1.7 R2 had an unwitnessed fall on 1/26/2022 at 9:47 AM. Surveyor reviewed the Event Report. R2 was reaching for something in the wardrobe and slid from the wheelchair onto the floor. R2 was smiling and laughing as staff got R2 off of the floor. R2 had shoes on at the time of the fall. R2 was removed from the room after the fall. Surveyor reviewed the Falls Investigation Report for the fall on 1/26/2022 at 9:47 AM. The IDT reviewed the fall on 1/27/2022. R2 had been started on an antibiotic for a [CONDITION(S)] on 1/25/2022. The Interventions section of the form indicated R2 was difficult to re-educate due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12 so staff need to perform frequent safety checks on R2 and remind/redirect frequently due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12. Interventions implemented were to continue to work with therapy for strengthening and mobility improvement and continue to monitor R2 for antibiotic use R2's Falls Care Plan was revised on 1/27/2022 with the following intervention: -I am very impulsive and have poor safety awareness due to my dementia- risk & benefits of self-transferring have been reviewed to me but I still choose to self-transfer so please continue to frequent checks on me and anticipate my needs to maintain safety & comfort. On 2/3/2022 at 9:00 AM, Surveyor observed R2 in resident room. A STOP banner was attached to the right door frame hanging down, not draped over the door. R2 was in the wheelchair facing away from the door. The wheelchair had anti-tippers in place. The bed was in a low position with a scoop mattress. A reacher was observed on the over-bed table in reach of R2. R2 had shoes on and had a Spanish television station on. R2 was attempting to use the telephone and when asked about the care R2 was receiving, stated R2 had no concerns with the care at the facility. R2 was appropriately dressed. The anti-tipper device on the wheelchair was not on R3's Fall Care Plan. In an interview on 2/3/2022 at 2:35 PM, Surveyor asked Registered Nurse (RN)-D what the facility process was when a resident had a fall. RN-D stated if a CNA or Licensed Practical Nurse (LPN) has a resident that falls, they need to get an RN to assess the resident before the resident is moved. RN-D stated the physician and family are updated on the fall and notified of any injuries. RN-D stated the floor nurse does the charting on the fall in the computer charting system and neurological checks are completed on a paper form with the timing of the assessments listed on the form; the form is then put in the resident's hard chart under the assessment tab. Surveyor asked RN-D who updates the resident care plan and when is that done. RN-D stated the care plan is updated at the time of the fall and if the resident has persistent falls, the IDT will look at the fall. RN-D stated interventions are put in the care plan based on the assessment and cause of the fall. RN-D stated the main intervention is to re-educate the resident until a new intervention is needed. In an interview on 2/3/2022 at 3:00 PM, Surveyor reviewed R2's falls with Director of Nursing (DON)-B and RN-C. DON-B stated R2 had so many interventions in place already that it is hard to get a new intervention. Surveyor asked DON-B how CNAs are aware of interventions for residents. DON-B stated new interventions are added to the CNA Care Card and those are pulled from the Care Plan. RN-C stated the Care Plan was updated when the falls are reviewed. Surveyor reviewed each fall with DON-B and RN-C. Surveyor shared the concern interventions were not added in a timely manner after the falls occurred and interventions that were added had already been in place prior to the fall. RN-C stated R2 was moved to the Memory Care unit for a smaller area which helped some, but R2 transfers and ambulates in therapy and then thinks that R2 can do things independently which is not the case. RN-C stated the facility changed their electronic charting system in the summer of 2021 and they had to develop their own pathways for investigations and then get all the staff educated on how the charting system worked so not everything that was implemented was easy to access and see where interventions were put in place. In an interview on 2/7/2022 at 11:00 AM, Surveyor met with DON-B and RN-C to discuss the concerns with R2's falls. Surveyor shared with DON-B and RN-C that R2's Care Plan was not revised after each fall with an intervention that was developed with the root cause analysis of the fall and the Care Plan was not revised timely. RN-C stated the IDT meets every day Monday through Friday at 12:30 PM to review falls. RN-C stated if the fall occurs late on Friday or over the weekend, the falls are looked at on the following Monday. Surveyor shared the concern that if interventions are not put into the Care Plan for up to six days after the fall, such as the fall that occurred on 12/30/2021, staff are not aware of preventive measures that could keep R2 safe. Surveyor shared the concern interventions that are added to the Care Plan as a new intervention had been in the Care Plan prior to the fall and were either not effective in preventing the fall or had not been in place as expected, such as the fall on 11/11/2021 where R2 had bare feet and the Care Plan indicated R2 should have gripper socks or non-skid foot wear on. No further information was provided at that time. 2. R3 was admitted to the facility on [DATE] with diagnoses of polyarthritis, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and a history of falling with a fractured left hip. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R3 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 10 with an activated Power of Attorney, and needed extensive assistance with bed mobility and transfers. The facility was transitioning from one computer charting system to another from 6/2021 through 8/2021 per facility administration. R3's falls were reviewed starting from 8/2021. R3's Fall Care Plan was initiated in the new system on 7/30/2021 and the following interventions were in place on 9/2/2021: -continue efforts to improve strength, mobility and overall functional capacity -explain needs to others -do frequent safety checks to closely monitor for safety -remind to use call light for all transfers as R3 has poor safety awareness and impaired cognition -make sure R3 has nonskid slipper -dangle feet before standing; stand-pivot transfer with a gait belt; encourage R3 to use assistance anytime for any reason -assure call light is at hand and R3 understands its use; report changes in abilities to the nurse -place call light at hand and promote safety -during frequent checks make sure important items are with reach -non-skid footwear -remind to get up and move slowly -promote safety with encounters and keep an eye on behaviors -check orthostatic blood pressure -assure call light is at hand and remind to ask for help -ensure proper footwear is in place 2.1 On 9/2/2021 at 3:15 PM in the progress notes, nursing charted the physician and Power of Attorney were aware R3 was sent out for evaluation due to complaints of pain. On 9/2/2021 at 4:24 PM in the progress notes, nursing charted the hospital notified the facility R3 was being sent back with a negative CT scan and pain medication provided for pain to the left hip. Nursing charted R3 did not appear to be in pain but was having issues bearing weight on the left leg. On 9/4/2021 at 6:29 AM in the progress notes, nursing charted a follow up note for a fall that occurred on 9/2/2021; no injuries were noted and R3 denied pain and was able to move all extremities. Surveyor reviewed the Post Fall Observation Report for the fall on 9/2/2021 at 2:58 PM. R3 fell from bed with R3 stating R3 was on the bed one minute and on the floor the next. R3 had bare feet at the time of the fall and was sent out 911 for complaints of left hip pain. Surveyor reviewed the Event Report for the fall on 9/2/2021. The Event Report indicated the fall occurred on 9/3/2021 at 2:36 PM with a description of the fall stating the fall occurred on 9/2/2021. The rest of the form was blank. Surveyor reviewed the Event Report for the fall on 9/3/2021. The Event Report indicated the fall occurred on 9/3/2021 at 3:01 PM. R3 was found sitting on the floor in resident room having been in the bed prior to the fall. R3 had pain to the left leg rated 8/10 with shortening noted to the left leg and pain with range of motion. The Report indicated R3 was sent to the hospital for evaluation. Evaluation notes indicated R3 no longer complained of pain and did not have any injuries. Surveyor reviewed the Falls Investigation Report for the fall with an observation date of 9/15/2021 stating the fall occurred on 9/2/2021 at 2:58 PM. The description of the fall stated R3 was lying in bed and had an independent transfer that caused the fall. The Interventions section of the form indicated R3 was difficult to re-educate due to poor cognition and poor safety awareness and staff should continue frequent safety checks when awake and when in bed, remind/redirect R3 frequently due to poor cognition and poor safety awareness, and encourage R3 to use call light and wait for assistance for all transfers. Interventions implemented were room rearranged for comfort and safety and to send R3 to the emergency room for further evaluation. R3's Fall Care Plan was revised on 10/6/2021 with the following interventions: -have room rearranged for comfort and safety -do frequent checks especially when in bed to closely monitor for safety (This was in the Fall Care Plan on 7/30/2021 when the Care Plan was initiated.) Surveyor was unable to distinguish if R3 had a fall on 9/2/2021 and 9/3/2021 or if only one fall occurred in that time frame due to the conflicting fall reports. 2.2 On 12/16/2021 at 11:09 AM in the progress notes, nursing charted the physician was notified of R3 having an unwitnessed fall. Surveyor reviewed the Event Report for the fall on 12/16/2021. The Event Report indicated the fall occurred on 12/16/2021 at 7:10 AM. R3 was in bed and self-transferred to a standing position and fell next to the bed. When asked why they fell , R3 stated they were trying to put on their pants. R3's wheelchair was in the bathroom. R3 sustained an abrasion to the back of the upper right thigh. R3 had regular socks on and was last toileted at 6:00 AM. No interventions were documented on the report as being implemented after the fall. Surveyor reviewed the Falls Investigation Report for the fall on 12/16/2021 at 7:05 AM. The IDT reviewed the fall on 12/20/2021. The Interventions section of the form indicated R3 was difficult to re-educate due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12 so staff need to remind/redirect frequently due to moderately impaired cognition and poor safety awareness due to a BIMS of 8-12. Intervention implemented was frequent redirection/reminders due to low BIMS and/or behaviors. Surveyor reviewed R3's Care Plan and the Care Plan was not revised with any interventions based on a root cause analysis of the fall to prevent future falls. On 2/3/2022 at 9:05 AM, R3 was observed by Surveyor in the communal dining area eating breakfast. R3 had shoes on and was appropriately dressed. R3's wheelchair had anti-roll back devices in place. Surveyor observed R3's room with a fall mat on the floor and the bed in low position. The fall mat and anti-roll back devices were not on R3's Fall Care Plan. In an interview on 2/3/2022 at 3:28 PM, Surveyor shared with Director of Nursing (DON)-B and Registered Nurse (RN)-C the confusion as to what date and time R3 had falls in 9/2021. RN-C stated R3 fell on [DATE] as reported on the investigation report. Surveyor shared with DON-B and RN-C the Fall Care Plan was not revised after the fall until 10/6/2021, over one month after the fall occurred. RN-C stated with the facility switching to a new charting system, the fall investigation report was not created when the fall occurred on 9/3/2021 so the follow up was done much later. RN-C stated the falls were looked at before 10/6/2021, but just not charted until 10/6/2021. RN-C stated the IDT always meets to review falls daily at 12:30 PM and interventions were put in place, but they had no way to sign them off on the report until later. Surveyor shared with DON-B and RN-C the concern no root cause analysis was done for the fall on 12/16/2021 and no Care Plan interventions were implemented. In an interview on 2/7/2022 at 8:21 AM, RN-C stated R3's fall in 9/2021 was investigated further by the facility and R3 had a fall on 9/2/2021 at 2:58 PM and not on 9/3/2021. RN-C stated they were able to review the fall documentation in more detail and determined the fall had actually occurred on 9/2/2021 and agreed with Surveyor confusion as to when the fall occurred due to conflicting documentation. RN-C stated after every investigation of a fall, the IDT members can sign off on review of the Care Plan. RN-C stated R3's room was rearranged on 9/2/2021 after the fall even though the Care Plan does not show that because at the time the staff were unaware of how to enter the information into the new computer charting system. RN-C stated R3's furniture was moved in the room when R3 was at the hospital being evaluated. RN-C showed Surveyor the interventions in R3's Activities of Daily Living Care Plan that were added on 12/20/2021 to correspond to the fall on 12/16/2021: to assure call light is at hand and help with adaptation and safety awareness and check on well-being frequently. On 2/7/2022 at 11:00 AM, Surveyor shared with DON-B and RN-C the concerns R3's Fall Care Plan was not updated timely or with interventions appropriate to the cause of the fall. Surveyor shared with DON-B and RN-C the interventions RN-C brought forward on 2/7/2022 at 8:21 AM for the fall on 12/16/2021 were already in place prior to the fall on 12/16/2021 in the Fall Care Plan. Surveyor shared with DON-B and RN-C the statement R3's wheelchair was in the bathroom when R3 fell on [DATE] should have been part of the comprehensive assessment and guided an appropriate intervention. Surveyor shared the concern a root cause analysis was not completed with the falls and interventions were not put in place timely or addressing the cause of the fall to prevent future falls. No further information was provided at that time.

Based on observation, interview, and record review, the facility did not ensure prevention of potential development and transmission of COVID-19 for 35 of 35 residents on the Rehabilitation Units. Staff were observed entering and exiting COVID-19 observation rooms in the facility without wearing isolation gowns. Findings include: Current CDC (Centers for Disease Control and Prevention) Guidelines (Website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) state: Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Current CDC Strategies for Optimizing the Supply of Isolation Gowns (Website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html) cover conventional, contingency, and crisis capacity strategies. The contingency capacity strategy states: Shift gown use towards cloth isolation gowns. The crisis capacity strategy states: Prioritize gowns. Gowns should be prioritized for the following activities: During care activities where splashes and sprays are anticipated, which typically includes aerosol generating procedures; During the following high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of healthcare providers, such as: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. When no gowns are available, the recommendation is: Consider using gown alternatives that have not been evaluated as effective. In situation of severely limited or no available isolation gowns, the following pieces of clothing can be considered as a last resort for care of COVID-19 patients as single use. However, none of these options can be considered PPE, since their capability to protect HCP is unknown. Preferable features include long sleeves and closures (snaps, buttons) that can be fastened and secured. Disposable laboratory coats; Reusable (washable) patient gowns; Reusable (washable) laboratory coats; Disposable aprons; Combinations of clothing: Combinations of pieces of clothing can be considered for activities that may involve body fluids and when there are no gowns available: Long sleeve aprons in combination with long sleeve patient gowns or laboratory coats; Open back gowns with long sleeve patient gowns or laboratory coats; Sleeve covers in combination with aprons and long sleeve patient gowns or laboratory coats. The facility policy and procedure entitled COVID-19 Infection Prevention and Control Plan dated 7/17/2020 states: COVID-19 Enhanced Isolation Precautions: Staff will adhere to Standard and Transmission Based Precautions per facility policy . with enhanced precautions as defined below. 1. Resident Containment Upon Admission: a. All new admissions and re-admissions, including long term care residents, will be admitted to rooms on Rehab 1 and Rehab 2 where they will be monitored up to 14 days. b. Every shift vitals (including temps) and every shift respiratory assessment will be conducted for each new and returning resident. c. At 14 days, LTC residents will be transferred back to their rooms in LTC if asymptomatic. d. All admissions and readmissions will be in Observation precautions for their first 14 days at facility. All therapy will be done in their room at the end of the day. Door will remain closed if is safe to do so. e. A red sign that says OBSERVATION will be taped to the resident's door and the 14 day observation policy will be taped on the door. f. All direct care staff will wear the following PPE in Observation rooms: gowns, gloves, surgical masks and face shields/goggles. The facility policy and procedure entitled 14-day Observation Rooms PPE (Personal Protective Equipment) guidelines, undated, states: Nursing team (CNA (Certified Nursing Assistant) and Nurses): Direct care (Examples are when toileting, bathing, wound care, Vital signs etc.) -Wear into the resident's room the following: face shields/goggles, surgical mask, gowns, and gloves. -Note: you CANNOT wear your observation gown into nonobservation rooms. Non-direct care (Examples passing meds or food trays, etc.) -Wear: face shields/goggles and a surgical mask. If you are going to touch anything in room put gloves on. Therapy: -Wear into the resident's room: a face shields/goggles, surgical mask, gowns, and gloves when doing therapy in observation resident's rooms. Social workers/Admissions/Discharges/Life Enrichment: -Wear a face shield/goggles, surgical mask, and gloves into resident's room. The Rehabilitation Unit consisted of three hallways: rooms R101-R112, rooms R113-R124, and R201-R212. The R100 rooms were on the first floor and the R200 rooms were on the second floor. The residents on this unit consisted of newly admitted residents and residents receiving therapy. All rooms were single-occupancy. 23 of the 35 residents on the Rehabilitation Unit were being monitored for 14 days for signs and symptoms of COVID-19 after being released from the hospital. None of the residents had tested positive for COVID-19. None of the residents were showing signs or symptoms of COVID-19. Signs were observed to be posted on the doors of all the COVID-19 observation resident rooms which read: Observation and instructions for donning and doffing PPE, as well as a red sticker on the door frame. On 7/28/2020 at 1:20 PM, Surveyor observed Certified Nursing Assistant (CNA)-C on the Rehabilitation unit. CNA-C was wearing a mask. CNA-C put on a face shield and entered R4's room. CNA-C was observed to squat down to be at face level with R4 who was in bed with the bed in the lowest position and have a conversation with R4. R4 did not have a mask on. CNA-C was observed to exit R4's room with a tied bag of garbage. In an interview with CNA-C on 7/28/2020 at 1:30 PM, CNA-C stated a face shield and gloves are put on when going into residents' rooms that are on observation. Surveyor asked if a gown is worn when going into observation resident rooms. CNA-C stated a gown is worn if there is going to be physical contact; the gowns are hung behind each door for staff to wear. On 7/28/2020 at 1:38 PM, Surveyor observed Life Enrichment-D in a resident's room that was in observation. Life Enrichment-D was wearing a mask, face shield, gown, and gloves while assisting the resident with a tablet. Surveyor interviewed Life Enrichment-D when Life Enrichment-D entered the hallway. Life Enrichment-D stated a mask, face shield, gown, and gloves are put on when going into a resident's room that is in observation. On 7/28/2020 at 1:40 PM, Surveyor observed Physical Therapist (PT)-E enter R5's room. R5 was in observation. PT-E was wearing a face mask. PT-E did not put on any additional PPE when entering R5's room. PT-E and R5 both held a piece of paper between the two of them and discussed what was on the paper. PT-E and R5 were in close proximity to each other. When PT-E exited R5's room, no hand hygiene was completed. Surveyor interviewed PT-E when PT-E exited R5's room. Surveyor asked PT-E what should staff wear when entering a resident's room that is in observation. PT-E stated a mask, face shield, gown, and gloves should be worn. When Surveyor questioned PT-E entering R5's room with only a mask on, PT-E stated PT-E was only dropping off a piece of paper. On 7/28/2020 at 1:50 PM, Surveyor observed CNA-F enter an observation resident's room. CNA-F had on a mask and put on a face shield, gown, and gloves to assist the resident with the call light. Surveyor interviewed CNA-F as CNA-F exited the resident's room. CNA-F stated a shield, gown and gloves are put on when you enter an observation room. (A mask is worn at all times.) Surveyor asked when CNA-F would wear a gown and CNA-F stated if a resident is in observation, a gown is always worn. CNA-F stated they keep changing what they are supposed to wear so people get confused. On 8/28/2020 at 2:30 PM, Surveyor met with Director of Nursing (DON)-B and Infection Control Registered Nurse (ICRN)-G to discuss the facility policy of gown utilization. DON-B and ICRN-G stated the facility was using the crisis mode for gown utilization. Surveyor asked how many gowns were in the facility, how many were used per week using the burn-rate calculator, and who they had reached out to in order to get more gowns. ICRN-G stated they currently have 4,161 gowns in the facility. 1,000 gowns had been delivered 7/24/2020 from the Public Health stockpile. ICRN-G stated the burn-rate was 1,323 gowns per week. Surveyor verified that the facility had over a 3-week supply of gowns, which would not put them at a crisis mode for gown usage. ICRN-G agreed they were not in crisis at that time, but had been just prior. ICRN-G stated if they used the gowns, then they would be in crisis mode in the future. DON-B stated the facility had reached out to their primary supplier and three additional suppliers to try and obtain the needed gowns in addition to Public Health. When asked what amount of gowns would be considered a crisis, ICRN-G stated one week or less. ICRN-G agreed they had more than a one week supply of gowns available. On 8/28/2020 at 3:45 PM, Surveyor met with DON-B and ICRN-G to discuss observations throughout the facility. CNA-F and Life Enrichment-D were observed using all the appropriate PPE. CNA-F stated people get confused because the rules keep changing on what to wear. CNA-C was observed not wearing an isolation gown and PT-E was observed not wearing an isolation gown, face shield, or gloves when entering the rooms of residents in observation for potential COVID-19. Surveyor shared the concern of not following the guidance issued by the CDC on the use of gowns and a face shield when caring for these residents. DON-B stated PT-E knows better than to not wear PPE when going into R5's room. The facility stated they are in contingency mode for gown usage, yet were not following the CDC recommendations for that level. The facility is not following the CDC guidance recommending PPE should be worn during cares of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. The facility's optimization of gown usage policy does not follow the CDC guidance for Strategies for Optimizing the Supply of Isolation Gowns.

Based on observation, interview and record review the facility failed to properly prevent the spread of infections such as COVID-19 as evidenced by failures to: (1) follow infection control practices related to the transport and storage of clean linens in four halls; (2) perform hand hygiene when providing assistance to one (R1) resident; and, (3) perform hand hygiene when delivering meal trays for four (R2, R3, R4 and R5) residents in the sample of five. The failures by staff to perform hand hygiene while delivering meal trays and providing assistance to residents and to properly transport and store clean linens to prevent contamination had the potential to affect residents residing on four units (Rehab, 200, 400 and 700 halls) of the facility. Findings include: 1.A. Observation of a laundry staff (E1) on 4/22/20 at 11:23am revealed that E1 was transporting clean linens to the Rehab Hall. E1 was transporting the clean linens using a cart that was not covered. In an interview with E1 when asked if the clean linens should have been covered during transport to the Rehab Unit, E1 stated, It's not usually covered (during transport). When asked why it was important to cover the clean linens during transport, E1 stated, For sanitation, to prevent contamination. The Administrator, who was in the area during this observation and interview, added, (The clean linens were) supposed to be covered. B. Observation of the linen cart in the shower room on 400 Hall, on 4/22/20 at 12:16pm, revealed that the linen cart was not covered. The shower room door was also wide open. C. Observation of the linen cart in the shower room on 200 Hall, on 4/22/20 at 12:40pm, revealed that the linen cart was not covered. The shower room door was also wide open. D. Observation of the linen cart in the shower room on 700 Hall, on 4/22/20 at 3:09pm, revealed that the linen cart was not covered. The shower room door was also wide open. Review of the resident room roster provided by the facility on 4/22/20 at approximately 11am, revealed 26 residents resided on the Rehab Unit, 14 residents on the 200 Hall, 19 residents on the 400 Hall and 18 residents on the 700 Hall. In an interview with the DON on 4/22/20 at 1:34pm when told about the observations of linen carts not being covered, the DON stated, (Linen carts) should be covered. Review of the facility's undated Linen & Laundry Policy revealed under Policy: 1. All linen carts must be covered when transporting or storing clean laundry . 2. Review of the current [DIAGNOSES REDACTED]. Observation of Nursing Assistant (NA)1 on 4/22/20 at 11:53am revealed that NA1 assisted R1 with transferring an iced water from a plastic cup to R1's tumbler. Without performing hand hygiene, NA1 went into R1's room and immediately removed the lid on R1's tumbler to transfer the iced water from the plastic cup to the tumbler per R1's request. In an interview with NA1 when asked if she should have performed hand hygiene before assisting R1 with her water, NA1 stated, (I) should have done it. In an interview with the Director of Nursing (DON) on 4/22/20 at 1:34pm when told about the observation of NA1 not performing hand hygiene before assisting R1 with transferring her water from the plastic cup to her tumbler, the DON stated, She should have washed her hands. 3. Observation on 4/22/20 at 12:10pm revealed that NA2 brought lunch trays to R2's, R3's, R4's and R5's rooms. NA2 was not observed performing hand hygiene before delivering the lunch trays to the four rooms. NA2 assisted in setting up the lunch trays on residents' over-bed tables then NA2 left their rooms without doing hand hygiene. In an interview with NA2 on 4/22/20 at 12:26pm when asked if she should have performed hand hygiene when delivering meal trays to the residents' rooms, NA2 stated, (I) should do it in between rooms. Review of the current [DIAGNOSES REDACTED]. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection.). Further review of R4's current [DIAGNOSES REDACTED]. In an interview with DON on 4/22/20 at 1:34pm, when told about the observations of lapses in hand hygiene by the NA2 while delivering meal trays to residents, the DON stated, (There should be) hand hygiene in between rooms. In an interview with the Administrator on 4/22/20 at 4:37pm, the Administrator stated, (There was) no policy that addresses doing hand hygiene in between resident rooms (when delivering meal trays). Review of the facility's undated Brookside's Hand Washing Policy revealed Hand washing doesn't take much time and effort, but it is the single most important step in preventing illness/communicable disease and significantly reducing the spread of infection . Further review of the same policy revealed under Purpose: The main reason if to cleanse the hands of pathogens, including bacteria or viruses and chemicals that can cause personal harm or disease. Review of the same policy further indicated, .Some situations that require hand hygiene including but not limited to: .Before and after assisting a resident with meals . The same policy stated, Clean hands are the single important factor in preventing the spread of dangerous germs and antibiotic resistance in health care settings .Compliance with hand hygiene in the USA could save 20,000 lives per year!!!

Based on observation, record review, and interview, the facility did not thoroughly assess and provide services consistent with professional standards of practice for pressure injuries for 2 (R116 and R25) of 3 residents reviewed with pressure injuries. * R116 was admitted to the facility with a Stage 2 pressure injury that developed into an unstageable pressure injury with slough. Documentation was conflicting as to the Stage of the wound and the description of the wound base. * R25 had mutiple pressure injuries/skin conditions. The facility did not accurately monitor and document the status of pressure injuries. The facility's assessments were not always completed weekly, there was inconsistent identification of the wounds and their locations. The location of the wounds were identified in different anatomical locations and it was unclear if areas mentioned in the medical were new wounds or if staff was referencing the same wounds using different identified locations such as; coccyx versus inner buttock versus left buttock, left heel having 2 DTIs, and the right heel having a DTI and a Stage 1. In addition, Surveyor noted the facility did not always contact the physician for treatment orders, nor did the Treatment Administration Record (TAR) reflect treatments as being done. The MD was not always contacted when pressure injuries/wounds worsened such as when the right outer heel stage 1 increased in size on 12/30/19. Findings include: The facility policy and procedure entitled Skin Care Management and Pressure Injury dated 12/21/2016 states: POLICY: Each resident will have a skin assessment and a treatment plan for the maintenance of skin integrity and wound management if required. The purpose of skin and wound management is to: 1. Identify residents at risk for skin breakdown. 2. Promote comfort and mobility. 3. Reduce or relieve pressure and maintain skin integrity. 4. Provide appropriate interventions to manage pressure ulcers and minimize infection. 5. Provide learning opportunities. 6. Monitor and evaluate resident outcome. PROCEDURE: . Monitoring: 1. Staff will perform routine skin inspections daily with cares and as needed notifying the nurse of any skin changes. 2. Nurses will conduct a weekly skin assessment to identify changes. 3. Identify cause and contributing factors such as friction, shear, pressure, malnutrition, dehydration, trauma, immobility, medications, disease, and moisture/incontinence. 4. If resident is diabetic, the nrse will observe feet. 5. If wound present, assess after cleansing for: location, size (length x width and depth in centimeters), color of wound bed (red, yellow, black), undermining/sinus tracts, amount/type color of drainage/exudate (serous, serous sanguineous, sanguineous, green, purulent), odor, tissue bleeding, wound edges (maceration, rolled), condition of surrounding skin (induration, redness, temperature, [MEDICAL CONDITION]), duration of wound, and pain. Notification: 1. MD (Medical Doctor). 2. Family/HCPOA (Health Care Power of Attorney). 3. Wound Certified Nurse: a. Wound nurse or designee to place resident on weekly wound rounds. b. Wound nurse or designee in collaboration with the MD will make recommendations for the treatment of [REDACTED]. c. Wound nurse or designee will maintain weekly measurements, description of each wound that has been identified documenting and updating MD as needed. 1.) R116 was admitted to the facility on [DATE] after hospitalization for a cardiovascular accident with left sided [MEDICAL CONDITION]. R116 had the following Diagnoses: [REDACTED]. R116's admission Minimum Data Set (MDS) assessment dated [DATE] coded R116 as needing extensive assistance with bed mobility, transfers, toileting, and hygiene and a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. On 12/11/2019 in the Patient Discharge Instructions from the hospital, R116's skin was documented as having a reddened area to the buttocks/coccyx with [MEDICATION NAME] in place. [MEDICATION NAME] is a foam border dressing used to treat wounds with exudate or potential pressure areas that need protection. On 12/11/2019 at 8:14 PM in the progress notes, nursing charted R116 had a wound to the sacrum/coccyx measuring 8 cm x 1.5 cm x 0 cm and was beefy red. No cause of the wound was given such as excoriation or pressure and no staging was done if it was considered a pressure injury. The treatment from the discharge orders from the hospital was to cleanse the open area with normal saline and apply Orange Remedy to the open area every shift. Orange Remedy is a protectant paste with zinc oxide used to prevent skin breakdown due to moisture or to treat superficial skin breakdown. an order for [REDACTED]. A Skin Injury to the Coccyx Area Care Plan was initiated on 12/11/2019 with the following interventions: -reduce pressure and friction in the bed or chair, -provide wound care, - limit the head of the bed being elevated to 30 degrees and encourage a 30-degree side lying position when in bed, -keep (R116) off the hips, -check skin with cares, -check skin weekly, -help with hygiene and general skin care, -avoid using hot water for washing and use moisturizer on the skin, -help reposition at least every 1-2 hours while in bed, -keep good padding around the bony areas, -use skin protective devices, -A and D cream, -use pillows for support, -keep clean and dry, -have dietary staff discuss nutrition needs, -and report any changes to the nurse. On 12/12/2019 at 5:56 AM in the progress notes, nursing charted this was the initial assessment of the coccyx wound that R116 was admitted with. The progress note stated the initial stage of the wound was unable to be staged, was a suspected deep tissue injury with red and purple intact skin measuring 2 cm x 5 cm with tissue type of slough. Surveyor interviewed Director of Nursing (DON)-B on 3/3/2020 at 2:00 PM regarding the documentation of R116's initial wound assessment. DON-B agreed the charting was conflicting with the documentation of beefy red tissue on 12/11/2019 and then a deep tissue injury with slough on 12/12/2019; a deep tissue injury is closed skin and slough is found on an open wound. Surveyor stated it was difficult to determine what R116's skin looked like on admission with the two skin integrity entries. DON-B stated the wound charting was a mess. On 3/3/2020 at 11:57 PM in the progress notes, the nurse amended the charting to state the skin was intact on 12/12/2019. On 12/18/2019 in the progress notes, nursing charted R116 had a Stage 1 unblanchable area to the coccyx. No measurements were documented. On 12/18/2019, R116's skin integrity care plan was revised to state the skin injury to the coccyx area was a deep tissue injury. No interventions were revised. On 12/21/2019 in the progress notes, nursing charted R116 had a small area of blanchable purple/redness to the right side of the coccyx. No measurements were documented. On 12/23/2019 at 1:07 PM in the progress notes, nursing charted the coccyx wound measured 1 cm x 1.75 cm x < (less than) 0.1 cm with a pink base and no exudate. The wound was not staged. No documentation was found of notification of the physician with the open wound. No documentation of R116's coccyx wound was found for 14 days. On 1/6/2020 at 2:15 AM in the progress notes, nursing charted R116's coccyx wound was worsening and was now a Stage 2 pressure injury measuring 1.5 cm x 1.2 cm x 0.2 cm with pink [MEDICATION NAME] tissue in the base of the wound. After Surveyor discussed wound charting with DON-B on 3/3/2020 at 2:00 PM, the nurse appended the wound entry for 1/6/2020 on 3/4/2020 at 2:49 AM stating the wound was a suspected deep tissue injury with partial thickness skin loss in the center of the wound, which was pink in color. No measurements were given to denote the size of the deep tissue injury or the open area. On 1/7/2020 in the physician exam note, the physician documented: Possible sacral decubitus. Patient remembers the nurses saying (R116) had a pressure ulcer. I am unable to examine (R116) at this time as (R116) requires a Hoyer lift for transfers. Plan: I will check with the nurses if there is any evidence of a sacral decubitus ulcer. On 1/13/2020 at 1:57 PM in the progress notes, nursing charted the Stage 2 pressure injury to the coccyx measured 1 cm x 1.5 cm x < 0.5 cm with [MEDICATION NAME] tissue in the wound base which had pallor noted. On 1/15/2020, R116's skin integrity care plan was revised to state the skin injury to the coccyx area was a Stage 2 pressure injury. Apply Orange Remedy cream to the coccyx was added as an intervention. No documentation of R116's coccyx wound was found for 10 days. On 1/23/2020 at 11:05 PM in the progress notes, nursing charted the Stage 2 pressure injury to the coccyx measured 1.5 cm x 1 cm x 0.2 cm with [MEDICATION NAME] tissue in the wound bed and light drainage. After Surveyor discussed wound charting with DON-B on 3/3/2020 at 2:00 PM, the nurse appended the wound entry for 1/23/2020 on 3/4/2020 at 4:33 AM stating the suspected deep tissue was no longer present, but the partial thickness skin loss remained. On 1/23/2020, the treatment to the coccyx was changed to cleanse the open area to the coccyx with normal saline, apply collagen powder to the open area, and cover with a dry 2x2 secured with hypofix daily. On 1/29/2020 in the progress notes, a Licensed Practical Nurse (LPN) documented the open area to the coccyx was healing well with the wound tissue pink and edges moist and white. On 2/3/2020 at 3:37 PM in the progress notes, LPN-G charted R116's Stage 2 to the coccyx measured 1.8 cm x 1.5 cm with no depth documented. The wound had slough in the wound bed with pink tissue and white around the edges with light drainage. In an interview with LPN-G on 3/5/2020 at 9:53 AM, LPN-G stated LPN-G did R116's wound treatment every day. The wound was a small open area with pink to the wound base and it was probably a Stage 2, but as an LPN, she could not stage the wound. When asked if there was slough in the wound on 2/3/2020, LPN-G stated the wound did not have slough; slough is yellow and it was just pink. LPN-G stated the slough button may have been clicked on accident when charting and the computer system has limited choices to pick for the type of tissue present so you select whatever is closest. LPN-G stated if there had been slough present, LPN-G would have contacted DON-B for further instructions. On 2/10/2020 at 1:25 PM in the progress notes, LPN-D charted R116's Stage 2 to the coccyx measured 2 cm x 2 cm with no depth documented. The wound had slough in the wound bed with pink tissue and light drainage. In an interview with LPN-D on 3/5/2020 at 8:48 AM, LPN-D stated R116's wound was pink and smooth and flat. LPN-D stated the slough button must have been bumped when charting because there wasn't any yellow or white tissue. When Surveyor showed LPN-D their charting had slough documented twice, LPN-D stated the slough was put in the charting later because it was slough earlier in the charting. No documentation of a Registered Nurse assessing R116's coccyx wound was found for 22 days. On 2/14/2020 at 3:58 AM in the progress notes, nursing charted R116's coccyx wound was a suspected deep tissue injury with 75% pink [MEDICATION NAME] tissue and 25% deep purple and boggy with moderate drainage. The healing progress stated this was a worsened Stage 2 pressure ulcer becoming larger with tenderness present. The area measured 2 cm x 2.5 cm and unable to determine depth with necrotic tissue. After Surveyor discussed wound charting with DON-B on 3/3/2020 at 2:00 PM, the nurse made a late wound entry for 2/14/2020 on 3/4/2020 at 6:48 AM stating the wound was a suspected deep tissue injury with partial thickness skin loss. The healing progress of a worsened Stage 2 pressure ulcer from the original entry was removed; the wound becoming larger and tenderness present was retained. The measurements remained the same and the necrotic tissue documentation was replaced with [MEDICATION NAME] tissue. On 2/14/2020, the treatment order was changed from daily to twice daily. On 2/19/2020 in the progress notes, an LPN charted the open area to the coccyx remains; a small amount of dark skin was noted to the left side of the wound while the remaining area was pink and the surrounding tissue was white. No documentation of measurements, an RN assessment, or of physician notification was found. On 2/23/2020 at 7:09 PM in the progress notes, nursing charted R116's coccyx wound measured 2 cm x 1.5 cm with a pink wound bed and moderate drainage. The wound was not staged. On 2/24/2020, R116's skin integrity care plan was revised to state the skin injury to the coccyx area was a suspected deep tissue injury and has proven difficult to heal. The treatment was removed as an intervention while assess prevention strategies, elevate heels when in bed, and offer toileting were added interventions. On 2/27/2020 at 11:41 PM in the progress notes, nursing charted R116's coccyx pressure wound was unable to be staged due to slough in the wound bed. The wound measured 1 cm x 2.6 cm with no depth documented. The wound had moderate drainage and the healing progress was noted to be improving due to becoming smaller, even though the wound now had slough. After Surveyor discussed wound charting with DON-B on 3/3/2020 at 2:00 PM, the nurse made a late wound entry for 2/27/2020 on 3/4/2020 at 12:11 AM stating the wound was a suspected deep tissue injury with partial thickness skin loss with slough covering the wound base. The description stated the wound was becoming smaller and the original suspected deep tissue injury had healed with the partial thickness skin loss still noted with slough tissue to the wound bed. R116 no longer had complaints of pain with dressing changes. No documentation of physician notification of slough in the wound bed was found. On 3/2/2020 at 10:36 AM, Surveyor interviewed R116. R116 stated there is a sore on her backside and gets hot and burning if sitting in a chair too long. R116 stated the bandage is changed at least daily and R116 should lay down in bed, on the side to relieve the pressure. R116 had a cushion in the wheelchair and an air mattress on the bed. On 3/2/2020 at 1:12 PM in the progress notes, nursing charted R116's coccyx wound measured 1 cm x 2.1 cm x 0.1 cm with no exudate. No staging or description of the wound base was documented. On 3/3/2020, R116 was admitted to the hospital for [MEDICAL CONDITION]. Surveyor did not observe R116's wound or treatment. On 3/4/2020 at 10:20 AM, Surveyor interviewed DON-B regarding R116's wound documentation. DON-B stated the floor nurses do the initial assessment when a resident is admitted , but the policy is to not have the floor nurse stage a pressure wound until the wound certified nurse looks at it the next day. The third shift nursing supervisor does wound rounds every Thursday and the floor nurses do all the measurements on Mondays so each resident should technically be charted on twice a week. Surveyor reviewed the skin charting with DON-B to show missing weeks of documentation. Surveyor reviewed R116's skin integrity care plan with DON-B showing how the care plan changed from a skin injury to the coccyx on 12/11/2019 to a deep tissue injury on 12/18/2019 to a Stage 2 on 1/15/2020 and back to a suspected deep tissue injury on 2/24/2020 and the interventions listed don't show limiting R116 sitting in the wheelchair which is a cause of the pressure injury. DON-B stated healing unstageable wounds is what the new terminology is so when a wound is unstageable and it starts to heal, it becomes a healing unstageable wound and that may be why the care plan terminology changed back and forth. DON-B stated the wound care team is responsible to change the care plan, but the nurses on the floor do go in and change things sometimes. DON-B agreed it was hard to determine the stage and status of R116's wound with the documentation as it was in the chart. DON-B stated the nurses that documented on R116's wound have been talked to about the conflicting charting. On 3/5/2020 at 2:00 PM, Surveyor reviewed the above findings with Nursing Home Administrator (NHA)-A, DON-B, and Director of Clinical Operations-F. R116 was admitted with a reddened area to the coccyx per hospital documentation that developed into a suspected deep tissue injury that opened up into an unstageable wound covered in slough. The wound was not documented on weekly and did not have accurate staging or descriptions of the wound or wound bed. After Surveyor showed DON-B the difficulty in following the wound progression, DON-B had some nurses amend their entries. The amended entries did not clarify the progression of the wound and with R116's admission to the hospital on [DATE], a current view could not be obtained. No further information was provided at that time. On 3/5/2020 via email at 3:50 PM after Surveyor exited the facility, Director of Clinical Operations-F forwarded the Admission Report Sheet taken by the nurse receiving R116 from the hospital, the admission body check form, and copies of the wound documentation by facility staff on 12/11/2019 and 12/12/2019 as already recorded by Surveyor. The Admission Report Sheet, undated and unsigned, stated R116 had a Stage 2 to the coccyx with a treatment of [REDACTED]. The Admission Body Check form, undated and unsigned, indicated a wound measuring 8 cm x 1.5 cm to the coccyx area. 2.) On 3/2/20 at 10:32 AM the survey team was provided with a wound list dated 2/14/20. The wound list included R25 with the following information wound type: stage 2, location: coccyx, upon admission . On 3/5/20 at 11:25 AM, surveyor observed wound care to R25's coccyx performed by Licensed Practical Nurse (LPN)-H. Surveyor observed R25's coccyx with 2 stage 2 pressure ulcers. R25's feet were observed. R25's left heel was observed with dark brown eschar (dead skin tissue). On 3/5/20 at 11:36 AM, Surveyor conducted an interview with LPN-H. LPN-H informed surveyor that R25 was not initially on their unit at facility but that LPN-H had treated R25's wounds since moving from the rehab unit. Surveyor asked LPN-H how staff know how to provide care to a resident with pressure injuries. LPN-H replied they would be directed by the resident care plan and their Treatment Administration Record (TAR) when to provide skin treatments to residents. Surveyor asked how wounds are monitored in facility. LPN-H responded that nursing staff monitors wounds by performing measurements to see if the treatment is working. LPN-H stated that wound progress is communicated to nursing staff via email. Surveyor asked how often wounds should be assessed by nursing staff. LPN-H replied that wounds should be charted upon with an assessment and measurements on a weekly basis. Surveyor reviewed R25's medical record and noted the following: R25 was admitted to the facility 12/5/2019 with [DIAGNOSES REDACTED]. R25's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/10/19 indicates a Brief Interview of Mental Status (BIMS) score of 14, indicating resident is cognitively intact and able to participate in daily decision making. Section G of R25's MDS indicates that resident requires extensive assist on two staff for bed mobility. R25 Requires total assistance of 2 staff for transfers with a mechanical lift. R25 requires extensive assist of 1 for personal hygiene and dressing. Section H of R25's MDS indicates resident is frequently incontinent of bowel and bladder. On 3/4/20 at 1:16 PM, surveyor reviewed R25's care plan 12/18/19 which states as follows: I have a skin injury, Deep Tissue Injury to my left heel, Stage 1 to Right outer heel (red), Moisture associated skin damage (MASD) to my tailbone .Because I can't move around well on my own. I show this by requiring daily skin treatment and ongoing preventative skin care. I need my nurses to provide wound care .I need everyone to make sure I change positions frequently and report any changes to my nurse. Per R25's admission skin assessment and medical record documentation R25 was with multiple pressure injuries which consisted of the following; Left Heel: Per review of initial skin admission assessment performed on 12/5/19, R25 was admitted to the facility with 2 suspected deep tissue pressure injuries (DTIs) to the left heel, measuring 2.0 x 4.5 cm and the other DTI measuring 1.0 x 1.0 cm. R25's Admission MDS indicated R25 has 1 Suspected DTI while the initial skin admission assessment indicates 2 suspected DTIs to the left heel and 1 suspected DTI to the right heel. Surveyor noted the discrepancy between the MDS which indicated 1 suspected DTI whereas the initial skin admission assessment dated [DATE] indicated 2 suspected DTIs to the left heel. From 12/9/19 to 3/3/20, there is wound documentation and measurements for the 1 suspected DTI to the left heel measuring 2.0 X 4.5 cm. There is no measurements for the 2nd suspected DTI measuring 1.0 X 1.0 cm. On 12/9/19, there is documentation of a suspected DTI measuring 2.0 x 4.5 cm. This suspected DTI is documented as noted upon admission. This wound's location on the left heel is not described, such as the actual location of this wound, tissue description, drainage etc. There is no physician notification related to the 2 DTIs or of the area's measurements. On 12/16/19, documentation notes left heel DTI 4.5 x 2.5 cm. There is no documentation in the medical record of physician notification of the increased size of the DTI to the left heel. On 3/4/20 at 10:05 AM, Surveyor reviewed R25's Treatment Administration Record (TAR) for December 2019 to March 4, 2020. Surveyor did not observe any treatments signed out by staff for suspected DTIs to the bilateral heels from 12/5/19 to 1/22/20. On 1/23/20, an order on the TAR was initiated. The order reads as follows: Apply skin prep to left heel wound daily HS (hours of sleep). On 3/5/20 at 11:25 AM, surveyor observed R25's feet, R25's left heel was observed with dark brown eschar (dead skin tissue). Right heel: Per the admission skin assessment dated [DATE], a suspected DTI noted to the Right heel measuring 0.5 x 0.5 cm On 12/9/19, documentation was noted of a Stage 1 pressure injury to R25's right outer heel measuring 1.5 x 1.0 cm. Documentation on 12/9/19 indicates stage 1 pressure injury to right outer heel was present upon admission to the facility. Surveyor noted there was no documentation found on the 12/5/19's admission skin assessment indicating a Stage 1 pressure injury to R25's right outer heel, only that R had a suspected DTI to the right heel. It was not clear to the surveyor if the DTI noted on the right heel and the stage 1 pressure injury to the right outer heel were the same injuries or if they were 2 separate areas. On 12/16/19, documentation states follow up assessment of right heel, no area of pressure sore present. On 12/18/19, documentation states a stage 1 pressure injury is present to right heel measuring 0.3 x 0.2cm. On 12/23/19, documentation states that stage 1 pressure injury to right outer heel measures 0.3 x 0.2 cm. On 12/30/19, documentation states that stage 1 pressure injury to right outer heel measures 0.5 x 0.5 cm and that the ulcer status is improving. Surveyor noted the measurements on 12/30/19 to the stage 1 pressure injury to right outer heel had increased in size from 0.3 x 0.2 to 0.5 X 0.5. Surveyor noted there no other description or explanation as to why the facility thought the stage 1 pressure injury to the right outer heel was improving. On 1/6/20, documentation states that stage 1 pressure injury to right outer heel measures 0.5 x 0.5 cm and that the ulcer status is the same. On 1/13/20, documentation states that stage 1 pressure injury to right outer heel measures 0.5 x 0.5 cm and that the ulcer status is the same. There is no documentation of any physician notification related to increased measurements from 12/30/19 to 1/13/20. Surveyor noted there was no additional documentation for the monitoring of the stage 1 pressure injury to right outer heel from 1/13/20 to 2/3/20 (including measurements). On 2/3/20, documentation states right heel, no open noted (sic), only dry skin. On 3/4/20 at 10:05 AM, Surveyor reviewed R25's TAR for December 2019 to March 2020. Surveyor did not observe any treatments signed out by staff for the suspected DTI to bilateral heels from 12/5/19 to 1/22/20. On 1/23/20, an order on the TAR was initiated. The order reads as follows: Apply skin prep to left heel wound daily HS. On 3/5/20 at 11:25 AM, surveyor observed R25's feet, R25's right heel was observed with no DTIs and/or pressure injuries. Coccyx/inner buttock: On 3/4/20 at 10:05 AM, Surveyor reviewed R25's TAR for December 2019 to March 2020. On 3/4/20, an order was added to the TAR that read as follows: Cleanse open areas to coccyx and bilateral buttock, apply orange remedy cream followed by dry dressing to open areas every shift. Surveyor noted R25 was admitted to the facility on [DATE] with Moisture Associated Skin Damage (MASD) to their coccyx. There was no initial measurement of the MASD to the coccyx area performed upon admission to facility. On 12/5/19, MASD to inner buttocks was assessed as red, blanchable with no initial measurements documented. Surveyor noted it was unclear if the MASD to the coccyx area and to the inner buttocks were the same areas or if these were 2 separate areas. On 12/9/19, measurements of MASD to R25's coccyx were performed and documented as 0.5 x 0.5 cm. On 12/23/19, measurements of MASD to R25's coccyx were performed, measuring 2.25 x 0.75 cm with an assessment stating area is denuded, not a stageable wound. Surveyor noted this measurement and assessment of R25's MASD to the coccyx was performed 14 days after the last documented assessment on 12/9/19, showing that R25's MASD to coccyx had increased in size and that there was no documented notification to R25's physician related to the change in the size of the wound. On 1/6/20, an assessment was performed to coccyx stating red excoriation noted. Ulcer status was documented as the same. Surveyor noted no measurements were documented for MASD to the coccyx on 1/6/20. On 1/13/20, an assessment was performed to coccyx stating ulcer status: improving. Surveyor noted no measurements were documented for MASD on 1/13/20. Surveyor noted there was no additional information as to why the facility concluded the area was improving. Measurements performed on 1/16/20 were documented as 0.4 x 0.3 cm. No depth was documented to this wound. Per documentation on 1/16/20, it is noted that R25 currently had 3 separate stage 2 pressure injuries documented to their coccyx and left buttock area. These areas were acquired while R25 resided in facility. On 1/16/20, an assessment was performed stating left buttock/coccyx, current stage: stage 2, healing progress: worsened from MASD. Surveyor noted there was no documentation regarding the date of onset if the documentation is referring to the left buttock as being a new and/or separate area from the coccyx and from the inner buttock. This is the first time Surveyor noted reference to the left buttock area. Measurements performed on 1/16/20 were documented as 1.5 x 0.4 x 0.2 cm. Surveyor noted the documentation did not include what area this measurement was for. On 1/16/20 documentation was noted to as follows: coccyx, current stage: stage 2, healing progress: worsened MASD. Measurements performed on 1/16/20 were documented as 0.4 x 0.4 x 0.1 cm. which was for the coccyx. On 1/20/20, an assessment was performed stating coccyx, 1.5 x 0.5 cm, wound type: stage 2. No depth was documented for the coccyx wound. Per documentation on 1/20/20, the area is no longer references as MASD associated. No further documentation was noted to address 2 other pressure injuries that were first documented upon on 1/16/20. On 1/27/20, an assessment was performed stating coccyx, 1.5 x 0.5 cm, wound type: stage 2. No depth was documented for this wound. No further documentation was noted to address 2 other pressure injuries that were first documented upon on 1/16/20. On 1/28/20, documentation was performed stating coccyx, small open red slit. No measurements were documented for this wound. Upon record review and staff interview, it is unclear if this area was a new pressure injury to the coccyx or if this was area referred back on 12/5/19 upon admission. On 2/3/20, documentation was performed stating coccyx, small open red slit. 0.5 x 0.2 x 0.1 cm. Additional documentation was noted stating coccyx, 1.2 x 0.3, open area noted. Upon record review and staff interview, it is unclear if this was a new pressure injury or a previously documented wound. No staging information was noted for these wounds on 2/3/20. On 2/10/20, documentation was performed stating coccyx, healing progress: improving. 0.5 x 0.3 x 0.1 cm. No staging information was noted for this wound on 2/10/20. On 2/21/20, documentation was performed stating coccyx has a small open slit, treatment done. No measurements or staging information was noted for this wound on 2/21/20. On 3/3/20, a late entry documentation dated for 2/27/20 was performed stating coccyx, onset: noted on admission, stage: 2. 0.6 x 0.2 x 0.1 cm. On 3/5/20 at 11:25 AM, surveyor observed R25's coccyx with 2 stage 2 pressure ulcers. Left buttock: On 1/16/20, an assessment was performed stating left buttock, current stage: stage 2, healing progress: worsened MASD. Measurements performed on 1/16/20 were documented as 0.4 x 0.3 cm. No depth was documented to this wound. Per documentation on 1/16/20, it is noted that R25 currently had 3 separate stage 2 pressure injuries documented to their coccyx and left buttock area. On 3/3/20, a late entry documentation date for 2/27/20 was performed stating left buttock, onset: noted on admission, stage: 2.1.1 x 0.5 x 0.1 cm. Surveyor noted the documentation for the left buttock started on 1/16/20 and not on admission which was 12/5/19. On 3/4/20 at 10:05 AM, Surveyor reviewed resident's TAR for December 2019 to March 2020. Surveyor did not observe any treatment orders on TAR related to R25's MASD for the coccyx, inner buttock and left buttock. Additionally, Surveyor did not observe any treatment orders on the TAR for the stage 2 pressure injuries to coccyx/left buttock. Surveyor did not observe any treatments signed out by staff related to R25's MASD or stage 2 pressure injuries from 12/5/19 to 3/4/20. On 3/4/20 the TAR read as follows: Cleanse open areas to coccyx and bilateral buttock, apply orange remedy cream followed by dry dressing to open areas every shift. On 3/5/20 at 11:25 AM, surveyor observed R25 did not have any MASD to the inner and left buttock. After Surveyor's review of R25's medical record and interview with staff, Surveyor identified the facility did not accurately monitor and document the status of pressure injuries. The facility's assessments were not always completed weekly, there was inconsistent identification of the wounds and their locations. The location of the wounds were identified in different anatomical locations and it was unclear if areas mentioned in the medical were (TRUNCATED)

Based on observation, record review, and interview, the facility did not ensure residents receive adequate supervision and assistance devices to prevent accidents for 1 (R57) of 9 residents reviewed for falls. R57 was transferred with a sit-to-stand lift and sustained a fall from the lift when the care plan stated R57 transfers with a Hoyer lift. The fall was never investigated by the facility. Findings include: The facility policy and procedure entitled Fall Prevention Program dated 9/19/2019 states: When a resident has a fall at (the facility) a fall report will be completed promptly by a licensed nurse. The fall scene investigation form will be used to help determine the reason for the fall. The form will be completed by the nurse and kept in the resident's chart. Notification of the fall will be made to the resident's primary care physician and to the resident's primary contact. All falls will be reviewed by an Interdisciplinary fall team. R57 was admitted to the facility on [DATE] after hospitalization . R57's Activities of Daily Living Care Plan dated 1/14/2020 indicated R57 transferred with the use of a Hoyer lift with two people. On 1/15/2020 in the physical therapy notes, therapy charted due to R57's inconsistency in standing, the use of a Hoyer lift is recommended for safe transfers at this time. On 1/19/2020 at 4:15 PM, R57 was attempted to be transferred by a Certified Nursing Assistant using a stand lift from the toilet to the recliner. R57 could not stand up during the transfer and was lowered to the floor. A Hoyer lift was then used to transfer R57 from the floor to the recliner. The progress note indicated the physician was not notified of the incident. On 3/2/2020 at 11:55 AM, Surveyor observed R57 in the dining room during lunch time. A Hoyer lift sling was noted under R57 while in the wheel chair. On 3/5/2020 at 11:54 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R57's incident with the stand lift on 1/19/2020. DON-B stated R57 has always been a Hoyer lift and was unaware of the incident on 1/19/2020. DON-B stated the nurse must not have clicked the fall button when charting. When the fall button is used, it alerts administrative staff that a fall has occurred and the fall team then meets to discuss the fall and determine the cause so interventions can be put in place to prevent future falls. DON-B stated the nurse clicked other instead of fall so the administrative staff was unaware of the fall and did not do an investigation or education on the fall. DON-B stated R57's care plan was not followed and therefore R57 sustained a fall from the stand lift. No further information was provided at that time.

Based on interview and record review, the facility did not assure bowel elimination and implement interventions to prevent constipation and fecal impaction for 1 of 2 residents (R75). The facility did not follow the facility's bowel and bladder policies, did not monitor or assess bowel movements, did not assess effectiveness of PRN (as needed) medication, did not develop and implement a care plan related to constipation, resulting in R75 not having a bowel movement for 8 days (11/6-11/13/18), then being hospitalized (on 11/13/18) and treated for [REDACTED]. Finding Include: Surveyor reviewed the facility Bowel Management Policy with a reviewed date of 1/16/19. The policy states procedure for bowel management will be, 1. Nursing staff to document all bowel movements (BM) in Electronic Charting System (ECS). 2. Each shift the unit nurse is to check the stool output log in ECS. The following interventions are to be followed after reviewing the stool output log: - N[NAME] (Night) Shift Nurse - For residents that have not had a bowel movement in over 24 hours will be added to a prune juice list. This list is to be given to the Certified Nursing Assistant (CNA) staff so they can give prune juice to these residents with breakfast. - PM Shift Nurse - For residents that have 2 days of no bowel movement Milk of Magnesia is to be administered, (check MAR for order), or other laxative per orders. - AM Shift Nurse - For residents that have 3 days of no bowel movement, administer PRN [MEDICATION NAME] suppository (check Treatment Administration Record (TAR) for order). - If above interventions are not effective, nurse to notify MD for further instructions. Interpretive guidelines: For residents with continuous and/or chronic constipation, update care plan to reflect all interventions. Evaluate and update as needed for effective bowel elimination. Surveyor reviewed the facility Bowel Training policy with a reviewed date of 2/28/05. Purpose of this policy is To achieve control of bowel evacuation on a regular basis, every 2-3 days either independently or assisted. To avoid constipation. To prevent skin irritation. To improve the resident's morale, help to restore dignity and self-respect. Procedure of this policy is Develop a plan. Discuss which of the following would be most effective for your resident based on your assessment and evaluation . Document in nurses' notes and Bowel Movement List whenever the resident has a stool (incontinent or continent), medication or interventions used. Surveyor reviewed R75's medical record. R75 was admitted to the facility 10/19/18 with a [DIAGNOSES REDACTED]. On 10/31/18, R75 was admitted to Kenosha Medical Center for Percutaneous Endoscopic Gastrostomy (PEG) tube (feeding tube) placement which was completed on 11/2/18 and was discharged back to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor reviewed the Hospital to Nursing Home Transfer Packet dated 11/5/18 and the Discharge Summary dated 11/5/18. During hospitalization R75's POA was activated and he was declared incompetent. Surveyor reviewed Brookside Care Center Admission Report Sheet dated 11/5/18 which stated Last Bowel Movement (BM): 11/5/18. Surveyor reviewed Certified Nursing Assistant (CNA) bowel charting from 11/5/18 to 11/13/18. There is no Bowel Movement charted from 11/6/18 at 12:48 AM to 11/13/18 at 7:29 AM, each entry stated Stool: No stool output during this time period. There is no documentation of nurse being notified. Surveyor reviewed the Nurse's Bowel and Bladder Assessments from 11/5/18 to 11/12/18. On 11/6/18 at 12:37 AM the assessment documented Toilet Use: Requires one aide for assist to toilet. At 4:25 AM Stool: No BM (until) this time which was again charted on 11/7/18 at 4:10 AM, 11/8/18 at 2:33 AM, and 11/9/18 at 3:17 AM. On 11/9/18 at 3:29 AM documented Urinary Toileting Program response: Unable to determine, or trial in progress. CNA 3 day B&B (bowel and bladder) charting was not completed. There are no bowel assessments documented between 11/5/18 and 11/12/18. Surveyor reviewed Physician orders [REDACTED]. Surveyor noted [MEDICATION NAME] 10mg suppository, 1 suppository daily PRN for Constipation with order date of 11/5/18, Milk of Magnesia (MOM) dose by mouth daily PRN for Constipation with order date of 11/5/18 and Polyethylene [MEDICATION NAME] 3350 Powder ([MEDICATION NAME]) 17 gram daily AM for Constipation with an order date of 11/6/18. Surveyor reviewed Medication Administration Record [REDACTED]. [MEDICATION NAME] was documented as administered daily from 11/6/18 to 11/12/18. No medication effectiveness was charted. Milk of Magnesia was documented administered on 11/12/18 which was Day 7 (with no bowel movement noted). No medication effectiveness was charted. [MEDICATION NAME] suppository was documented as administered on 11/13/18 which was Day 8 (with no bowel movement noted). No medication effectiveness was charted. Surveyor reviewed Nurse's Notes from 11/5/18 to 11/12/18. There are no notes related to bowel assessments completed, bowel movements charted, PRN medications administered, physician notification of lack of bowel movement, medication effectiveness assessments or interventions completed. Surveyor reviewed the comprehensive plan of care for R75 dated 12/18/18. There is no focus area related to constipation, bowel management or monitoring. On 01/16/19 at 9:07 AM, Surveyor interviewed RN Unit Manager (RN)-D. Surveyor asked what the policy or protocol is for bowel monitoring. RN-D stated there is a BM list the nurse reviews daily that includes residents who have not had bowel movements. These residents are reviewed and the facility protocol is: after 2 days, resident is given prune juice or MOM, after 3 days no BM suppository. After admission/readmission RN checks the bowel charting filled out by CNAs. All residents are tracked for bowel movements for 3 days after admission and readmission. BM list is checked daily by the nurse on the unit. This form is kept in each resident's chart under assessments. Surveyor requested this assessment for R75 from readmission on 11/5/18. RN-D could not find any documentation in hard chart. RN-D checked electronic chart for assessments and Nurse's notes from (MONTH) (YEAR) in ECS. There were no assessments or bowel monitoring related to R75 in chart from 11/5/18 to 11/12/18. There is no documentation of prune juice being given to R75 between 11/5/18 and 11/12/18. There is no documentation of MOM being administered on day 2 with no BM. There is no documentation of suppository being administered on day 3 with no BM. Surveyor reviewed both Minimum Data Set (MDS) assessments of 10/26/18 and 11/12/18. Both MDS assessments under G I Toilet Use state R75 is 3/2 or Extensive Assistance- resident involved in activity, staff provide weight bearing support, one person physical assist. Both MDS assessments under H0600 Constipation present state, No. Surveyor reviewed the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual for the definition of constipation which reads, If the resident has two or fewer bowel movements during the 7-day look-back period or if for most bowel movements their stool is hard and difficult for them to pass (no matter what the frequency of bowel movements). On 1/17/19 at 8:54 AM Surveyor interviewed MDS Coordinator (MDS Coor)-F. Surveyor asked MDS Coor-F where the information is gathered from that is entered into the MDS, and specifically Section H: Bowel and Bladder, question H0600, if constipation was present. MDS Coor-F stated he would use the 7 day look back period. The assessment date of 11/12/18 would mean information would be gathered from 11/6/18 to 11/12/18 otherwise known as the rule of 7. Information is gathered from ECS including nursing notes and assessments. Surveyor asked MDS Coor-F if there was any documentation that would indicate a bowel movement during this time. MDS Coor-F could not provide any documentation of this. Surveyor asked what other methods would he use to gather information to make this assessment. MDS Coor-F stated he would interview the staff. Surveyor asked if there was an interview completed. MDS Coor-F stated the person who I would have spoken to would have been the nursing assistant or the nurse or the nursing supervisor but there would not be any written documentation of that. MDS Coor-F stated, I don't remember who I spoke to. There was no documentation provided to support H0600 marked No for constipation present. Surveyor reviewed Nurse's Bowel and Bladder Assessments from 11/13/18. At 9:56 AM the assessment documents, Complaint/Symptom: nausea/rectal pain; Abdomen: soft nontender; Vomitus: spit up bile; Procedure Done: rectal check positive had suppository from earlier shift and firm stool still in rectum; Action: Physician notify, family notified. At 2:46 PM was Bowel Sounds: at (9:15 AM) bowel sounds present right left upper lower all quadrants discomfort; Stool: liquid and firm stool noted in rectum. Surveyor reviewed the Situation, Background, Appearance, Review and notify (SBAR) Communication form dated 11/13/18. Primary Care Physician was notified that R75 was moaning, whining and complaining of rectal pain started on 1/13/18 and since this started it has gotten worse. Primary Care Physician recommended Transfer to the hospital (non-emergency). Surveyor reviewed hospital records from 11/13/18 to 11/15/18. R75 health issues and [DIAGNOSES REDACTED]. chronic constipation, 3. nausea and vomiting resultant from above, 4. Number [MEDICAL CONDITION] from above, 5. right lower lobe infiltrate as found on CT scan. The history of present illness states, .the patient was just recently in-house admitted on [DATE]. He had low blood pressure at that time and some chronic constipation though he had a bowel movement in the emergency room . At this time the patient has developed nausea and vomiting today and no stool for a while and he has had a PEG tube in for about 10 days. He was quite upset in the emergency room . They gave him a milligram of [MEDICATION NAME] and that settled him down quite nicely. In the workup of his fatigue, nausea and vomiting his CAT scan reveals a proctitis stercoral and moderate fluid and distention of the remainder of the colon consistent with severe constipation. He also has a right lower lobe airspace disease that is suspicious for pneumonic infiltrate . He did have a bowel movement in the emergency room . However, he is quite packed and will have an enema to clean as well as [MEDICATION NAME] and mineral oil above in the PEG tube.

F157 G Based on record review, staff interview and family interview the facility did not promptly consult with the physician and did not notify the resident's family member, POAHC (Activated Power of Attorney for Health Care) when the resident developed a change in condition that occurred after there was a fall that resulted in injury and had the potential for requiring physician intervention. This occurred for 1 (Resident #4) of 2 residents reviewed who experienced a change in condition and for 1 (Resident #4) of 2 residents reviewed who were at risk for falls. On 11/30/15 at 10:50 p.m., Resident #4 had a witnessed fall. The resident sustained [REDACTED]. The physician was notified of the fall and the resulting injuries. No new orders were obtained, however the physician instructed the facility to monitor the resident. On 12/01/15, from 12:44 a.m. through 10:49 a.m., the resident developed significant changes to the facial injuries: developed bruising to the bridge of the nose, had an increase in the size of the hematoma to the forehead, and complained of a headache. The Resident was uncooperative for assessments, and the facility was only able to obtain partial neurological assessments. On 12/01/15 at 8:54a.m., the resident's physician was notified of the facial bruising, but not the extent of the bruising and swelling of the facial injuries and not the Resident's complaints of a headache. The Resident's physician and the Resident's POAHC were not notified of the extensive bruising and swelling to the resident's nose and face until 12/01/15 at 10:45 a.m., at which time the Resident was transported to the hospital for evaluation. On 12/01/15 at 2:05a.m., the resident had a witnessed fall. The resident did not sustain any injuries. The physician was notified of the fall on 12/01/15 at 8:57a.m., and the resident's family member was notified of the fall on 12/01/15 at 9:04a.m. On 12/08/15 at 2:35 p.m., Surveyor # spoke with Resident #4's family member who is the Activated Power of Attorney for Health Care (POAHC). The POAHC indicated that he is the person who would be notified if Resident #4's condition changed or there was a need to alter treatment. The POAHC indicated he was notified that Resident #4 had a fall on 11/30/15 at 10:50 p.m., and that the Resident had hit her head during the fall. The POAHC indicated that during the night the resident developed a headache and an increase in swelling and bruising to facial injuries that were sustained during the fall. The POAHC indicated he was not notified of the change in condition until 12/01/15 at 10:45 a.m., when the Resident was being sent to the hospital. The POAHC indicated he was concerned that the physician was not notified of the Resident's change in condition until 12/01/15 at 10:45 a.m., when the facility obtained an order to the send the Resident out to be evaluated. In addition, the POAHC indicated the Resident fell on [DATE] at 2:05a.m., and he was notified of that fall on 12/01/15 at 9:04a.m. On 12/11/15, Surveyor# reviewed Resident #4's medical record. The record indicates the Resident was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED].#4 has severe cognitive impairments and has an activated Power of Attorney for Health Care. The Nursing Note dated 11/30/15 at 11:34 p.m., indicates the Resident had an observed fall on 11/30/15 at 10:50 p.m. The note indicates the resident sustained [REDACTED]. The note indicates the physician was notified of the fall. The Nursing Note dated 12/01/15 at 12:44 a.m., late entry for 11/30/15 at 11:50 p.m., indicates the Resident refused assessment, has continuous oozing to small laceration on her nose, has a hematoma to the middle of the forehead, and bruising to the nose bridge is gradually developing. The note indicates the Resident remains alert but refused ice or other neurological parameters. The Nursing Note dated 12/01/15 at 2:26a.m., indicates the Resident had an observed fall at 2:05 a.m. when the resident stood up from the wheelchair, reached for a door handle, fell to the floor and landed on her buttock. The note indicates the resident sustained [REDACTED]. The Nursing Note dated 12/01/15 at 3:10a.m., indicates the Resident complained of a headache, refused Tylenol, and refused ice to the hematoma on the middle of the forehead. The note indicates the hematoma appears larger and that the bruising to the nose bridge is more pronounced. The note indicates the Resident refused to be assessed. The Nursing Note dated 12/01/15 at 3:16a.m., indicates the Resident is alert and the neuro check remains negative with very limited exam, refusing vital signs and assessment. The nursing note dated 12/01/15 at 6:05a.m., late entry for 4:50 a.m., indicates the Resident continues to complain of a headache, refuses ice to hematoma on the forehead and refuses Tylenol. The note indicates the bruising is more noticeable to the bridge of the nose, some swelling and small laceration to the nose. The note indicates the hematoma remains to the mid forehead. The Neurological Flow Sheet, dated 11/30/15 at 10:50 p.m. through 12/01/15 at 8:50a.m., indicates the Resident was alert, refused blood pressure, hand grasps and pupil assessment. The flow sheet indicates the Resident complained of a headache at 2:50 a.m. and 8:50 a.m. The next nursing note is dated 12/01/15 at 8:54 a.m. The note indicates the Resident's Psychiatrist was notified and new orders were received for [MEDICATION NAME]. The next nursing note is dated 12/01/15 at 8:57 a.m. and indicates the Resident's primary care physician was notified of the fall that occurred during the night and the Resident's facial bruising. The nursing note dated 12/01/15 at 9:04a.m., indicates the POAHC was notified of the recommendation for the [MEDICATION NAME]. The nursing note dated 12/01/15 at 9:20am, indicates the Resident was given medication for complaints of a headache. The next Nursing Note is dated 12/01/15 at 9:23 a.m. The note indicates the Resident has extensive bruising and some swelling to the bridge of the nose and face. The note indicates the Resident is alert, is able to grasp both hands equally, and refuses vital signs and pupil check. The next Nursing Note is dated 12/01/15 at 10:49 a.m. The note indicates the physician was notified of the Resident's increase in facial swelling and bruising, and that new orders were obtained to send the Resident to the hospital for evaluation. The note indicates the POAHC was made aware of the Resident's condition and the order to send the Resident to the hospital for an evaluation. The Hospital Emergency Department Encounter, dated 12/01/15 at 12:33 p.m., indicates the Resident has extensive bruising on her face and around her nose. The note indicates the Resident is able to answer some questions and that the vital signs are stable. The Hospital Medical Consult, dated 12/01/15 at 4:46p.m., indicates [DIAGNOSES REDACTED]. The Hospital Discharge Summary, dated 12/04/15 at 4:30 p.m., indicates the Discharge [DIAGNOSES REDACTED]. On 12/08/15 at 10:45 a.m., Surveyor # spoke with Registered Nurse (RN)-G who worked the night shift of 11/30/15. RN-G indicated that the Resident fell just prior to the start of the night shift (referring to the 11/30/15 10:50 p.m. fall), and that the Resident had a bump to her forehead and a one cm laceration to her nose. RN-G indicated that throughout the night, the Resident refused to go to bed, developed a headache and had increase in swelling and bruising to the facial injuries. RN-G indicated the Resident had an observed fall at about 2:00 a.m. RN-G indicates she did not call the Resident's physician or POAHC when the Resident developed a headache and had increase in swelling and bruising to the facility injuries. RN-G indicated she did notify the RN Supervisor of the Resident's condition throughout the night and of the fall that occurred at 2:05 a.m. On 12/08/15 at 12:20 p.m., Surveyor# spoke with Nurse Supervisor/Registered Nurse (RN)-D who worked the night shift of 11/30/15. RN-D indicated that the Resident fell just prior to the start of the night shift, and that the Resident had sustained an injury to the face. RN-D indicated that throughout the night, the Resident refused to go to bed, developed a headache and had increase in swelling and bruising to the facial injuries. RN-D indicates she did not call the Resident's physician or POAHC when the Resident developed a headache and had increase in swelling and bruising to the facility injuries. RN-D indicated she was made aware that the Resident had an observed fall at about 2:00a.m. On 12/08/15 at 1235 p.m., Surveyor# spoke with Licensed Practical Nurse (LPN)- E who worked the dayshift 12/01/15. LPN-E indicated that the Resident had a hematoma to the forehead, that both eyes were black, the nose was swollen and crooked and looked broke, and that the resident complained of a headache. LPN-E indicated RN/Nurse Manager-C was made aware of the Resident's condition. On 12/08/15 at 11:30 a.m. and on 12/11/15 at 12:00 p.m., Surveyor # spoke with Nurse Manager/RN-C who worked the dayshift 12/01/15. RN-C indicated that she observed the Resident at 8:57a.m., when she went into the resident's room and noted bruising to the bridge of the nose. RN-C indicated the Resident was in the bed at the time of the observation and the room lights were off. RN-C indicated she did not thoroughly visualize or assess the resident at 8:57a.m. RN-C indicated that at 9:20a.m., the resident was up in the wheelchair, was alert, had bruising and swelling around the nose, had a bump and discoloration to the forehead, and was administered medication for a headache. RN-C indicated that at 10:49 a.m., the physician was called and the Resident was sent to the hospital for an evaluation. On 12/08/15 at 3:10p.m., Surveyor# spoke with the Resident's Physician/Medical Director-F who indicated he was notified of the Resident's fall and head injury at about 11:00 p.m. on 11/30/15. Physician/Medical Director-F indicated he was not called throughout the night when the resident developed a headache and had an increase in swelling and bruising of the facial injuries. Physician/Medical Director-F indicated that he would have given an order to send the Resident out to the hospital for an evaluation during the night, if he would have been notified of the development of a headache and an increase in swelling and bruising of the facial injuries. On 12/11/15 Surveyor # reviewed the facility policy, Change of Condition Assessment, dated 06/24/13. The policy indicates that the purpose of the policy is to identify residents that are at risk for an acute change of condition(ACOC), to communicate changes to the Physician, to initiate emergency and STAT orders, and to notify the family/legal representative of the condition change. The policy indicates significant changes should be communicated to the physician immediately, and if the resident is not progressing as expected, reassess the situation to determine if a complication is occurring. The policy indicates staff should request that the physician re-evaluate the resident and the current regimen as needed. There was no evidence that on 12/01/15, from 12:44 a.m. through 10:49 a.m., when the Resident developed significant changes to the facial injuries (developed bruising to the bridge of the nose, had an increase in the size of the hematoma to the forehead, and complained of a headache), that the resident's physician and POAHC were notified. On 12/11/15 Surveyor # reviewed the facility policy Fall Prevention Program, dated 12/07/15. The policy indicates that when a resident has a fall at the facility notification of the fall will be made to the resident's primary care physician and to the resident's primary contact. On 12/01/15 at 2:05 a.m. the Resident had a fall without injury. The physician was notified of the fall on 12/01/15 at 8:57 a.m. The Resident's POAHC was notified of the fall on 12/01/15 at 9:04a.m. Head injuries include injury to the scalp, skull fractures, concussions, bruises (contusions) and tears (lacerations) of the brain, accumulation of blood within the brain or between the brain and skull (intracranial hematoma), and damage to nerve cells thorough the brain. Bleeding can also develop between the layers that cover the brain injured people are checked for symptoms that indicate brain function could be worsening these symptoms include persistent or increasing sleepiness and confusion, [MEDICAL CONDITION], repeated vomiting, severe headache . these symptoms may develop hours or sometimes days after the original injury. If these symptoms occur, prompt medical attention is essential. http://www.merckmanuals.com/home!injuries-and -poisoning/head-injuries/overview-of-head-injuries