Every finding on record at Burlington Health and Rehabilitation Center

Based on record review, interview, and facility policy review, the facility failed to ensure that wound care was documented as completed according to physician's orders for 1 of 3 residents (R 2) reviewed for wound care out of a total sample of 27 residents. This has the potential to cause infection, prolonged healing, scarring, and in extreme or untreated cases, sepsis.Findings include: Review of facility's policy titled, Wound Treatment Management, revised 11/11/25, indicated, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatment in accordance with current standards of practice and physician orders. Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders .7. Treatments will be documents on the TAR or in the electronic health record (EHR) . Review of R2's admission Record, located in Census tab in the electronic medical record (EMR), indicated that R4 was admitted to the facility on [DATE] with a diagnosis of cellulitis of the abdominal wall with an open wound of the abdominal wall. R2 was transferred to the hospital on [DATE] at 8:48 PM. Review of R2's Order Entry, dated 02/19/26, located under the Orders tab in the EMR, indicated, Negative Pressure Wound Therapy: Wound Type and Site: Surgical wound/incision, millimeters of mercury (mmHg) 100 mmHg, skin prep to peri wound, pack tunneling. Change dressing three times a week and as needed (PRN), day shift every Tuesday, Thursday, Saturday and PRN. Review of another Order Entry, dated 02/19/26, located under the Orders tab in the EMR, indicated, If wound vac is not available, cleanse surgical wound/incision on abdomen with normal saline (NS), place moistened gauze (with NS) inside of wound, cover with dry dressing, as needed. Review of R2's Order Entry, dated 02/21/26, located under the Orders tab in the EMR, indicated, Cleanse abdominal wound with full strength Dakins, pack wound with gauze moistened in Dakins [a topical antiseptic], cover with ABD [abdominal] pads [absorbent dressing] every evening shift. Review of R2's Treatment Administration Record (TAR) for February 2026, located under Orders in the EMR, indicated no documented evidence that any routine and/or PRN treatment was completed as ordered. Interview on 06/17/26 at 5:54 PM, Licensed Practical Nurse (LPN) 3 confirmed R2's wound care orders and stated that wound care was completed; however, nothing was documented and indicated that if it was not documented, it was not done.

Based on facility document review, record review, and interviews, the facility failed to ensure a qualified social worker was employed on a full-time basis for a period of approximately two months. The facility, certified for more than 120 beds, did not have a qualified social worker to provide for and meet the needs of the 94 residents residing in the facility. This deficient practice had the potential to result in unmet resident psychosocial needs.Findings include: On 06/16/26 at 9:45 AM, observation of the facility license hanging on a wall by the 100/200 units revealed the facility was licensed for 123 beds. Review of the Facility Assessment, provided by the facility and approved on 06/20/25, indicated the Number of residents for which we are licensed to provide care: Licensed Beds: 123, Certified beds: 123. Review of the undated Social Services/Social Worker Assistant Job Description, provided by the facility, indicated, The primary purpose of your job position is to plan, organize, develop, and assist the overall operation of our facility's Social Services Department in accordance with current federal, state, and local standards, guidelines, and regulations. During an interview on 06/15/26 at 10:00 AM, the Social Services Assistant (SSA) stated that she had been the Assistant Social Worker since mid-April 2026. She indicated she had been completing admissions, discharges, and assisting residents; however, she was not a licensed social worker and was hired as the assistant. The SSA further stated, Currently, there is no licensed social worker working in the building and there has not been since mid-April 2026. The SSA stated the previous social worker and assistant left prior to her being hired as the social services assistant. She stated when she was hired, there was no certified social worker in the building, and she had been trying to rely on assistance from the Administrator, Business Office Manager, and Director of Nursing. Review of the employee personnel file for the SSA revealed she was hired as a Social Services Assistant on 04/22/26. Further review of the personnel file indicated no certifications, social worker degree, or bachelor's degree in a human services field. During an interview with the Administrator and Director of Nursing (DON) on 06/15/26 at 7:08 PM, the DON stated, Our previous social worker left in late May [or] early April 2026. The Administrator stated, The person we have in that role right now is the Social Worker Assistant. She is not a certified social worker. We are trying to hire a social worker, and in the meantime, we have her [the SSA] working with the Business Office Manager (BOM), contacts with our sister facilities, and managers to help her until we get a social worker hired as our director. During an interview with the Administrator on 06/16/26 at 9:00 AM, he stated that the facility was licensed for 123 beds. When asked who was overseeing the role of the Social Services Director, the Administrator stated, We have borrowed someone from our sister facility to come to help a few times, and our current Social Service Assistant is utilizing our management team for help as well. The Administrator stated that he, with the help of the BOM and management team, had been helping the current Social Services Assistant with admissions and discharges until they hired a Social Services Director. During a second interview with the SSA on 06/16/26 at 9:30 AM, she stated When it comes to long-term care, I have no experience. [Name of the Administrator and the BOM] have helped me. They know what I should be doing and have offered training. The SSA stated, When I got here, there was no social worker in the building. The SSA then stated she had been assisting with admissions and discharges.

Based on record review, observations, interview, and review of the facility policy, the facility failed to ensure three residents (R2, R18, and R23) out of 18 residents in the sample who were reviewed for meal choices and alternates were regularly offered alternate meals of equal nutritional value when they declined to eat the meal they were originally served. This failure created the potential for residents to experience a poor overall dining experience and potential loss of weight. A total of 26 residents were reviewed in the sample. Findings include:Review of R2's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/25 and found in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R2's current Physician Order Set, found in the EMR under the Orders tab, revealed an order for the resident to receive a regular No Added Salt (NAS) diet. Review of R2's Nutritional Care Plan, dated 12/09/25 and found in the EMR under the Care Plan tab indicated, Provide and serve diet as ordered. Review of the facility's daily menu, dated 12/21/25 and 12/22/25 and found posted on the wall next to the nurse's station, revealed the residents were to be served the following meals:12/21/25 Lunch Meal: Beef Pot Roast with Gravy, New Red Roasted Potatoes, Sliced Carrots, Wheat Dinner Roll, and Peach Crisp. The main entree alternate was indicated to be Grilled Bratwurst. There was no alternate listed for the vegetable or the carbohydrate portions of the meal noted on the posted menu.12/21/25 Dinner Meal: Slice Turkey [NAME] Sandwich on Rye Bread, Cucumbers Marinated with Onion, and Sugar Cookie. The main entree alternate was indicated to be Grilled Bratwurst (the same alternate offered at lunch). There was no alternate listed for the vegetable or the carbohydrate portions of the meal noted on the posted menu.12/22/5 Lunch Meal: Beef Chili with Kidney Beans, Tossed Lettuce Salad with Dressing, Saltine Crackers, and Butterscotch Delight Pudding. The main entree alternate was indicated to be Baked Ziti with Italian Sausage and Ground Beef. There was no alternate listed for the vegetable or the carbohydrate portions of the meal noted on the posted menu. 12/22/5 Dinner Meal: Pulled Smoked Pork, Macaroni and Cheese, Mixed Vegetable Blend, Wheat Dinner Roll, and Hot Spiced Apples. The main entree alternate was indicated to be Baked Ziti with Italian Sausage and Ground Beef (the same alternate offered at lunch). There was no alternate listed for the vegetable or the carbohydrate portions of the meal noted on the posted menu.The facility's Always Available Menu, which was not observed to be posted next to the daily menus or anywhere else in the facility common areas or resident rooms during the duration of the investigation, was provided to the survey team and indicated the following always available foods:Hamburger/CheeseburgerHotdogGrilled CheeseChef Salad/Side SaladFruit CupSoupDuring an observation on 12/21/25 at 12:07 PM revealed 12 residents were observed receiving their lunch meals. Brats or pot roast was served to each of the residents. Some of the residents were observed being served carrots and some received mashed potatoes with gravy. A dinner roll was served with each meal. There were no additional vegetable or carbohydrate/starch alternates observed to be served or offered to any of the residents during the meal. During an observation and interview on 12/21/25 at 12:13 PM R2 was observed eating her lunch in the dining room. The resident was served the pot roast with gravy, mashed potatoes, and a roll. The resident did not have any vegetables on her plate. R2 confirmed she was not served any vegetables for lunch and stated the only vegetable option for the meal was carrots, and she did not eat carrots. R2 stated, There is no different vegetable. They (the facility) used to have a whole list of things (food options) but they don't have that anymore. We eat what they bring us. R2 stated she had not been offered an alternate vegetable for lunch when she stated she did not want the carrots indicated on the daily menu. During an observation on 12/22/25 at 11:36 AM the lunch meal had no alternate vegetable and no alternate starch observed to be served or offered to residents during the meal. During an interview on 12/22/25 at 11:36 AM with the Food Services Manager (FSM) she confirmed there was only one alternate main entree served each day, and it was the same alternate served for both lunch and dinner. She confirmed there was not an alternate vegetable or starch served with each meal. The FSM stated the Always Available Menu was expected to be posted next to the daily menus throughout the facility as well as in each resident's room. The FSM further confirmed residents receiving special diets received the meal posted on the menu for each day and no alternate was available for those meals. During an interview on 12/22/25 at 12:55 PM with the Registered Dietician (RD) she confirmed her expectation was alternates were to be available for each meal of equal nutritive value to the original meal served. She stated she expected the menus, including the Always Available Menu to be posted were residents would have access to them. During an interview on 12/21/25 at 10:00 AM with the Resident Council, R23 stated the alternative menu disappeared about a month (November 2025) ago. They no longer had the alternative choices to choose from. When R23 asked why, staff informed her that it was too complicated for the staff in the kitchen. R18 stated they added a new alternative, but it was the same food. He added if they were being served a chop salad the alternative would be a Caesar salad or a hamburger for a hamburger. R18 stated staff does not offer alternatives if residents want something other than the main meal being served. Review of the facility's Menus and Adequate Nutrition Policy dated 06/26/25 revealed, The purpose of this guideline is to ensure menus are developed and prepared to meet resident choices, including their nutritional, religious, cultural, and ethnic needs; while using established guidelines; and Alternatives shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking.

Based on observation, interview and record review, the facility did not maintain an effective pest control program to address the flies in the facility. *R15 and R16 informed Surveyor that the facility has a problem with flies and R15 uses items in the room to ‘swat’ at the flies. *Surveyor observed a fly flying around R34’s room during observation of a treatment to the right leg on 8/11/25. *Flies were observed around R8 at mealtime during the survey process and R10 informed Surveyor that R10 had killed 18 flies in 3 days. *R29 complained of so many flies they had to purchase fly strips to catch the flies in their room. *R8, R35, R49, and R78 informed Surveyor at resident council on 8/11/25 the concern of numerous flies throughout the facility. *Surveyors observed flies in resident unit hallways, the common dining room for residents, the conference room and in a resident's bathroom. *During the tour of the kitchen, several flies were observed. *The facility did not have a pest control company to service the facility for the months of May, June, and February 2025 and July of 2024. This deficient practice has the potential to affect all 93 of 93 Residents residing in the facility at the time of the survey. Findings include: Surveyor reviewed the facility's Pest Control Program implemented 4/2/25 which documents: . Guideline: It is the guideline of this facility to maintain and effective pest control program that eradicates and contains common household pests and rodents. … Explanation and Compliance Guidelines: 1. 1. Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. 2. 2. Facility will ensure the appropriate chemicals are used to control pests but can be used safely inside the building without compromising Resident health. 3. 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. 4. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. Flies. These will include indoor and outdoor methods that are deemed appropriate by the outside service and state and federal regulations. 5. 5. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures, i.e. dumpster area. 1 1) Surveyor observed flies in R15 and R16’s shared room. R15 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis (skeletal muscle breaks down rapidly). R15 is currently her own person. R15’s admission Minimum Data Set (MDS) completed 6/30/25 documents R15’s Brief Interview for Mental Status (BIMS) score to be 12, indicating R15 demonstrates moderately impaired skills for daily decision making. 2) R16 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (congenital disorder of movement, muscle tone, or posture), Spastic Hemiplegia Affecting Unspecified Side (one side of body experiences muscle stiffness and weakness), and Insomnia (sleep disorder characterized by difficulty falling asleep). R16 is currently her own person. R16’s admission Minimum Data Set (MDS) completed 7/14/25 documents R16’s Brief Interview for Mental Status (BIMS) score to be 13, indicating R16 is cognitively intact for daily decision making On 8/6/2025, at 11:49 AM, R16 informed Surveyor there is a problem with flies in the room. R16 stated the flies land on the walls, sit on the chains hanging from the ceiling. R16 stated other people have complained. R16 stated R16 and R15 eat their meals in the room, and the flies landing on the food. R16 informed Surveyor the flies have bit R16. On 8/6/2025, at 11:55 AM, R15 informed Surveyor R15 got bit by a fly on the ear. “I have to use my underwear to kill the flies”. On 8/6/2025, at 12:10 PM, Surveyor observed a fly on R16’s bed and another fly at the end of the bed on the air mattress component. On 8/7/2025, at 11:07 AM, Surveyor observed a fly flying and landing on R16's bed. On 8/7/2025, at 12:43 PM, Surveyor observed 2 flies flying around R15 and R16’s room. R15 stated R15 is using a washcloth to swat at the flies. 3) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis muscles under voluntary control to feel weak), Depression (mood disorder that causes persistent feelings of sadness and loss of interest). R34 is currently his own person. R34's admission Minimum Data Set (MDS) completed 7/22/25 documents R34's Brief Interview for Mental Status (BIMS) score to be 15, indicating R34 is cognitively intact for daily decision making. On 8/11/2025, at 1:55 PM, Surveyor observed R34’s treatment being completed to R34’s right leg. Unit Manager (UM)-C and Unit Manager (UM)-E completed the treatment with Licensed Practical Nurse (LPN)-R coming in and out of the room with supplies. During the observation of the treatment being completed, a fly landed on Surveyor. LPN-R confirmed there is a fly flying around and LPN-R swatted at the fly. On 8/13/2025, at 10:16 AM, Surveyor observed R34’s windows. The window on the right was open with a cobweb hanging from it. Surveyor observed two dead flies hanging from it. On 8/13/2025, at 10:44 AM, Surveyor had Housekeeping Supervisor (HS)-T observe R34’s window. HS-T confirmed there is a cobweb with 2 flies hanging from R34’s slightly open window. On 8/06/2025, at 8:20 AM, Surveyor observed a fly upon entrance into the facility. On 8/6/2025, at 10:16 AM, Surveyor observed a fly flying around the 4 unit in the hallway. Surveyor had a fly land on Surveyor’s computer in the hallway while touring the 4 unit. On 8/7/2025, at 8:59 AM, Surveyor observed a fly flying around the nurse's station by unit 4. On 8/7/2025, at 12:49 PM, Surveyor observed a fly flying around room [ROOM NUMBER] and in the hallway of unit 4, and Surveyor observed a fly walking around on the floor. On 8/7/2025, at 2:27 PM, Surveyor observed a fly in the conference room. On 8/11/2025, at 7:59 AM, Surveyor interviewed Maintenance Director (MD)-F regarding the facility pest control. MD-F stated MD-F has not been notified of any fly issues. MD-F informed Surveyor pest control comes in 1 time a month and the facility has some UV lights in hallways with sticky pads and those are changed as needed. MD-F has not been informed of a fly issue in the kitchen. MD-F stated, “there is a fly problem yearly, it is normal”. Surveyor requested to view the logs of the monthly pest control visits. On 8/11/2025, at 8:49 AM, Surveyor reviewed the pest control monthly visits and notes there were no pest control visits for July of 2024 or February, May, and June 2025. On 8/11/2025, at 3:20 PM, Surveyor shared the concern with numerous flies throughout the facility with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor pointed out the fly in the conference room at the time of exit meeting. No further information was provided by the facility at this time. On 8/12/2025, at 11:16 AM, Surveyor observed Certified Nursing Assistant (CNA)-HH at the nurse’s station close to 4 unit with a fly swatter and is swatting at a fly. On 8/13/2025, at 11:18 AM, NHA-A informed Survey pest control comes to the facility monthly, but that pest control has been called to treat for flies. NHA-A also stated blue lights to attract pests were hung yesterday and the facility has ordered five extras to place around the facility. 4) R10 was admitted to the facility on [DATE]. R10’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R10 is cognitively intact. On 8/6/25 at 9:50 AM, R10 informed Surveyor the facility has a problem with flies. R10 stated last week, R10 had killed 18 flies in 3 days. R10 stated R10’s shared bathroom frequently has an increase of flies. Surveyor noted 2 flies in R10’s room. Surveyor was swatting at a fly during interview. 5) R8 was admitted to the facility on [DATE]. On 8/6/25 at 1:07 PM, Surveyor observed R8 in the common dining area with R8’s lunch tray. Surveyor observed a fly, flying around R8’s table and observed the fly landing on R8’s food. R8 used R8’s hand to wave the fly away. At a different table, Surveyor observed 3 residents sitting together. A resident complained that a fly keeps landing on their drink. *) R29 was admitted to the facility on [DATE]. R29’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R29 is cognitively intact. On 8/6/25, at 3:23 PM, R29 informed Surveyor the facility has a problem with flies. R29 stated that R29’s room is close to an exit door which makes it worse. R29 stated R29 bought fly strips online because the flies are everywhere. 6) On 8/6/25 at 12:38 PM, Surveyor noted multiple flies while walking the 200-unit hallway. Surveyor observed a fly landing on Surveyors computer and another fly, flying around Surveyors head. On 8/6/25 at 1:05 PM, Surveyor noted multiple flies while walking the 100-unit hallway. Surveyor counted 3 flies. On 8/7/25 at 11:13 AM, Surveyor was in the 100-unit hallway when a fly landed on Surveyor’s hair. *During Resident Council meeting held on 08/11/2025, at 10:30 AM, R8, R35, R49 and R78 informed Surveyor pf the resident's concerns about a large number of flies in the facility. Surveyor asked the resident council members present if the members had any concerns about the cleanliness of the facility. 7) R78 informed Surveyor there were so many fruit flies when R78 was first admitted to the facility. R78 informed Surveyor the flies were so bad because they were everywhere, and it made it uncomfortable for R78 in her room. R78 informed Surveyor “I had to get my own ZEVO (a blue light sticky trap)” because the facility wouldn't do anything about the flies. R78 informed Surveyor staff told R78 the flies were from the previous person in the room. R78 informed Surveyor R78 had fruit flies fill R78’s ZEVO trap daily when R78 first started using the ZEVO. R78 informed Surveyor the fruit flies have decreased substantially in her room but R78 still sees a lot of big flies in the dining room. R78 informed Surveyor R78 gets big flies in R78’s room if the door is left open. 8) R8 informed Surveyor R8 has flies in R8’s room daily. R8 informed Surveyor R8 needs a fly swatter every day. R8 informed Surveyor R8 sees big flies in the dining room daily. 9) R35 informed Surveyor the R35 still has little flies and big flies daily in R35’s room, the flies never go away. R35 informed Surveyor there are always flies in the dining room. 10) R49 informed Surveyor the R49 sees sewer flies all over. R49 informed Surveyor R49 knows they are sewer flies because R49 came from an apartment with sewer flies. R49 informed Surveyor R49 had a lot of sewer flies at the apartment and a lot of sewer flies at the facility currently. R49 informed Surveyor there are a lot of flies in the dining room. During the entire survey the survey team observed flies through-out the facility and in the dining room. On 08/13/2025, at 9:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about Surveyor’s concerns with the large number of flies in the building reported by members of the resident council. NHA-A informed Surveyor that NHA-A already has a vendor working on getting rid of the flies and are placing traps today for the flies. NHA-A stated the vendor is placing blue light nonchemical traps in several places through-out facility. NHA-A informed Surveyor the facility is committed to getting the fly problem under control. Surveyor observed a blue light trap being placed in the dining room after leaving NHA-A’s office. 11) On 8/6/25 at 11:00 a.m. Surveyor was observing meal preparation in the kitchen. There were a few flies in the kitchen. Flies were flying around the food. Dietary staff were covering food to prevent flies from landing on it. On 8/7/25, at 12:39 p.m., Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the flies. Surveyor explained to NHA-A the observation made on 8/6/25, in the kitchen, regarding flies. NHA-A stated he understood the concern and had no additional information.

Based on individual and group interviews, the facility does not always provide reasonable access to residents' mail. Mail that is delivered to the facility on Saturdays by the Postal Service is not delivered to the residents until the following Monday afternoon. This has the potential to affect 93 out of 93 residents in the facility.Findings include:The facility's policy document titled Resident's Rights to Privacy in Communication dated 03/04/2025 and revised 07/01/2025 documents: Definitions: Promptly means delivery of mail or other materials to the resident within 24 hours of delivery by the Postal Service (including a post office box) and delivery of outgoing mail to the Postal Service within 24 hours, except when there is no regularly scheduled postal delivery and pickup service.Explanation and compliance guidelines:1. The facility will honor the resident's right to privacy in communications including the right to:a. Send and promptly receive mail that is unopened.During Resident Council held on 08/11/2025, at 10:30 AM, R78 and R49 informed Surveyor that mail is not delivered on Saturdays. R78 informed Surveyor Saturday's mail is delivered on Monday in the afternoon.On 08/12/2025, at 11:53 AM, Surveyor Interviewed Business office assistant (BOA)-Z about how mail is delivered in the facility. BOA-Z informed Surveyor that the Activities department delivers Resident packages and mail after BOA-Z sorts the mail. BOA-Z informed Surveyor that the Resident's Saturday mail is placed into Business Office Manager (BOM)-H's office for safe keeping until activities can deliver to the Residents. BOA-Z informed Surveyor the facility receives mail on Saturday from the postal service, but Resident mail is not delivered until Monday because we don't know if a Resident's mail has sensitive information, and no one from the business office is here Saturdays to sort the Resident's mail for delivery. Surveyor asked BOA-Z to explain the mail delivery procedure on Mondays. BOA-Z informed Surveyor that BOA-Z will sort mail on Mondays and the Activities department delivers Resident mail after the mail is sorted by someone from the business office. Surveyor asked BOA-Z what the time frame on Mondays the Resident's mail is delivered. BOA-Z informed Surveyor the Resident's Saturday mail was delivered sometime after 01:30 pm on Monday. Surveyor asked BOA-Z to clarify if the residents always need to wait until Monday afternoon for Saturday's mail. BOA-Z informed Surveyor yes because I need to sort it to make sure sensitive materials are handled correctly, and we don't really have anyone from the business office on the weekends.On 08/12/2025, at 01:10 PM, Surveyor interviewed BOM-H about resident's mail delivery. BOM-H informed Surveyor Resident's mail is stored in BOM-H's office when it is received from the Postal Service on Saturday. BOM-H informed Surveyor the business office sorts the mail before it goes out to the residents on Monday.On 08/13/2025, at 9:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about Surveyor's concerns with no Saturday mail delivery for the facility's Residents. Surveyor asked if NHA-A knew there was no Saturday mail delivery for the residents. NHA-A informed Surveyor there was no one from the business office on the weekends. Surveyor informed NHA-A the facility policy documents that residents should received their mail within 24 hours and that the resident's mail was not being delivered until Monday afternoon. NHA-A informed Surveyor that the facility was working on fixing all the issues the Surveyor's presented.No other information was presented to Surveyor at this time.

Based on observation, interview and record review the facility did not ensure the kitchen was storing and preparing food in a safe and clean manner. This has the ability to affect all 93 residents.The walk-in freezer had buildup of thick ice on the floor, walls and ceiling including boxes of food in the freezer.Two fans in food prep area had buildup of red substance making the fan appear dirty and in disrepair.A bag of lettuce salad was opened with a date that was faded so it made the date unreadable. The lettuce was brown.The exhaust fan over the stove area had a buildup of dust.No beard restraint used for Dietary Staff (DS)-LL and Dietary Manager (DM)-MM.Findings include: The facility policy regarding dietary staff attire dated 10/2023 documents:1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.On 8/6/25, at 8:50 a.m., Surveyor toured the kitchen. Surveyor observed the walk-in cooler with a thick buildup of ice along the ceiling, walls and floor of the freezer. There were boxes in the freezer had a buildup of ice. Surveyor did not walk in the freezer due to safety issues due to ice on the floor.Surveyor walked into the walk-in cooler and observed a bag of lettuce salad that was opened and dated. The date had faded off and made it unreadable. The lettuce was observed to look brown. On 8/6/25, at 11:00 a.m., Surveyor observed a fan mounted on the wall. The front covering of the fan was off and there was a buildup of red substance on the fan, making it appear dirty. The fan was above the food prep area.Surveyor observed a box fan, on a table facing a food prep area, that had the same buildup of red substance.The exhaust fan, above the stove, was thick with dust.Surveyor observed DS-LL, who had a mustache and beard, preparing food without a beard restraint in the kitchen. On 8/6/25, at 12:00 p.m., Surveyor observed DM-MM in the kitchen, assisting with meal prep. DM-MM has facial hair and did not have a beard restraint on.On 8/6/25, at 12:00 p.m., Surveyor interviewed DM-MM. Surveyor asked DM-MM, why did the walk-in freezer have a thick coating of ice all over. DM-MM stated about a month ago they got a new freezer and the company that installed the freezer place the temperature too cold and it froze everything. DM-MM also stated the freezer door wasn't closing well but maintenance fixed it. DM-MM stated he only orders three days' worth of freezer food items because of the state of the freezer. DM-MM stated Nursing Home Administrator (NHA)-A is aware of the state of the freezer. Surveyor explained to DM-MM observations made earlier in the day regarding the brown lettuce in the cooler, the fans and the exhaust fan. DM-MM stated daily, he usually will walk around and get rid of expired or old food items. DM-MM had no further explanation regarding the dirty appearing items. On 8/7/25, at 12:39 p.m., Surveyor interviewed NHA-A. Surveyor explained the concern of the walk-in freezer, old salad, dirty fans and exhaust fan and male staff without beard restraint. NHA-A stated he understood the concerns and stated the facility ordered plastic curtains for the freezer to prevent frost build up when the door opens. NHA-A had no additional information.

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect 93 of 93 residents residing in the facility.Staffing information for Quarter 2 (January 1 - March 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS triggering a one-star staffing rating for Quarter 2: January 1-March 31 of 2025.Findings include:Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2025 (run on 8/4/25) which indicated the Facility had a one-star staffing rating for the 2nd Quarter (January 1-March 31).The facility document titled Facility Assessment dated 06/20/2025, documents:Overall needs per shift daily (adjust as needed) under Ratio of staff to residents or #HPRD: Night shift: RN (Registered Nurse)-1, LPN (Licensed Practical Nurse)-1, CNA (Certified Nursing Assistant)-4. Evening shift: RN 1, LPN 3, CNA 7. Day shift: RN 1, LPN 3, CNA 7. The facility guideline document titled Nursing Service and Sufficient Staff dated 12/17/2024 and revised 02/05/2025 documents: Guideline: It is the guideline of the facility to provide sufficient staff with appropriate competencies and skill sets to assure Resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care. The facility census acuity and diagnosis of the resident population will be considered based on the facility assessment. 7. The facility is responsible for submitting timely and accurate staffing data through the CMS payroll-based journal (PBJ) System.Surveyor reviewed the Facility's schedules from January 1, 2025, to March 31, 2025. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules included call ins, agency staff and staff who picked up shifts. Surveyor noted that several night shifts during the second quarter were documented as having 3 CNAs and not 4 CNAs, which could have potentially triggered the one star staffing rating from CMS. On 08/12/2025, at 8:12 AM, Surveyor interviewed Scheduler-M on staffing for the facility. Scheduler-M informed Surveyor staffing was based on acuity and census and Corporate provided a staffing ladder and daily staffing letter. Scheduler-M informed Surveyor the facility's corporate structure informed the facility of the daily staffing allowance.Surveyor asked Scheduler-M what the minimum staffing level for each day for the direct care staff was. Scheduler-M informed Surveyor it is currently 10-16 licensed staff including unit managers and 18 certified nursing assistants (CNA). Scheduler-M informed Surveyor the current daily staffing is 10 CNAs on day shift, 4 CNAs on evening shift and 4 CNAs on the night shift. Scheduler-M informed Surveyor the facility has had Registered Nurse (RN) every day and tries to have one RN every shift as direct care staff. Surveyor asked if the Director of Nursing (DON) is counted as an RN for direct care. Scheduler-M informed Surveyor no the DON is not counted as a direct care staff. Surveyor asked Scheduler-M who in the facility reports the Payroll Based Journal (PBJ) data to the Center for Medicaid and Medicare Services (CMS). Scheduler-M informed Surveyor that Scheduler-M was not sure.On 08/12/2025, at 10:30 AM, Surveyor interviewed Director of Nursing (DON)-B about the facility staffing. DON-B informed Surveyor that minimum staffing level is 7 CNAs on the day and evening shifts and 4 CNAs on the night shift. DON-B informed Surveyor that currently staffing levels are being adjusted based on census and acuity in the facility. DON-B informed Surveyor corporate reports the staffing data to CMS for the CASPER report. Surveyor informed DON-B that several night shifts during the second quarter were documented as having 3 CNAs and not 4 CNAs which could have triggered the one star staffing rating from CMS for the second quarter. DON-B informed Surveyor the facility runs staffing based on census and acuity and that 4 is the desired staffing but not the minimum and that the facility was not short staffed at that time. Surveyor asked DON-B if DON-B felt the staffing data was reported incorrectly for the CASPER report that was submitted to CMS by the facility's corporate structure. DON-B informed Surveyor she reviewed staffing with Scheduler-M and that the reporting to CMS was inaccurate.On 08/12/2025, at 1:15 PM, Scheduler-M provided Surveyor with schedules that documented that in January and February of 2025, on the days in question by Surveyor, the facility had at least 4 CNAs during the night shift. On 08/13/2025, at 9:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the facility triggering a one-star staffing rating from CMS for quarter two on the facility [NAME] reports from 1/1/25 through 3/31/25. NHA-A informed Surveyor that Corporate reports the PBJ data to CMS for the CASPER report. NHA-A informed Surveyor that NHA-A has been working on the staffing concerns with corporate and the report for the next quarter would document an accurate number of staff and address any reporting issues. No additional information was provided as to why the facility did not ensure that the accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS) was provided to CMS from 1/1/25 through 3/31/25.

Based on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained and the Enhanced Barrier Policy was implemented to help prevent the development and transmission of communicable diseases potentially affecting 93 of 93 residents. Enhanced Barrier Precautions (EBP) were not in place throughout the facility. Two of the six units provided signs and Personal Protective Equipment (PPE) for residents that required EBP; four of the six units did not implement EBP. *R3 was in Contact Isolation and observations were made of staff entering R3’s room without putting on PPE. *R1’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment. *R16’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment. *R34’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment. *R27 had an indwelling urinary catheter with no EBP in place. *R24 had a gastrostomy tube with no EBP in place. Medication administration was observed using the gastrostomy tube and staff did not put on PPE. *R5 had an indwelling urinary catheter with no EBP in place and staff did not put on PPE when providing cares. *R53’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment. *The sink in the contaminated laundry area was not functional and no other sink or hand hygiene methods were available to staff to use after sorting contaminated laundry and removing PPE. Findings include: The facility policy and procedure titled “Enhanced Barrier Precautions” dated 2/5/2025 documents: “Guideline: It is the guideline of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. … Explanation and Compliance Guidelines: … 2. Initiation of Enhanced Barrier Precautions: … b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) … 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident’s room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident’s room. … 4. High-contact resident care activities include: a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline cathetersh. Wound care: any skin opening requiring a dressing …10. Enhanced barrier precautions should be used for the duration of the affected resident’s stay in the facility or util resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.” In an interview on 8/11/2025 at 3:12 PM, Surveyor asked Director of Nursing (DON)-B what would denote a resident to be in EBP. DON-B stated residents that have multi-drug resistant organisms (MDROs) present would be placed in EBP. Surveyor requested the facility EBP policy and procedure. On 8/12/2025 at 3:04 PM at the daily exit, Surveyor shared with DON-B the concern the facility was not following their own policy on EBP. Surveyor shared that any resident in the facility that met the criteria for EBP should be placed in EBP. DON-B stated there are two residents in the facility that currently have MDROs. DON-B stated any resident that meets the criteria for EBP on the units where the residents with the MDROs reside are placed in EBP. DON-B stated residents on the other four units have not been placed on EBP because they are not in close proximity to the residents with MDROs. Surveyor shared with DON-B the concern that the residents that meet the criteria for EBP and are not in EBP could be cross contaminated because PPE is not being worn to protect and prevent infections. On 8/13/2025 at 8:17 AM, DON-B stated the EBP policy and procedure was reviewed extensively and are working on getting all the residents that meet the criteria for EBP carts with PPE and signs for their rooms in place. DON-B stated DON-B now understands the reasoning behind the EBP and will be working on carrying the protocol out. 1.) R3 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder characterized by changes in mental and cognitive function), diabetes, chronic obstructive pulmonary disease, dementia, depression, anxiety, and coronary artery disease. R3’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R3 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. R3’s Power of Attorney (POA) was activated. Surveyor noted R3 did not have any documentation of a multi-drug resistant organism (MDRO) on R3’s diagnosis list. R3’s Impaired Immunity Care Plan was created on 7/17/2025 and was placed on Contact Precautions (requiring anyone entering R3’s room to put on a gown and gloves) for an MDRO. The Care Plan did not document what MDRO was present. On 8/6/2025, at 9:38 AM, Surveyor observed R3’s doorway to have an isolation cart with a sign documenting Contact Precautions. Surveyor asked Licensed Practical Nurse (LPN)-G passing medications in the hallway why R3 was in Contact Precautions. LPN-G was unsure but thought maybe R3 had VRE (Vancomycin-Resistant Enterococci). On 8/6/2025, at 10:06 AM, Surveyor observed Activity Aide (AA)-P enter R3’s room. AA-P did not put on a gown or gloves prior to entering R3’s room. AA-P was in R3’s room for approximately three minutes and then left the room. AA-P did not perform any hand hygiene after leaving R3’s room. AA-P then entered another resident room and left the room pushing the resident in a wheelchair. In an interview on 8/6/2025, at 11:01 AM, Surveyor asked AA-P what the different precaution signs on resident isolation carts meant. AA-P stated AA-P did not know what the different signs meant. AA-P stated if there is a sign on the door, AA-P does not go in. AA-P stated AA-P was new to the facility so was not really sure what the different signs meant. On 8/6/2025, at 11:05 AM, Surveyor observed Certified Nursing Assistant (CNA)-O enter R3’s room. CNA-O did not put on a gown or gloves prior to entering R3’s room. CNA-O was in R3’s room for approximately four minutes. CNA-O did not perform any hand hygiene after leaving R3’s room. At 11:09 AM, Surveyor asked CNA-O if staff needed to wear any PPE when going into R3’s room. CNA-O stated you do not have to put anything on unless you are doing personal cares. CNA-O picked up the Contact Precaution sign but did not read the directions of use. As Surveyor was talking to CNA-O, DON-B walked past and told CNA-O that the sign says what should be worn. CNA-O responded to DON-B, “That’s what I said, right?” Surveyor noted the Contact Precaution sign documented a gown and gloves should be worn prior to entering R3’s room, which CNA-O did not do. On 8/12/2025, at 10:49 AM, Surveyor shared with DON-B the observations of AA-P and CNA-O going into R3’s room without wearing any PPE as documented on the Contact Precaution sign or performing hand hygiene upon leaving the resident rooms. 2.) R1 was admitted to the facility on [DATE] with diagnoses of malignant carcinoid tumor of the stomach, malignant neoplasm of the right kidney, and hyperparathyroidism. R1’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R1 did not have an activated Power of Attorney. R1 was admitted with Stage 3 pressure injuries to the left upper buttock, the left lower buttock, the left upper posterior thigh, the left lower posterior thigh, and the left ischium, and Unstageable pressure injuries to the left outer ankle, the left second toe, the right heel, and the left trochanter. On 8/6/2025, at the time of survey, eight of R1’s nine pressure injuries that were present on admission had healed. R1’s Stage 4 pressure injury to the left trochanter had healed on 7/1/2025 and reopened on 7/8/2025. On 8/12/2025, at 8:53 AM, Surveyor observed Unit Manager (UM)-C, UM-D, and UM-E provide wound care to R1’s left trochanter Stage 4 pressure injury. R1 did not have a sign for EBP or an isolation cart outside of the room. UM-C, UM-D, and UM-E did not put on a gown while providing wound care. Surveyor asked UM-E if staff should wear PPE when providing wound care. UM-E stated PPE is only needed for residents in EBP. Surveyor asked UM-E what the criteria is for someone to be on EBP. UM-E stated on the two units where residents are that have MDROs, any resident that has a tracheostomy, a wound, an indwelling urinary catheter, or anything else that would make them compromised would be in EBP. UM-E stated since there are not any residents with MDROs on R1’s unit, R1 does not need to be in EBP. Surveyor noted staff were not following the EBP policy and procedure or standards of practice. 3.) R16 had a pressure injury to the coccyx. On 8/12/2025, at 8:41 AM, Surveyor observed UM-C, UM-D, and UM-E provide wound care to R16’s coccyx pressure injury. R16 did not have a sign for EBP or an isolation cart outside of the room. UM-C, UM-D, and UM-E did not put on a gown while providing wound care. Surveyor asked UM-E if staff should wear PPE when providing wound care. UM-E stated PPE is only needed for residents in EBP. Surveyor asked UM-E what the criteria is for someone to be on EBP. UM-E stated on the two units where residents are that have MDROs, any resident that has a tracheostomy, a wound, an indwelling urinary catheter, or anything else that would make them compromised would be in EBP. UM-E stated since there are not any residents with MDROs on R16’s unit, R16 does not need to be in EBP. Surveyor noted staff were not following the EBP policy and procedure or standards of practice. 4) R24 was admitted to the facility on [DATE] with diagnoses of Epileptic Seizures (brain has sudden, uncontrollable surge of electrical activity), Dysphagia (difficulty swallowing foods), Gastrostomy Status (artificial opening in stomach used for feeding). R24 currently has a legal guardian. R24’s Quarterly Minimum Data Set (MDS) completed 6/23/25 documents R24 demonstrates severely impaired skills for daily decision making. R24’s memory was not assessed. R24 is dependent for upper/lower dressing, showers/bathing, mobility, and transfers. R24 is always incontinent of bowel and bladder. R24 currently receives feeding tube. R24’s active physician order effective 4/4/25 document; Infuse feeding via pump at 65ml(milliliter)/hr (hour) with 260cc (cubic centimes) of water every 4 hours Jevity 1.5. Surveyor notes that R24’s comprehensive care plan and Kardex did not contain documentation instructing nursing staff to don personal protective equipment (PPE) when providing cares to R24 or that R24 should be in EBP. On 8/7/2025, at 11:12 AM, Surveyor observed R24’s door to be open. Surveyor observed Licensed Practical Nurse (LPN)-II hanging a bottle of tube feeding. Surveyor observed LPN-II maneuvering the tubing in the area of R24’s stomach. Surveyor observed LPN-II with no gloves or gown on. LPN-II informed Surveyor LPN-II is looking for the correct dressing to put on the tube feeding site because the last nurse did not put the correct one on. Surveyor observed LPN-II exited R24’s room and did not perform hand hygiene. LPN-II entered back into R24’s room with a new dressing. LPN-II put the dressing on the tube feeding site without wearing gloves or a gown. LPN-II went into R24’s bathroom and washed LPN-II’s hands before exiting R24's room. 5) R27 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (congenital disorder of movement, muscle tone, or posture), Neuromuscular Dysfunction of Bladder (nerves controlling bladder and urinary sphincter are damaged and not working correctly), Paraplegia (paralysis of lower half of body). R27 is currently his own person. R27’s quarterly minimum data set (MDS) completed 5/31/25 documents R27’s brief interview for mental status (BIMS) score to be 13, indicating R27 is cognitively intact for daily decision making. R27’s MDS documents R27 has range of motion impairment on one side of lower extremity. R27’s MDS also documents R27 requires substantial/maximum assistance for upper dressing and is dependent for lower dressing. R27 is dependent for mobility and transfers. R27 requires substantial/maximum assistance for showers. R27 has an indwelling catheter and is always incontinent of bowel. R27’s active physician order effective 11/22/24 document: Foley Catheter cares every shift and as needed. Surveyor notes R27’s comprehensive care plan and Kardex did not contain documentation instructing nursing staff to don personal protective equipment (PPE) when providing cares to R27 or that R27 should be in EBP. On 8/11/2025, at 7:39 AM, Surveyor observed no sign on the door for EBP, and no PPE cart outside of R27’s room. Surveyor observed Certified Nursing Assistant (CNA)-X come out of the R27’s room. CNA-X informed Surveyor when asked that CNA-X had adjusted R27 in bed. Surveyor observed CNA-X was not wearing gloves or a gown. On 8/11/2025, at 7:49 AM, Surveyor observed Medication Technician (MT)-N give medications in applesauce to R27 and raise R27’s bed. MT-N was not wearing gloves or gown at this time. On 8/11/2025, at 9:39 AM, Surveyor observed CNA-X and CNA-Y exit R27's room. CNA-Y had gloves on but no gown. CNA-X had no gloves or gown on. CNA-Y informed Surveyor both CNA-X and CNA-Y emptied the foley catheter bag and provided other incontinence cares for R27. CNA-Y informed Surveyor there was no alcohol wipes so they could not clean the foley catheter. CNA-Y also informed Surveyor they would know if R27 required EBP because there would be a sign on the door. 6) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis (muscles under voluntary control to feel weak). R34 is currently his own person. R34's admission Minimum Data Set (MDS) completed 7/22/25 documents R34's Brief Interview for Mental Status (BIMS) score to be 15, indicating R34 is cognitively intact for daily decision making. R34 requires partial/moderate assistance for upper dressing and substantial/maximum assistance for transfers. R34 is dependent for lower dressing and mobility. R34 is at risk for developing a pressure ulcer and currently has one venous and arterial ulcer. R34’s active physician order effective 7/23/25 document: Left Lower Extremity: cleanse with normal saline. Foam border Xeroform to wound beds foam border, Ulna Boot with zinc gauze foam border, cotton patting foam border Coban wrap. Change Monday, Wednesday, Friday and as needed for wound care. Surveyor notes that R34’s comprehensive care plan and Kardex did not contain documentation instructing nursing staff to don personal protective equipment (PPE) when providing cares to R34 or that R34 should be in EBP. On 8/11/2025, at 1:55 PM, Surveyor observed R34’s treatment to R34’s outer leg. Unit Manager (UM)-C and (UM)-E completed the treatment. Surveyor observed UM-C did not wear gloves when cutting the foam border with scissors. During the treatment, UM-C put gloves on, but upon exiting the room for more supplies, UM-C did not perform hand hygiene. UM-C and UM-E did not wear a gown during the treatment process. On 8/11/2025, at 3:20 PM, Director of Nursing (DON)-B informed Surveyor EBP as only being for a Resident that is Multidrug-Resistant Organism (MDRO), Vancomycin-Resistant Enterocci, and Carbapenem-Resistant Enterobacteriaceae. On 8/12/2025, at 1:32 PM, Surveyor interviewed UM-E regarding EBP. UM-E stated two Residents on Unit 5 and 6 have a MDRO. Other residents on Unit 4 have wounds, tube feeding, and foley catheters do not need EBP because they are not within the vicinity of the two residents with a MDROs. UM-E stated Centers for Disease Control and Prevention (CDC) is always changing EBPs. UM-E stated typically, anyone providing cares with an Intravenous Therapy, Foley Catheter, Tube Feeding should have PPE for EBPs but UM-E explained the Residents on Unit 4 do not require PPE because they are not in the vicinity of the two residents on Unit 5 and 6. UM-E stated the facility determined housekeeping should gown up when cleaning the rooms. UM-E provided Surveyor with a sign that reads:EBPEveryone Must:Clean their hands, including before entering and when leaving the room.Providers and Staff Must Also:Wear gloves and a gown for the following High-Contact Resident Care Activities.DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use:Central line, urinary catheter, feeding tube, tracheostomyWound Care: any skin opening requiring a dressing On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R24, R27, and R34 by CDC recommendations should have been in EBP. The facility provided no further information at this time as to why R24, R27, and R34 were not in EBP during the survey process. 8) R5 was admitted to the facility on [DATE]. R5’s Electronic Medical Record (EMR) documents R5 having a urinary catheter in place. On 8/7/25, at 1:23 PM, Surveyor observed no sign or indication of R5 being placed in Enhanced Barrier Precaution (EBP). Surveyor knocked on R5’s room. R5 responded for Surveyor to enter R5’s room. Surveyor observed a staff member with no gown or gloves in R5’s room. On 8/11/25, at 8:21 AM, Surveyor observed no indication for R5 having EBP. Surveyor observed no EBP sign or a supply cart with gown and gloves outside R5’s room. On 8/12/25, at 2:28 PM, Surveyor observed no indication for R5 having EBP. Surveyor observed no EBP sign or a supply cart with gown and gloves outside R5’s room. On 8/13/25, at 9:01 AM, Surveyor interviewed Concierge Coordinator (CC)-K who entered R5’s room without donning a gown or gloves for the interview. Surveyor observed no EBP sign or a supply cart with gown and gloves outside R5’s room. On 8/13/25, at 10:35 AM, Surveyor notified Director of Nursing (DON)-B of concerns with R5 having a urinary catheter in place throughout the survey, with no EBP in place for R5 throughout the survey. DON-B acknowledged these concerns and indicates the facility is currently making changes with their EBP practice and will be putting residents with urinary catheters in EBP, however, the facility does not have enough supplies at this time and has ordered supplies. DON-B indicates, once the facility receives the EBP supplies, the facility will be putting R5 and all residents who have a urinary catheter, in EBP. 7) R53 was admitted to the facility on [DATE] with diagnosis that include Chronic Obstructive Pulmonary (lung) disease, Heart failure, Stage 2 kidney disease, and Metastatic melanoma (skin cancer) progressing to metastatic lung cancer. R53’s Annual Minimum Data Set (MDS) assessment dated [DATE] documents R53 is moderately cognitively impaired. R53 has a guardian. R53 is on hospice which was started in June of 2023. Surveyor reviewed R53’s medical record and noted R53 developed a Suspected Deep Tissue Injury (DTI) on 7/22/25. R53’s MD order dated 8/5/25 documents: DTI to lower mid spine: Cleanse with 1/4 strength Dakins, skin prep to surrounding area, apply calcium alginate, [followed by] border foam dressing daily. Surveyor reviewed R53’s MD orders, Comprehensive Care Plan and Certified Nursing Assistant Kardex. Surveyor noted R35’s medical record did not contain documentation instructing nursing staff to put on personal protective equipment (PPE) when providing cares to R53. On 8/7/25, at 10:39 AM, Surveyor observed R53’s room. Surveyor noted R53’s door does not have a sign indicating Enhanced Barrier Precaution (EBP) for R53 and PPE is not visualized outside of R53’s room. On 8/11/25, at 12:59 PM, Surveyor observed R53’s room. Surveyor noted R53’s door does not have a sign indicating EBP for R53 and PPE is not visualized outside of R53’s room. On 8/12/25, at 10:06 AM, Surveyor observed R53’s room. Surveyor noted R53’s door does not have a sign indicating EBP for R53 and PPE is not visualized outside of R53’s room. Surveyor entered R53’s room to observe wound rounds with Unit Manager (UM)-D. R53 was observed sitting in R53’s electric wheelchair and leaning forward. After washing hands and donning gloves, UM-D removed the old dressing and completed R53’s wound care treatment. While observing R53’s wound care treatment, UM-D and one other staff member assisting, did not wear a gown. Surveyor asked UM-D if UM-D needed to wear a gown while completing wound care. UM-D stated no. On 8/12/25 at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that EBP precautions were not followed and gowns were not worn while staff completed wound care on R53. 9) The only sink in the laundry department located in the contaminated laundry sorting room was not functional for 1-2 weeks with no other sink or hand hygiene methods available to staff to use after sorting contaminated laundry and removing personal protective equipment (PPE). The Facility’s policy document titled; “Laundry” dated 05/29/2024 documents: Policy: The facility launders linens and clothing in accordance with CDC (Centers for Disease Control and Prevention) guidelines to prevent transmission of pathogens. Definitions: “Contaminated” refers to laundry which has been soiled with blood/body fluids or other potentially infectious materials or may contain sharps. Policy explanation and compliance guidelines: 1. Aligning with principles of standard precautions, staff shall consider all previously worn clothing as contaminated. 2. The facility’s laundry area will provide readily available hand washing facilities and products as well as adequate PPE. On 08/11/2025, at 12:42 PM, Surveyor was given a tour of the laundry process by Housekeeping Manager (HM)-T and Laundry Staff (LS)-U. Surveyor asked HM-T to explain the laundry process. HM-T informed Surveyor the dirty linens and clothing come down the laundry chute in bags (Surveyor observed laundry in hamper below chute in bags). HM-T stated the laundry staff separate personal items from the facility dirty linens and place them in these hampers for transport through the door to the washer. Surveyor asked HM-T if the sink in the dirty sorting room was the only sink and means of hand hygiene in the department. HM-T informed Surveyor staff do not use the sink in the dirty chute room because there is no water to the sink, and it has been down a week or two and it is the only sink in the department. Surveyor asked HM-T how staff performs hand hygiene after handling contaminated linen with urine and feces before placing and removing their personal protective equipment (PPE). HM-T informed Surveyor we don't use this sink that often, but staff mostly used the employee break room across the hall to wash their hands. Surveyor asked HM-T to clarify that the staff must leave the dirty area and the department to perform hand hygiene after handling soiled facility laundry. HM-T informed Surveyor HM-T knew it is not ideal to walk across the hall to the employee break room and staff probably should not do it that way. HM-T informed Surveyor HM-T does make sure staff remove PPE before staff crosses over the hall to the employee break room to perform hand hygiene. Surveyor asked LS-U to demonstrate how the process of dirty laundry to clean works and the use and removal of PPE was performed by staff. LS-U informed Surveyor gown and gloves and sometimes a mask are put on before staff go into the dirty laundry chute room. LS-U informed Surveyor LS-U brings the dirty clothes out of the dirty laundry room in the sorting hampers into the washer room and laundry is placed in different washers based on the settings listed on the wall. LS-U informed Surveyor the gown is then removed placed in the washer and then staff walk back to the dirty chute room to throw the gloves away because the trash container in the washer room is too close to the clean dryers. LS-U informed Surveyor LS-U walks back to the department exit door. LS-U informed Surveyor staff then walk across the hall to the employee breakroom and wash their hands in the sink. LS-U informed Surveyor LS-U does make sure LS-U’s gown goes into the washer before going out the door to wash hands in the employee break room. (Surveyor noted no hand sanitizing gel anywhere in department). Surveyor asked HM-T if the broken sink had been reported to maintenance. HM-T informed Surveyor HM-T reported it last week. On 08/11/2025, at 1:07 PM, Surveyor interviewed Maintenance Director (MD)-F. Surveyor asked MD-F if maintenance was aware of the broken sink in the dirty laundry room. MD-F informed Surveyor they were not informed until the end of last week. MD-F informed Surveyor it was scheduled to fixed by the end of this week. On 08/13/2025, at 9:50 AM, Surveyor informed Nursing Home Administrator (NHA)-A about Surveyor’s concerns with the broken sink in the laundry area causing staff to leave the contaminated room to wash hands in the employee break room across the hall. Surveyor informed NHA-A no other hand hygiene methods were available to the staff according to the HM-T. Surveyor asked NHA-A if leaving a dirty room to go to the employee break room was an infection control concern. NHA informed Surveyor that “yes” that was a problem with infection control. NHA-A informed Surveyor MD-F informed NHA-A the laundry sink is fixed now, and proper hand washing was discussed with the staff.

Based on interview and record review, the facility did not ensure the Minimum Data Set (MDS) assessments accurately reflected residents' status for 4 (R33, R46, R53, and R10) of 4 residents reviewed for comprehensive MDS assessments. *R33 had behavioral symptoms not directed toward others, wandering, and elopement behaviors since the time of admission. R33's admission MDS assessment dated [DATE] documented R33 did not exhibit any behavioral symptoms or wandering. *R46 had a Preadmission Screening and Resident Review (PASARR) level 1 and level 2 completed. R46's Annual MDS assessment dated [DATE] documented R46 had not been evaluated by the Level 2 PASARR. *R53 had a PASARR level 1 and level 2 completed. R53's Annual MDS assessment dated [DATE] documented R53 had not been evaluated by the Level 2 PASARR. *R10 had a PASSAR level 1 and level 2 completed. R10's Annual MDS assessment dated [DATE] documented R10 had not been evaluated by the Level 2 PASARR. Findings include: 1.) R33 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset, obstructive sleep apnea, and diabetes. R33 had a court appointed Guardian. On 6/17/2025 at 1:49 PM in the progress notes, nursing documented R33 was oriented to self only and had Wanderguard (electronic monitoring system to prevent a resident from eloping by activating an alarm) placed to the right ankle due to confusion and wandering. R33 needed frequent redirection. On 6/17/2025 at 10:19 PM in the progress notes, nursing documented R33 had been wandering around the facility needing constant redirection. R33 had been attempting to eat from other residents' finished trays and picking up random items. R33 unknowingly had been exit seeking multiple times during the shift needing constant redirection. R33 had a Wanderguard placed on admission. R33 was witnessed pushing the door open and walking out of it by residents and staff. Staff followed R33 out the door and redirected R33 back into the facility. R33 was immediately put on direct one-on-one temporary supervision due to a new environment and behaviors to ensure safety and allow time to adjust to the facility. On 6/18/2025 at 7:23 AM in the progress notes, nursing documented R33 was a very high elopement risk. R33 had a very restless night with a lot of tossing and turning. R33 was dressed and taken for a walk around the facility. Afterwards R33 remained up for the remainder of the shift. R33 required many redirections. R33's Behavior Care Plan was initiated on 6/18/2025 to address R33's wandering, digging in the trash, and attempting to eat off of other residents' trays. R33's Elopement Care Plan was initiated on 6/18/2025. On 6/19/2025 at 3:51 AM in the progress notes, nursing documented R33 continued to be a high elopement risk and had one-on-one supervision. On 6/20/2025 at 10:28 PM in the progress notes, nursing documented R33 had one-on-one supervision. R33 was wandering and not receptive to redirection and was not aggressive. On 6/23/2025 at 4:39 AM in the progress notes, nursing documented R33 was a high elopement risk and had one-on-one supervision. R33's Wanderguard was in place. R33 had a rough night with tossing and turning and was wheeled around. R33 was given a shower but continued to be restless. Psychotropic medication was administered and R33 finally settled in shortly after 3:00 AM. On 6/23/2025 at 2:39 PM in the progress notes, nursing documented R33 was wandering throughout the building and was very confused. R33 attempted to exit the building, attempted to open medication and treatment carts, and wandered into other resident rooms. R33 remained on one-to-one supervision. On 6/23/2025, R33's psychological notes were requested from R33's hospital stay and a conversation was had with R33's Guardian and Psych Nurse Practitioner (NP) regarding adjustments to R33's medications. R33's admission Minimum Data Set (MDS) assessment dated [DATE] documented R33 did not have any behavior symptoms or wandering behaviors. In the seven day lookback period, R33 displayed behaviors that were disruptive to others and wandering with multiple elopement attempts. In an interview on 8/13/2025 at 12:51 PM, Surveyor asked Social Worker (SW)-J what sections of the MDS were completed by social services. SW-J stated SW-J completes sections C, D, E, and Q. Surveyor shared with SW-J the concern R33's admission MDS dated [DATE] documented R33 did not have any behaviors or wandering. SW-J stated SW-J did not know why SW-J did not put behaviors for R33. SW-J stated maybe SW-J was thinking of a different resident when SW-J was completing the MDS. 2.) R46 was admitted to the facility on [DATE]. A PASARR level 1 and level 2 were completed in 2022. R46's Annual MDS assessment dated [DATE] documented R46 had not been evaluated by the Level 2 PASARR. In an interview on 8/12/2025 at 10:24 AM, Surveyor shared with MDS Registered Nurse (RN)-DD the concern R33 was not coded on R33's Annual MDS assessment as having the PASARR level 2 completed. MDS RN-DD stated social services completes that section and will let the Social Worker know about the concern. On 8/12/2025 at 3:04 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R46's Annual MDS was not completed accurately because the Level 2 PASARR section was checked no instead of yes. 3.) R53 was admitted to the facility on [DATE] with diagnosis that include Depressive disorder and generalized anxiety disorder. R53's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R53 has not been evaluated by the Level 2 PASARR. Surveyor noted that R53 has diagnosis that require a PASARR level 2 be completed. R53's MDS documents that the PASARR 2 was not completed. R53 Electronic Medical Record contains a PASARR level 1 completed on 1/3/23 and a PASARR level 2 completed on 1/12/23. On 8/12/25 at 10:28 AM, Surveyor interviewed MDS Registered Nurse (RN)-DD. Surveyor informed RN-DD of the concern that R53's PASARR level 2 was not marked as completed on the R53's Annual MDS assessment. RN-DD stated that R53's MDS should have been coded that the level 2 PASARR was completed. RN-DD looked at R53's MDS and stated that RN-DD answered the question wrong. On 8/12/25 at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that R53's Annual MDS was coded incorrectly when answering the question regarding a PASARR level 2 evaluation. 4.) R10 was admitted to the facility on [DATE] with diagnosis that include Depression with psychosis. R10's last Annual Minimum Data Set (MDS) assessment dated [DATE] documents R10 has not been evaluated by the Level 2 PASARR. Surveyor noted that R10 has diagnosis that require a PASARR level 2 be completed. R10's MDS documents that the PASARR 2 was not completed. R10 Electronic Medical Record contains a PASARR level 1 completed on 7/8/2010 and a PASARR level 2 completed on 8/11/10. On 8/12/25 at 10:28 AM, Surveyor interviewed MDS Registered Nurse (RN)-DD. Surveyor informed RN-DD of the concern that R10's PASARR level 2 was not marked as completed on R10's Annual MDS assessment. RN-DD stated that R10's MDS should have been coded that the level 2 PASARR was completed. RN-DD looked at R10's MDS and stated that RN-DD answered the question wrong. On 8/12/25 at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that R10's Annual MDS was coded incorrectly when answering the question regarding a PASARR level 2 evaluation.

Based on interview and record review the facility did not ensure residents were free from physical abuse for 1 (R59) of 5 residents reviewed for abuse. This has the potential to affect all residents who resided on the unit where R59 lives from 7/2/25 through 7/9/25 when CNA-FF continued working and had access to facility residents after an allegation of abuse.*R59 informed Surveyor that CNA-FF was rough with a transfer on 7/2/25, had been rough with cares in the past and that CNA-FF was bossy and made R59 feel intimidated. On 7/2/25, R59 informed 3 different facility staff members that CNA-FF was rough with R59. This allegation of abuse was not reported to the Nursing Home Administrator (NHA)-A per the facility abuse policy. After the allegation of abuse, CNA-FF continued working at the facility from 7/2/25 through 7/9/25. During that time, CNA-FF was scheduled to work multiple times on R59's unit.Findings include:The facility policy, with a last reviewed/revised date of 7/1/25, titled Abuse, Neglect and Exploitation documents, in part: It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: Identifying staff responsible for the investigation. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations: Focusing the investigation on determining if abuse, neglect exploitation, and/or mistreatment has occurred, the extent, and cause: and providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation-This should include staying with the alleged perpetrator to ensure no further contact (verbal or physical) until removal from the facility/environment. Increased supervision of the alleged victim and residents, Room or staffing changes, if necessary, to protect the resident from the alleged perpetrator. Reporting/Response: . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. It is important staff feel comfortable to report all concerns by assuring that reporters are free from retaliation or reprisal.R59 was admitted to the facility on [DATE] with diagnosis that includes Cerebral Palsy.R59's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documents that R59 is cognitively intact. R59 uses a wheelchair and is dependent for transfers.On 8/7/25 at 8:48 AM, Surveyor interviewed R59. R59 informed Surveyor that a few weeks ago, R59's CNA, CNA-L, needed help getting R59 into the wheelchair. CNA-L went to get help from CNA-FF. Both CNA-L and CNA-FF returned to R59's room. R59 stated that during the transfer, CNA-FF was really, really rough. R59 stated that when R59 was put in R59's wheelchair, R59's feet got caught in some plastic on the wheelchair footrests. While CNA-L was trying to gently guide R59's feet, CNA-FF yanked the chair back hard. R59 stated that the yanking did not cause R59's skin to break but stated that the action really hurt. R59 stated that on other occasions, CNA-FF had been very rough with cares and was bossy and intimidating. Surveyor asked if R59 told anyone about what happened. R59 stated that R59 told CNA-L, a nurse and R59's Occupational Therapist (OT)-GG. R59 stated that OT-GG helped R59 fill out a grievance form. R59 stated that after R59 informed staff about the concern, CNA-FF came back to R59's room and started apologizing. R59 stated that R59 thinks that administration told the staff member of R59's concern and that is why CNA-FF returned to R59's room. R59 stated that R59 felt intimidated.Surveyor reviewed the grievance log for the last 6 months and noted that there was no grievance logged about CNA-FF being rough with R59.Surveyor reviewed the Facility Reported Incident folders for the last 6 months and noted that there were no incidents documented about CNA-FF being rough with R59. On 8/7/25 at 9:01 AM, Surveyor interviewed CNA-L. Surveyor asked about the incident with CNA-FF. CNA-L stated that R59 is very sore when R59 wakes up in the AM. CNA-L stated that CNA-L works slower with R59 because of that. CNA-L stated that CNA-FF was helping get R59 into R59's wheelchair via the Hoyer lift. CNA-L indicated that CNA-FF yanked R59 from behind and caused R59 to start yelling about R59's feet. CNA-L indicated that CNA-L could not believe how CNA-FF was treating R59. CNA-L stated that CNA-L felt like CNA-FF was rough with R59 and many other residents during cares and transfers. CNA-L stated that other residents had complained about CNA-FF. Surveyor asked what residents complained. CNA-L indicated that CNA-L cannot recall specific names, but the residents are no longer at the facility. Surveyor asked when CNA-L last saw CNA-FF working at the facility. CNA-L stated that CNA-L had not seen CNA-FF in a while. Surveyor asked if CNA-L told anyone about the incident. CNA-L stated that it is a hard position to be in CNA-L was not sure what to do. CNA-L indicated that R59 told the Social Worker.Surveyor noted that CNA-L had concerns about CNA-FF being rough with R59 on 7/2/25 and other residents previously and did not report this allegation of abuse to NHA-A per facility protocol.On 8/7/25 at 10:40 AM, Surveyor interviewed OT-GG. Surveyor asked if OT-GG recalled a time that R59 reported a CNA being rough. OT-GG stated that a few weeks ago, R59 reported to OT-GG that CNA-FF was rough during cares and a transfer. OT-GG stated that CNA-FF can be rough. OT-GG stated that R59 told OT-GG that CNA-FF pulled too hard during a transfer and hurt R59. R59 asked OT-GG for help writing a grievance. OT-GG indicated that OT-GG told R59 that they could write it out and contact the Social Worker. Surveyor asked who OT-GG gave the grievance form to. OT-GG indicated that OT-GG would normally give it to the Unit Manager or the Social Worker, but OT-GG is not sure who OT-GG gave the form to. On 8/7/25 at 1:10 PM, Surveyor returned to OT-GG and asked about the grievance form. OT-GG stated that OT-GG thinks that OT-GG helped R59 fill out the grievance form because R59 has such a hard time writing. OT-GG unsure where it ended up. OT-GG stated that OT-GG usually takes copies of everything. OT-GG began looking in office. After looking, OT-GG stated that OT-GG could not find the form and thinks maybe R59 handed it in. OT-GG stated that Surveyor should check with Unit Manager (UM)-D. OT-GG stated that a lot of times, the Unit Mangers will address the concern with the resident and then feel like that concern is complete and maybe that is the case with this, but OT-GG was not sure.Surveyor noted OT-GG was told by R59 on 7/2/25 that CNA-FF was rough with cares and transfers and did not report this allegation of abuse NHA-A per facility policy.On 8/7/25 at 10:58 AM, Surveyor interviewed UM-D. Surveyor asked if UM-D had received a grievance from R59 or heard about a concern that R59 had about a CNA staff member. UM-D stated that about a month ago, CNA-L and CNA-FF were transferring R59 and R59 was upset with the transfer. UM-D stated that CNA-FF did not push where R59 prefers to be pushed when completing a transfer. UM-D stated that there was not a formal grievance placed. UM-D stated that UM-D took CNA-FF back to R59's room after asking R59's permission. UM-D stated that they all talked, and everything was ok after that. UM-D stated that CNA-FF even took care of R59 after that incident. Surveyor asked if any other residents had concerns about CNA-FF cares. UM-D stated no. UM-D indicated that residents like CNA-FF. Surveyor asked if UM-D received a filled-out grievance form from OT-GG or from R59. UM-D stated that R59 did not want to do a grievance and UM-D did not receive a grievance from OT-GG.On 8/7/25 at 11:09 AM, Surveyor interviewed Social Worker (SW)-I. Surveyor asked if R59 or any other staff member reported a grievance for R59. SW-I stated that SW-J is R59's social worker. SW-I indicated that SW-I had not heard of any grievance for R59 but SW-J would be back to work next week and could address this with Surveyor.On 8/7/25 at 11:20 AM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is if a staff member is told by a resident that another staff member was rough and hurt them. NHA-A stated that they should follow the abuse policy and report it to me. Surveyor asked if NHA-A was informed about a CNA being rough with R59. NHA-A stated that NHA-A did not recall the incident of the top of NHA-A's head. Surveyor asked if CNA-FF continues to be employed by the facility. NHA-A stated that NHA-A did not recall the name but stated that NHA-A would get back to Surveyor.On 8/7/25 at 12:22 PM, NHA-A provided Surveyor with a note completed and signed by UM-D regarding the incident. NHA-A stated that there is no documentation of the event aside from this note given to Surveyor.The undated word document signed by UM-D documents: CNA came to get writer regarding resident [R59] and a transfer that happened. [R59] stated that CNA-L and CNA-FF were transferring [R59] and pushed on [R59's] leg when the transfer occurred. Writer asked [R59] to show [UM-D] where they pushed on [R59's] leg. [R59] stated [R59] was fine now just during the transfer it hurt. [R59] has chronic discomfort with transfers due to [R59's] cerebral palsy and leg pain in which [R59] is on pain medication for. [R59] stated [R59 has never had issues with [CNA-FF or CNA-L] but the transfer felt different today. Writer asked if [writer] could bring [CNA-FF] in to speak with us. [R59] agreed. [CNA-FF] apologized that [R59] experienced pain with the transfer. [R59] stated that [R59] understood that it was not done purposeful just wants everyone to be very careful when putting [R59] from Hoyer into chair due to the pain. Writer watched a transfer with staff and saw no issues. Staff is aware of not pushing on residents' leg to position [R59] into the chair. On 8/7/25 at 1:08 PM, Surveyor returned to UM-D and asked when UM-D signed the note regarding CNA-FF and R59. UM-D indicated that the transfer occurred on 7/2/25 and that is when the note was signed.On 8/7/25 at 1:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who was the nurse working on R59's unit on 7/2/25. Surveyor asked if R59 talked to LPN-G about another staff member. LPN-G stated that R59 informed LPN-G that CNA-FF was rough with cares and R59 does not like having CNA-FF as an aide and did not want CNA-FF as R59's aide. Surveyor asked if LPN-G informed anyone about R59's concerns. LPN-G stated that LPN-G told the Unit Manager. Surveyor asked if any documentation was completed after being told that by R59. LPN-G stated that LPN-G was not sure but stated that residents/staff usually have to fill out a grievance or incident report when something like that happens.Surveyor noted that on 7/2/25, a third staff member was told by R59 about CNA-FF being rough and this allegation of abuse was not reported to NHA-A per facility policy.On 8/7/25 at 3:34 PM, Surveyor informed NHA-A of the concern that 3 staff members were told by R59 that CNA-FF was rough. This allegation of abuse was not communicated to NHA-A. NHA-A stated again that the incident was more of a resident preference with transferring and that UM-D educated, watched a transfer and after asking R59 if CNA-FF could come back to R59, UM-D took CNA-FF to R59, and CNA-FF apologized. Surveyor asked what NHA-A expects if a resident reported a staff member was rough with cares. NHA-A stated that NHA-A would expect the staff member/Unit manager to follow up with NHA-A. NHA-A continued and stated that NHA-A would then try to understand what rough with cares means from the resident. Surveyor asked if NHA-A had spoken to R59. NHA-A stated that NHA-A had not spoken to R59 about this incident.On 8/11/25 at 8:53 AM, Surveyor interviewed SW-J who is R59's social worker. Surveyor asked if SW-J received a grievance from R59 on 7/2/25. SW-J stated that there is no grievance for that. Surveyor asked if SW-J had heard from R59 or another staff member that a CNA was rough. SW-J stated that SW-J never heard from any staff about another staff member being rough with R59. Surveyor asked what the protocol is if a resident reports that a staff member was rough. SW-J stated that SW-J would report that to the unit manager.Surveyor noted that SW-J told Surveyor that SW-J would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/7/25 at 10:43 AM, Surveyor interviewed CNA-S. Surveyor asked what CNA-S would do if a resident reported that a different staff member was rough with cares or a transfer. CNA-S stated that CNA-S would report that to a manager right away so they can start investigating.Surveyor noted that CNA-S told Surveyor that CNA-S would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/7/25 at 10:36 AM, Surveyor interviewed Nurse Technician (NT)-BB. Surveyor asked what NT-BB would do if a resident reported that a different staff member was rough with cares or a transfer. NT-BB stated that NT-BB would report it right away. NT-BB stated that NT-BB would tell the Administrator, Director of Nursing (DON)-B, and the Charge nurse. NT-BB would then fill out an incident report. On 8/11/24 at 3:31 PM, Surveyor asked NHA-A when CNA-FF's last day of employment was at the facility. NHA-A stated that it was sometime around July 3rd. Surveyor asked why CNA-FF no longer works at the facility. NHA-A stated that CNA-FF was contracted through an agency and CNA-FF's contract had ended.Surveyor reviewed CNA-FF's punch card details for the month of July. Surveyor noted CNA-FF continued to work after the incident with R59 on 7/2/25. Surveyor noted that the last day CNA-FF worked at the facility was 7/9/25. Surveyor reviewed the facility staffing schedule and CNA-FF's punch card details from 7/2/25 through 7/9/25. The facility has a total of 6 units labeled one through 6. R59 is located on unit 1 of the facility. Surveyor noted the following schedule for CNA-FF: 7/2/25, CNA-FF worked from midnight until 6:30 AM, 6:45 until 2:30 PM and then returned at 10:15 PM to work the night shift. CNA-FF was on the staffing schedule to work on unit 1 (R59's unit) and 2 for both shifts. 7/3/25, CNA-FF worked from midnight until 6:31 AM and then returned at 10:06 PM to work the night shift. CNA-FF was on the staffing schedule to work on unit 1 (R59's unit) and 2 from midnight until 6:31 AM and was on the staffing schedule to work on units 3 and 4 when returning at 10:06 PM. 7/4/25, CNA-FF worked from midnight until 6 AM and from 6:15 AM until 2:30 PM. CNA-FF was on the staffing schedule to work on units 3 and 4. 7/5/25, CNA-FF worked from 6:32 AM until 10:32 PM. CNA-FF was on the staffing schedule to work on units 1 (R59's unit) and 2. 7/6/25, CNA-FF worked from 6:30 AM until 10:28 PM. CNA-FF was on the staffing schedule to work on units 3 and 4 for the first shift and units 1 (R59's unit) and 2 for the second shift. CNA-FF did not punch in for work on 7/7/25. 7/8/25, CNA-FF worked from 9:53 PM until midnight. CNA-FF was on the staffing schedule to work on units 1 (R59's unit) and 2. 7/9/25, CNA-FF worked from midnight until 6:34 AM. CNA-FF was on the staffing schedule to work on units 1 (R59's unit) and 2. Surveyor noted that CNA-FF continued to work on R59's unit 6 additional shifts after R59 reported to 3 different facility staff members that CNA-FF was rough.On 8/11/25 at 8:58 AM, Surveyor interviewed DON-B. Surveyor asked what DON-B would expect a staff member to do if a resident reported that a different staff member was rough with cares. DON-B stated that staff should report it to DON-B or NHA-A. On 8/13/25, Surveyor informed NHA-A and DON-B of the continued concern that 3 staff members were informed by R59 that CNA-FF was rough. This allegation of abuse was not reported to the NHA-A per facility policy. CNA-FF continued to work on R59's unit and had access to all residents residing in the facility after an allegation of abuse was made.

Based on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 7 (R15, R16, R24, R27, R34, R81,and R6) of 8 Residents reviewed for ADLs (Activity of Daily Living). * R15, R16, R24, R27, R34, R81,and R6 did not receive showers at least one time a week. Findings include:The facility’s Resident Showers policy and procedure reviewed/revised 6/11/25 documents:”Guideline: It is the practice of this facility to assist Residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.” ”Explanation and Compliance Guidelines:1.Residents will be provided with showers as per request and within reasonable accommodation, or as per facility schedule protocols(at least offered weekly) and based upon Resident safety.” 1.) R15 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis(skeletal muscle breaks down rapidly), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Protein-Calorie Malnutrition (deficiency of both protein and energy), and Hyperlipidemia (high levels of fat particles in blood). R15’s admission Minimum Data Set(MDS) completed 6/30/25 documents R15’s Brief Interview for Mental Status(BIMS) score to be 12, indicating R15 demonstrates moderately impaired skills for daily decision making. R15 has no ROM impairment. R15 requires set-up for eating and is always incontinent of bowel and bladder. R15 requires partial/moderate assistance for showers/bathing and substantial/maximum assistance for upper and lower dressing, mobility, and transfers. R15’s MDS documents it is somewhat important to choose between tub bath or showers. R15’s Care Card as of 8/1/25 document R15’s shower days is on Wednesday AM. R15’s care plan documents the intervention that R15 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 6/30/25 R15’s ADL Care Area Assessment(CAA) for ADLS dated 7/7/25 documents the overall objective is improvement, maintain current level of functioning and minimize risks. There is no other documentation in R15’s CAA. On 8/6/2025, at 1:15 PM, Surveyor interviewed R15. R15 informed Surveyor that R15 has not been receiving showers on a regular basis since admission. On 8/7/2025, at 2:14 PM, R15 informed Surveyor that R15 received a shower on 8/6/25, but stated that is the first shower R15 has received since admission to the facility. Surveyor reviewed R15’s electronic medical record(EMR) and notes that no showers sheets are uploaded in the system. Based on R15’s showers being on Wednesday, R15 missed showers on 6/30/25, 7/6/25, 7/13/25, 7/20/25, and 7/27/25. On 8/12/2025, at 8:33 AM, Surveyor reviewed R15 and R16’s documentation of shower sheets that R15 received showers. R15's shower sheets documented: 7/2/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule.7/9/25-Certified Nursing Assistant(CNA)- signature, no nurse signature7/2/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule. 7/16/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule.7/23/25-Certified Nursing Assistant(CNA)- signature, no nurse signature7/30/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule. On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R15 had not been receiving a weekly shower. No further information has been provided by the facility as to why R15 did not receive showers on consistent weekly basis. 2.) R16 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Essential Hypertension(most common type of high blood pressure), Spastic Hemiplegia Affecting Unspecified Side(one side of body experiences muscle stiffness and weakness), and Insomnia(sleep disorder characterized by difficulty falling asleep). R16 is currently her own person. R16’s admission Minimum Data Set(MDS) completed 7/14/25 documents R16’s Brief Interview for Mental Status(BIMS) score to be 13, indicating R16 is cognitively intact for daily decision making. R16’s MDS documents that R16 is always incontinent of bowel and bladder, that R16 is dependent for lower dressing, mobility, and transfers. The MDS documents that R16 requires partial/moderate assistance for upper dressing and showers/bathing. R16 currently has an unhealed pressure injury to the Coccyx. R16’s MDS documents it is very important to choose between a tub bath, shower, bed bath, or sponge bath. R16’s Care Card as of 8/1/25 document R16’s shower day is on Tuesdays AM. R16’s care plan documents the intervention that R16 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 7/21/25 R16’s ADL Care Area Assessment(CAA) for ADLS dated 7/17/25 documents the overall objective is avoid complications, maintain current level of functioning and minimize risks. There is no other documentation in R16’s CAA. On 8/6/2025, at 1:10 PM, Surveyor interviewed R16. R16 stated has not been getting showers on a regular basis. Surveyor observed R16’s hair to be greasy. On 8/7/2025, at 1:58 PM, R16 informed Surveyor that R16 did not get a shower on 8/5/25. R16’s hair appears to be greasy. Surveyor reviewed R16’s electronic medical record(EMR) and notes that no showers sheets are uploaded in the system. Based on R16’s showers being on Tuesday, R16 missed showers on 7/8/25, 7/15/25, 7/22/25, 7/22/25, and 8/5/25. On 8/12/2025, at 8:33 AM, Surveyor reviewed R15 and R16’s documentation of shower sheets that R15 and R16 received showers. R16's shower sheets documented: 7/15/25-no CNA signature, nurse signed7/22/25-no CNA signature, MT-N signed but did not work that day according to the facility schedule.7/29/25-no CNA signature, MT-N signed but did not work that day according to the facility schedule. On 8/13/2025, at 10:49 AM, R16 informed Surveyor that R16 received a shower late evening on 8/12/25. On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R16did not receive a weekly shower per R16's plan of care. No additional information was provided by the facility as to why all R16 did not receive showers on consistent weekly basis. 3.) R24 was admitted to the facility on [DATE] with diagnoses of Epileptic Seizures(brain has sudden, uncontrollable surge of electrical activity), Encephalopathy(group of conditions that cause brain dysfunction), Essential Hypertension(chronic condition of persistently high blood pressure), Dysphagia(difficulty swallowing foods), Gastrostomy Status(artificial opening in stomach used for feeding), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R24 currently has a legal guardian. R24’s Quarterly MDS completed 6/23/25 documents R24 demonstrates severely impaired skills for daily decision making. R24’s memory was not assessed. R24 is dependent for upper/lower dressing, showers/bathing, mobility, and transfers. R24 has both upper and lower extremity range of motion(ROM) impairment on both sides. The MDS does not document that R24 utilizes a splint or brace and documents that R24 is always incontinent of bowel and bladder. R24 currently has a feeding tube. R24’s Care Card as of 8/1/25 document R24’s shower day is on Fridays PM. R24’s care plan documents the intervention that R24 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 9/20/24 Surveyor reviewed R24’s electronic medical record(EMR) and notes the only shower sheets found were dated 8/1/25, 4/11/25, 4/18/25, 3/7/25, 2/7/25, and 11/1/24. Surveyor noted that R24 did not have any documented showers provided for the month of July 2025, June 2025 or May 2025. No additional information was provided as to why R24 did not receive showers per R24's plan of care. 4.) R27 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Paraplegia(paralysis of lower half of body), and Schizoaffective(combination of schizophrenia and mood disorder symptoms including hallucinations and delusions and manic/depressive episodes). R27 is currently his own person. R27’s quarterly minimum data set(MDS) completed 5/31/25 documents R27’s brief interview for mental status(BIMS) score to be 13, indicating R27 is cognitively intact for daily decision making. R27’s MDS documents R27 has range of motion impairment on one side of lower extremity. R27’s MDS also documents R27 requires substantial/maximum assistance for upper dressing and is dependent for lower dressing. R27 is dependent for mobility and transfers. R27 requires substantial/maximum assistance for showers. R27 has an indwelling catheter and is always incontinent of bowel. R27’s admission MDS documents it is somewhat important for R27 to choose between a tub bath, shower, bed bath, or sponge bath. R27’s Care Card as of 8/1/25 document R27’s shower day is on Thursday PM. R27’s care plan documents the intervention that R27 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 6/11/25 R27’s ADL Care Area Assessment(CAA) for ADLS dated 12/3/24 documents the overall objective is improvement, slow or minimize decline, maintain current level of functioning and minimize risks. There is no other documentation in R27’s CAA. Surveyor reviewed R27’s electronic medical record (EMR) and notes the only shower sheets found were dated 1/30/25, 2/13/25, 2/20/25, 3/6/25. Surveyor noted that R27 had no documented showers for May, June, July August 2025. No additional information was provided as to why R27 did not receive documented showers per R27's plan of care. 5.) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis(muscles under voluntary control to feel weak), Protein-Calorie Malnutrition (deficiency of both protein and Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R34's admission Minimum Data Set(MDS) completed 7/22/25 documents R34's Brief Interview for Mental Status(BIMS) score to be 15, indicating R34 is cognitively intact for daily decision making. R34’s MDS documents R34 has no range of motion impairment. R34 is independent with eating. R34 requires partial/moderate assistance for upper dressing and substantial/maximum assistance for transfers. R34 is dependent for lower dressing and mobility. R34’s MDS documents R34 is receiving oxygen(O2) therapy. R34’s MDS also documents that R34 is at risk for developing a pressure ulcer and currently has one venous and arterial ulcer. It is somewhat important for R34 to choose between a tub bath, shower, bed bath or sponge bath. R34’s Care Card as of 8/1/25 document R34’s shower day is on Friday PM. R34’s care plan documents the intervention that R34 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Created 7/18/25 Revised 7/21/25 On 8/11/2025, at 12:45 PM, Surveyor interviewed R34. R34 informed Surveyor that R34 has not had a shower since admission. On 8/12/2025, at 2:14 PM, R34 confirmed R34 has not received any showers since arriving at the facility R34 states R34’s leg is wrapped and “they haven't figured out a way to give R34 a shower. Why don't they shower me on my treatment days when its unwrapped”. Surveyor reviewed R34’s electronic medical record(EMR) and notes that no showers sheets are uploaded in the system. Based on R34’s showers being on Friday, R34 missed 7/18/25, 7/25/25, 8/1/25, 8/8/25. No additional information was provided as to why R34 did not receive showers per R34's plan of care. 6.) R81 was admitted to the facility on [DATE] with diagnoses of Essential Hypertension(chronic condition of persistently high blood pressure), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Hypertensive Heart Disease(long term conditions developed from chronic high blood pressure), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R81 has an activated health care power of attorney. R81’s annual minimum data set(MDS) completed 7/3/25 documents R81’s brief interview for mental status(BIMS) score to be 5, indicating R81demonstrates severely impaired skills for daily decision making. R81’s MDS documents R81 has no range of motion impairment. R81is independent with eating. R81’s MDS also documents R81 is dependent for upper and lower dressing, showers/bathing, mobility and transfers. R81is always incontinent of bowel and bladder. somewhat important for R81 to choose between a tub bath, shower, bed bath, or sponge bath. R81’s Care Card as of 8/1/25 document R81’s shower day is on Monday AM. Surveyor notes there is no instructions in R81’s care plan or care card for nursing staff on what type of assistance R81 requires for showering. Surveyor notes on 12/12/21 it is documented on R81’s care plan that R81 has a history of refusing showers/baths. There is no revisions and no updated interventions for R81 refusing showers. R81’s EMR has no documentation that R81 has been refusing showers and what approaches nursing staff has attempted. Surveyor reviewed R81’s electronic medical record(EMR) and noted the only shower sheets found were dated 6/30/25, 2/1//25, 1/18/25, 4/28/25, 4/17/25,2/10/25, 1/20/25,11/18/24,10/31/24. On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R81 had not been receiving a weekly shower. Surveyor requested documentation for showers given back to 11/2024 for R81. DON-B replied, Did the Residents tell you that?” Surveyor responded that 3 interviewable Residents confirmed they had not received showers. No further information has been provided by the facility at this time as to why R81 had not received shower on consistent weekly basis. Surveyor was provided 6 documented showers for R81 in July and August. No other documentation that R81 received showers prior to July on a consistent weekly basis. On 7/21/25, and 7/25/25, the nurse signing off on R81’s shower sheet did not work that day according to the facility schedule. No additional information was provided. 7.) R6 admitted to the facility on [DATE] and has diagnoses that include nontraumatic intracerebral hemorrhage in subcortical hemisphere, Cerebral Infarction due to occlusion or stenosis of small artery, chronic pancreatitis, Hyperglycemia, gastrostomy status, Hypertension, Chronic Kidney Disease stage 3 and dysphagia. R6’s admission Minimum Data Set (MDS) dated [DATE] documents under Section F (Preferences for Routine & Activities): How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important. Indicate primary respondent for Daily and Activity Preferences: Family or significant other. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair): Dependent. R6’s Care Plan documents: The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) impaired mobility, CVA (Cerebrovascular Accident) with Right sided Spasticity/deficits - initiated 5/22/25. BATHING/SHOWERING: The resident requires assistance by 1 staff with bathing/showering as scheduled and as necessary. On 8/11/25 at 3:07 PM, Surveyor spoke with R6‘s mother and Power of Attorney (POA) who reported she has complained about cares because there were times when she'd come in and R6 was in bed and both she and the linen was wet, and she has helped staff change her sometimes. R6’s POA reported she has not filed any grievances but does report concerns to the staff if she has any, and things have gotten better since she has voiced concerns. The POA reported she is not sure if R6 gets or has ever gotten a shower and believes staff only do bed baths because she doesn’t think there is enough help. Surveyor reviewed R6’s medical record and was unable to locate any documentation or evidence R6 has received a shower since admission. Surveyor was unable to locate any progress notes indicating a skin check was completed during shower or any documentation regarding showers. R6’s Kardex indicates she is to receive a shower every Friday AM. Review of the Certified Nursing Assistant (CNA) Point of Care (POC) documentation for the last 30 days revealed only 1 entry on 7/15/25 at 1:57 AM, which documented: Question 1 - What type of bathing did resident receive? Options include shower, tub bath, bed bath, resident not available, resident refused, and NA (Not Applicable). Surveyor noted a check mark under “not applicable.” Question 2 - Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. Surveyor noted a check mark under “not applicable - not attempted and the resident did not perform this activity prior to the current illness, exacerbation or injury.” On 8/12/25 at 3:20 PM, during the daily exit meeting, the facility was advised of concern there is no evidence R6 is receiving or has received a shower since admission. Surveyor advised of facility POC documentation the past month of only 1 entry documenting “NA.” Surveyor asked for shower sheets or evidence R6 has received showers. Director of Nursing (DON)-B reported she has seen R6 receiving a shower “because her office is just down the hall” but can't speak to how many times. No additional information was provided as to why R6 did not receive any documented showers per R6's plan of care.

Based on observations and interviews the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 6 medication carts reviewed. Insulin vials and pens were not labeled, dated when opened and/or were expired. Findings include:On [DATE], at 8:42 AM, Surveyor observed the unit 5 medication cart. In the right-side drawer, Surveyor located the following:Lispro insulin vial belonging to R75 was open and used but not dated when opened. Lispro insulin pen with no label. Surveyor noted a handwritten residents' first name in black marker. The insulin pen was open and used but not dated when opened. Lantus insulin pen belonging to R6 was open and used but not dated when opened. Lantus insulin pen belonging to R33 was open and used but not dated when opened. Lispro insulin pen belonging to R33 was open and used but not dated when opened. Lantus insulin pen belonging to R3 was open and used but not dated when opened. Lantus insulin pen belonging to R75 was open and used but not dated when opened. On [DATE], at 9:11 AM, Surveyor asked Nurse Technician (NT)-BB how long insulin good for once opened. NT-BB reported she thought 30 days. NT-BB reported the facility policy is to date insulin when opened and showed Surveyor an insulin vial she opened and dated today. Surveyor advised NT-BB of the above insulins that are opened and not dated. NT-BB confirmed the insulin pen with the handwritten name in black marker belonged to R6. On [DATE], at 9:14 AM, Surveyor observed the unit 3 medication cart. In the right-side drawer, Surveyor located the following: Lispro insulin vial (belonging to a deceased resident) was open and used but not dated when opened. Lispro insulin vial belonging to R1 was open and used dated opened [DATE]. Lispro insulin vial belonging to R1 was open and used but not dated when opened. On [DATE], at 9:22 AM, Surveyor asked Licensed Practical Nurse (LPN)-R how long insulin is good for once opened. LPN-R stated, 28 days. Surveyor advised LPN-R of the above insulins that were open, not dated and/or expired. LPN-R confirmed the 1 Lispro insulin vial belonged to a resident that was deceased . On [DATE], at 9:27 AM, Surveyor observed the unit 1 medication cart. In the right-side drawer, Surveyor located the following: Lispro insulin vial belonging to R5 was open and used dated [DATE].Lispro insulin vial belonging to R5 was open and used but not dated when opened. Surveyor asked LPN-CC how long insulin was good for once opened. LPN-CC reported she thought 30 days. LPN-CC showed Surveyor a binder in the nurse's station, which contained a sheet of paper titled Insulin 28-day Expiration Date Calculator and then reported insulin is good for 28 days after opening. Surveyor noted the sheet of paper in the binder at the nurse's station titled Insulin 28-day expiration date calculator documents: Select a box with the month insulin was initially opened. Locate date on the top row of that box when the insulin was initially opened. Bottom row shows the expiration date (Do not use medication beyond this date). Discard multi-dose vials 28 days after initially opening, or expiration date/beyond use date on vial, whichever is earlier. On [DATE], at 9:42 AM, Surveyor asked Nursing Home Administrator-A for the facility policy and procedure regarding insulin labeling, dating and expiration. The facility policy titled Medication Storage revised [DATE] documents (in part) . 8. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. These medications are destroyed in accordance with out Destruction of Unused Drugs Policy. On [DATE], at 3:30 PM, during the daily exit meeting, Surveyor informed the facility of the above concerns regarding insulins that were not labeled, dated and/or were expired. Surveyor informed the facility policy provided does not include insulin dating or expiration dates. Director of Nursing (DON)-B reported they are trying to find additional information. No additional information was provided.

Based on observation, interview and record review the facility did not ensure 5 (R15, R16, R27, R34, and R8) of 20 residents received necessary care and treatment in accordance with professional standards of practice, a comprehensive person-centered care plan or facility policies and procedures. *R15 was observed not wearing compression stockings during the survey per physician orders and R15's plan of care. *R16 was observed not wearing compression stockings during the survey per physician orders and R16's plan of care. *R27 was observed not wearing compression stockings during the survey per physician orders and R27's plan of care. *R34 did not have a treatment completed to R34’s vascular/venous statis ulcer on 8/8/25. On 7/18/25, a physician order was obtained for R34 to receive an air mattress and R34 did not receive an air mattress until 7/21/24. *R8 had an unwitnessed fall on 4/8/25 and no neurological checks were documented as completed for R8. Findings include: The facility’s Provision of Quality Care policy dated as reviewed/revised on 4/1/25 documents: Guideline: Based on comprehensive assessments, the facility will ensure that Residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the Residents’ choices Explanation and Compliance Guidelines: 1. Each Resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 3. Responsibility for interventions on the care plan will be clearly identified. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the Resident’s care plan, and the Resident’s choices.”… 1.) R15 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis (skeletal muscle breaks down rapidly), Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Protein-Calorie Malnutrition (deficiency of both protein and energy), and Hyperlipidemia (high levels of fat particles in blood). R15’s admission Minimum Data Set (MDS) completed 6/30/25 documents a Brief Interview for Mental Status (BIMS) score to be 12, indicating R15 demonstrates moderately impaired cognition. The MDS documents that R15 has no ROM (range of motion) impairment, that R15 requires set-up for eating and is always incontinent of bowel and bladder. The MDS also documents that R15 requires partial/moderate assistance for showers/bathing and substantial/maximum assistance for upper and lower dressing, mobility, and transfers. R15’s physician order dated 6/27/25 documents that R15 is to have compression stockings to bilateral lower extremities, on in AM (morning), off at HS (bedtime). Two times a day for bilateral lower extremity edema. R15’s Treatment Administration Records (TARS) documentation for R15’s compression stockings from June through August 2025 documents: June 28th and 29th stockings are not signed as placed on R15. June 30th does not indicate the stockings were taken off R15. July 6th and 14th does not indicate the stockings were taken off R15. July 22nd, 25th, 26th, and 27th stockings are not signed as placed on R15. August 3rd and 10th stockings are not signed as placed on R15. August 6th, 7th, 11th, and 12th it is documented R15 is wearing the compression stockings on the TAR however, Surveyor observed no compression stockings on R15 those dates. R15’s CNA (Certified Nursing Assistant) care card dated 8/1/25 documents that nursing staff are to place compression stockings to R15's bilateral lower extremities, on in AM and off at HS. On 8/6/2025, at 1:15 PM, Surveyor observed R15 is not wearing compression stockings. Surveyor observed R15 wearing no-show socks and tennis shoes. On 8/7/2025, at 2:14 PM, Surveyor observed R15 is not wearing compression stockings. On 8/11/2025, at 10:29 AM, Surveyor observed R15 is not wearing compression stockings. On 8/12/2025, at 2:18 PM, Surveyor observed R15 is not wearing compression stockings. R15 confirmed to Surveyor that nursing staff have not been putting compression stockings on R15. On 8/12/25, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R15 not wearing compression stockings as ordered by the physician. UM-E stated the expectation if there is a physician order and it is on a resident’s care card, the compression stockings should be put on and if refused, it should be documented. On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R15 was observed not wearing their compression stockings as ordered by the physician. Surveyor also informed NHA-A and DON-B that there is no documentation in R15's electronic medical record as to why R15 would not wearing their compression stockings. No additional information was provided as to why R15 was observed not wearing compression stockings per physician orders. 2.) R16 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Essential Hypertension(most common type of high blood pressure), Spastic Hemiplegia Affecting Unspecified Side(one side of body experiences muscle stiffness and weakness), and Insomnia(sleep disorder characterized by difficulty falling asleep). R16 is currently her own person. R16’s admission Minimum Data Set(MDS) completed 7/14/25 documents a Brief Interview for Mental Status(BIMS) score to be 13, indicating R16 is cognitively intact. R16’s MDS documents that R16 is always incontinent of bowel and bladder and that R16 is dependent for lower dressing, mobility, and transfers. The MDS also documents that R16 requires partial/moderate assistance for upper dressing and showers/bathing and that R16 currently has an unhealed pressure injury to the coccyx. R16’s physician order dated 7/21/25 documents that R16 is to have compression stockings to bilateral lower extremities, on in AM, off at HS. Two times a day for bilateral lower extremity edema. R16’s Treatment Administration Record (TAR) for July and August of 2025 for the use of compression stocking documents: July 22, 25, 26, and 27 stockings were not documented as being placed on R16. August 3 and 10 stockings were not documented as being placed on R16. August 6,7,11,12 it is documented the compression stockings are on, however, Surveyor observed R16 to be wearing compression stockings. R16’care card dated 8/1/25 instructs nursing staff to place compression stockings to bilateral lower extremities, on in AM and off at HS. On 8/6/2025, at 1:10 PM, Surveyor observed R16 is not wearing compression stockings. Surveyor observed R16 wearing only gripper socks. On 8/7/2025, at 1:58 PM, Surveyor observed R16 is not wearing compression stockings. On 8/11/2025, at 10:30 AM, Surveyor observed R16 is not wearing compression stockings. On 8/11/2025, at 1:23 PM, R16 verified to Surveyor that compression stockings have not been put on today. On 8/12/2025, at 2:18 PM, Surveyor observed R16 is not wearing compression stockings. R16 confirmed to Surveyor that nursing staff have not been putting compression stockings on R16. On 8/12/25, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R16 not wearing compression stockings as ordered by the physician. UM-E stated the expectation if there is a physician order and it is on a resident’s care card, the compression stockings should be put on and if refused, it should be documented. On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R16 was observed not wearing their compression stockings as ordered by the physician. Surveyor also informed NHA-A and DON-B that there is no documentation in R16's electronic medical record as to why R16 would not wearing their compression stockings. No additional information was provided as to why R16 was observed not wearing compression stockings per physician orders. 3.) R27 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Paraplegia(paralysis of lower half of body), and Schizoaffective(combination of schizophrenia and mood disorder symptoms including hallucinations and delusions and manic/depressive episodes). R27 is currently his own person. R27’s quarterly minimum data set(MDS) completed 5/31/25 documents a brief interview for mental status(BIMS) score to be 13, indicating R27 is cognitively intact. R27’s MDS documents that R27 has range of motion impairment on one side of lower extremity and that R27 requires substantial/maximum assistance for upper dressing and is dependent for lower dressing. The MDS also documents that R27 is dependent for mobility and transfers, that R27 requires substantial/maximum assistance for showers and that R27 has an indwelling catheter and is always incontinent of bowel. R27’s physician order dated 11/22/24 documents that R27 is to have compression stockings to bilateral lower extremities, on in AM, off at HS. Two times a day for bilateral lower extremity edema. R27’s Treatment Administration Record (TAR) for R27’s compression stockings being placed on R27 for July and August 2025 documents: July 22, 25, 26, and 27 compression stockings are not documented as being placed on R27. August 3 and 10 compression stockings are not documented as being placed on R27. August 6,7,11,12 it is documented the compression stockings are on R27, however, Surveyor observed no compression stockings on R27. R27’care card as of 8/1/25 instructs nursing staff to place compression stockings/tubi grips to bilateral lower extremities, on in AM and off at HS. On 8/7/2025, at 9:02 AM, Surveyor observed that R27 is not wearing compression stockings or tubi grips. On 8/11/2025, at 2:25 PM, Certified Nursing Assistant (CNA)-Q informed Surveyor that R27’s care card states R27 is to have compression stockings on, but did not want to wear them because R27 has bandages on. CNA-Q informed Surveyor that CNA-Q did not inform the nurse. On 8/11/2025, at 3:06 PM, Surveyor confirmed that R27 is not wearing compression stockings and notes there is no documentation in R27’s electronic medical record as to why R27 is not wearing compression stockings. On 8/12/2025, at 11:48 AM, R27 stated R27 is not wearing compression stockings. On 8/12/2025, at 2:19 PM, R27 confirmed R27 is not wearing compression stockings and does not know why. On 8/13/2025, at 9:34 AM, R27 is not wearing compression stockings and there is no documentation in R27’s electronic medical record as to why R27 is not wearing compression stockings. On 8/12/25, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R27 not wearing compression stockings as ordered by the physician. UM-E stated the expectation if there is a physician order and it is on a resident’s care card, the compression stockings should be put on and if refused, it should be documented. On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R27 was observed not wearing their compression stockings as ordered by the physician. Surveyor also informed NHA-A and DON-B that there is no documentation in R27's electronic medical record as to why R27 would not wearing their compression stockings. No additional information was provided as to why R27 was observed not wearing compression stockings per physician orders. 4.) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis(muscles under voluntary control to feel weak), Protein-Calorie Malnutrition (deficiency of both protein and Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R34's admission Minimum Data Set(MDS) completed 7/22/25 documents a Brief Interview for Mental Status(BIMS) score to be 15, indicating R34 is cognitively intact. R34’s MDS documents R34 has no range of motion impairment, that R34 is independent with eating and that R34 requires partial/moderate assistance for upper dressing and substantial/maximum assistance for transfers. The MDS also documents that R34 is dependent for lower dressing and mobility that R34 is receiving oxygen(O2) therapy and that R34 is at risk for developing a pressure ulcer and currently has a 1 venous ulcer. On 8/6/2025, at 9:28 AM, Surveyor interviewed R34. R34 stated that it took days for R34 to get an air mattress on the bed. R34 stated, “They knew I was coming; they should have had it ready”. R34 stated R34 laid on a metal frame for several days and now R34’s back hurts. R34's physician order dated 7/18/25 documents an order for an air mattress for R34. On 7/16/2025, Unit Manager (UM)-E documented 3/10 pain located at left lower extremity non healing wound. Non healing wound present on left lower extremity due to venous stasis. On 7/20/25, Licensed Practical Nurse (LPN)-II documented that R34 requested an air mattress. On 7/21/25, LPN-AA documented that R34 was transferred to a bed with an air mattress. R34 settled in well and slept well through the night. On 8/11/2025, at 12:45 PM, R34 informed R34’s treatment didn't get done on 8/8/25. R34 stated R34 had to keep reminding them to get the treatment done, but it never did. Surveyor observed the wrap marked 8/6 on R34’s leg. R34 confirmed that R34 had to ask for an air mattress after being admitted to the facility. R34 stated R34’s back hurt laying on the metal bar of the regular mattress. On 8/11/2025, at 12:52 PM, Surveyor brought LPN-R to observed R34’s bandage. LPN-R confirmed the bandage is marked 8/6. LPN-R stated to Surveyor LPN-R is not sure if able to get to the treatment today. LPN-R stated, “Have a lot to do yet. If I don’t get it done, it will go to PM shift, I don't have time to do treatments today”. On 8/12/2025, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E. Surveyor asked UM-E why R34’s treatment had not been completed on 8/8. UM-E does not know why. UM-E agrees the bandage was marked 8/6 when observed on 8/11. Surveyor asked UM-E why R34’s air mattress was not placed on R34’s bed until 7/21/25 after R34 requested it and after a physician order for an air mattress was written on 7/18/25. UM-E informed Surveyor that UM-E will contact maintenance about a work order for an air mattress and get back with Surveyor. On 8/12/2025, at 3:17 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R34 did not receive an air mattress until 7/21/25, despite a physician order on 7/18/25 and R34 requesting it. Surveyor also shared that R34 has not had R34’s treatment completed to R34’s venous stasis ulcer. No additional information was provided by the facility in regard to why there was a delay in getting an air mattress for R34 and treatments have not been completed as ordered by physician for R34’s venous stasis ulcer. 5.) The facility policy with a last reviewed/revised date of 12/3/24, titled “Fall Prevention Program” documents, in part: When any resident experiences a fall, the facility will: Assess the resident . Document all assessments and actions . Monitor residents’ condition and response to interventions as per standard of practice. The facility policy with a last reviewed/revised date of 7/10/25 documents, in part: It is the guideline of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Assess resident following a known, suspected or verbalized head injury… Example protocol for actual/suspected head injury may include: Every 15 min, for 1 hour, then; hourly for 4 hours, then’ every 8 hours (every shift) for 72 hours… R8 was admitted to the facility 6/1/2014 with diagnosis that include Hemiplegia/Hemiparesis (weakness on one side of the body) following a stroke, stage 2 kidney disease and epilepsy (seizure disorder). R8’s Significant change Minimum Data Set (MDS) assessment dated [DATE] documents R8 is moderately cognitively impaired. R8 has impairments on one side of both of R8’s upper and lower extremities. R8 requires substantial/maximum assistance for personal hygiene and transfers. R8 has had one fall with major injury since R8’s last MDS Assessment. R8’s Care Area Assessment for falls dated 3/1/25 documents, in part: [R8] had a recent fall and has a history of falls [related to] [stroke] and weakness. R8’s care plan documents the following pertinent interventions: Assist of with toileting needs [as needed], initiated on 10/29/23. Prompt [R8] to toilet upon rising, after meals and [at bedtime] and per request at night. Keep urinal at bedside at night, initiated on 1/13/19. Toilet use: [R8] requires assistance x 2 [standing pivot transfer] with front wheeled walker. Assist x 1 with toileting hygiene. Prompt to use the bathroom every 2-3 hours and [as needed], initiated on 3/23/25. R8’s Fall Risk Evaluation dated 2/12/25 documents a score of 8 which puts R8 at moderate risk for falls. R8’s progress note dated 4/8/25 at 10:49 AM documents, in part: [R8] had an unwitnessed fall around 700 am. [R8] was discovered by CNA who alerted this nurse. [R8] was found in front of wheelchair, lying on [R8’s] left side, and the wheelchair was also on its side. Per [R8], [R8] forgot to lock [R8’s] wheelchair. Vital signs taken and documented . Surveyor reviewed R8’s electronic medical record for evidence of neurological checks being completed after R8’s unwitnessed fall. R8 has one neurological check completed on 4/8/25 at 1:47 PM. Surveyor reviewed R8’s fall investigation dated 4/8/25. The first page of the fall packet revealed a “Checklist for Accidents/Incidents.” The checklist is arranged with a column of Nurse responsibilities, a column where staff can write in the completed date and a column for staff to put their signature for each responsibility. One of the nurse responsibilities on the checklist is, “[NAME] (sic) checks initiated (only if unwitnessed, resident hits head or states they hit their head). Surveyor noted that the completion date of [NAME] (sic)/Neurological check is blank and there is no staff signature. On 8/12/25 at 2:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-OO. Surveyor asked about R8's fall on 4/8/25. LPN-OO stated R8 was found laying on the floor. LPN-OO stated that vitals and an assessment were completed, and the physician was notified. LPN-OO stated R8 did not sustain an injury with this fall. Surveyor asked what the neuro (neurological) check policy is for the facility. LPN-OO indicated that neuro checks should be completed after any unwitnessed fall. LPN-OO stated that LPN-OO did complete a neuro check but could not keep up with them due to her other nurse duties on the unit. On 8/12/25 at 1:30 PM, Surveyor asked LPN-G what should be completed after a resident sustains an unwitnessed fall. LPN-G stated the resident is assessed, then, if safe, assisted back to chair/bed. LPN-G would inform the MD and the resident’s power of attorney. LPN-G that staff must fill out the fall packet and checklist. Neuro checks would be started after an unwitnessed fall. On 8/13/25 at 9:04 AM, Surveyor interviewed Nurse Technician (NT)-BB. Surveyor asked what should be completed after a resident sustains an unwitnessed fall. NT-BB stated that the resident is assessed, vital signs completed, and neuro checks started. After caring for the resident, staff must fill out the fall packet. The packet contains a checklist with everything to complete including witness statements. On 8/13/25 at 10:44 AM, Surveyor interviewed Unit Manager (UM)-D. Surveyor asked if UM-D could explain the facilities Neuro check policy regarding falls. UM-D indicated that neuro checks are started after an unwitnessed fall. The neuro checks are started right away and carry on for the appropriate amount of time. UM-D stated that the initial neuro check can be documented in the electronic medical record, but the rest of the neuro checks are documented on paper. On 8/13/25 at 12:47 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked about R8’s neuro checks after R8’s fall. DON-B reviewed R8’s fall packet and did not locate any documented neuro checks. Surveyor alerted DON-B to the fact that the checklist in the fall packet is blank in the row related to neuro checks. DON-B acknowledged the row was blank. On 8/13/25 at 2:45 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that on 4/8/25, R8 was transferred to the toilet by a CNA according to documentation, 2 minutes later, R8 sustained an unwitnessed fall. Neurological checks were not completed per facility policy. No additional information was provided.

Based on observation and interview the facility did not ensure 1 (R27) of 3 Residents reviewed for indwelling catheters were treated with dignity and respect.*R27's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors.Findings Include:R27's quarterly minimum data set (MDS) completed 5/31/25 documents R27 has an indwelling catheter.R27's comprehensive care plan documents:R27 has indwelling catheter due to diagnosis of Neurogenic BladderInitiated 11/23/24 Revised 6/11/25On 8/11/25, at 9:55 AM, Surveyor observed Certified Nursing Assistants (CNA) - X and (CNA) - Y bring R27 out of R27's room. R27 was in a wheelchair that was reclined. Surveyor observed CNA-X push R27 down the hall, turn left at the nurse's station, and continue pushing R27 down the hallway and placed R27 in the activity room. Surveyor observed other Residents in the activity room. Surveyor observed R27's catheter bag laying at the bottom of R27's legs with the urine side facing up which would be visible to other Residents, visitors, and staff. R27's foley catheter bag was not covered in a privacy bag.On 8/11/2025, at 3:06 PM, Surveyor observed R27 in the main dining room in a wheelchair. R27's foley catheter bag was hanging on the right side of the wheelchair with the urine side visible to other Residents, visitors, and staff. R27's foley catheter bag was not covered in a privacy bag. R27 was playing bingo. On 8/12/2025, at 11:48 AM, Surveyor observed R27 in the activity room and R27's foley catheter bag was covered in a privacy bag. Surveyor asked R27 if R27 prefers to have R27's bag covered in a privacy bag. R27 stated, Why would I want everyone to see my pee? On 8/12/2025, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R27's foley catheter bag. UM-E confirmed the expectation is have the foley catheter bag always in a privacy bag and not visible to other Residents, visitors, and staff.On 8/12/2025, at 3:17 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R27 did not have R27's foley catheter bag covered in a privacy bag on 8/11/25 on 2 different occasions in common areas resulting in R27's foley catheter bag visible to other Residents, visitors, and other staff.

Based on observation, interview and record review, the facility did not promote and facilitate 1 (R65) of 1 Resident's right to self-determination through support of R65's choice about an aspect of R65's life that is significant to R65.R65 changed rooms in the facility on 7/25/25. R65 had boxes with items important to R65 on R65's dresser and closet area. R65 went to a group activity in a common area on 8/4/25. When R65 returned to R65's room, R65's boxes and items important to R65 were gone. R65 informed Surveyor that Social Worker (SW)-J and Nurse Technician (NT)-BB entered R65's room without permission and removed R65's items. Findings include:The facility policy with a last reviewed date of 7/1/25 titled, Resident Rights documents, in part: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The resident has the right to be informed of and participate in his or her treatment, including: . The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. The right to be informed, in advance, of changes to the plan of care. The right to be informed in advance, of the care to be furnished and the type of caregiver or professional that will furnish care. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including, but not limited to: . The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.R65 was admitted to the facility on [DATE].R65's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents that R65 is cognitively intact.On 8/6/25 at 10:36 AM, R65 informed Surveyor that R65 changed room at the end of July. R65 stated that R65 thinks R65 had 3 boxes on his dresser. R65 pointed to the dresser in R65's room and Surveyor noted that there were no boxes on R65's dresser. R65 stated that R65 had 2 other boxes on the opposite corner in R65's room. Surveyor did not observe any boxes in R65's room. R65 stated that R65 went to a group activity and when R65 returned to R65's room, R65's boxes were gone. R65 stated that R65 found out that SW-J and NT-BB went in R65's room and tossed the room. Surveyor asked if R65 was told prior to the group activity that staff would be entering R65's room. R65 stated no. Surveyor asked what was missing from R65's room. R65 stated that R65 had emptied some of each of the boxes so they were not all the way full. R65 stated that R65 is missing a cup that R65 used to hold ink pens and sharpies. The pens and sharpies are gone too. R65 stated that there was a paper flag banner used at group party/activity at the facility and that was gone. R65 stated a small [NAME] ball that was also given away at a facility group activity was gone. R65 stated that these items did not have any monetary value, but it was sentimental. R65 stated that R65 had a collection of used plastic shopping bags that R65 uses on a regular basis and that was gone. R65 stated that R65 was missing some shelf food and a reusable tote bag as well. R65 stated that there is probably more but R65 can't remember everything that was in the boxes. R65 stated that all the staff needed to do was talk to R65. R65 stated that if R65 thought R65 had time to empty the rest of R65's boxes. R65 stated that R65 approached staff members about his room after the items were removed. R65 stated that staff told R65 that R65 was hoarding and that they needed to remove trash from R65's room. R65 stated that R65 asked staff to go through the boxes and belongings removed from R65's room. R65 was told that it was trash and that it had already been taken to the dumpster. R65 stated that R65 had given a list of missing items to Unit Manager (UM)-D and directed Surveyor to speak to UM-D.On 8/11/25 at 5:01 PM, Surveyor interviewed NT-BB. Surveyor asked if NT-BB had gone into R65's room to remove anything. NT-BB stated to R65 they were belongings but really it was garbage that R65 was saving. NT-BB stated that there was food that was sitting out greater than 24 hours and that was thrown away. NT-BB told R65, after the fact, that the next time R65 wants to save food, staff can label it and put it in the refrigerator. NT-BB stated that R65 had 2 empty pizza boxes and old medicine cups that NT-BB threw away. NT-BB stated that R65 was also stock piling and hiding facility silverware and dishes that NT-BB removed and took to the kitchen. Surveyor asked if NT-BB remembered a paper flag banner or [NAME] ball. NT-BB stated No. On 8/12/25 at 9:36 AM, Surveyor interviewed SW-J regarding R65's items being removed from R65's room. SW-J stated that SW-J just removed garbage. SW-J stated that SW-J care planned R65 as a hoarder. SW-J stated that there were no belongings removed from the room. SW-J stated that they removed old napkins, straws, cups with mold, about 30 facility plates, and empty cigarette packs. SW-J stated there was a box of garbage with a moldy sandwich and cookies removed. Surveyor asked if R65 was aware that SW-J was going to enter R65's room. SW-J stated yes and stated that it occurred on the same day that SW-J care planned R65 as a hoarder.R65's care plan initiated 8/4/25 documents: The resident has a behavior problem [related to] hoarding. Pertinent interventions include Encourage resident to express their feelings. Social services will go in resident's room to remove old food, drink, garbage, plates, silver wear, cups, etc.On 8/12/25 at 10:38 SW-J returned to Surveyor with a post it note dated 8/4/25 and reads, [R65] refused to clean room. Went in with nursing. Surveyor asked if R65 was involved in the care planning regarding hoarding. SW-J stated no, R65 was not involved in that decision. R65 has behaviors and SW-J indicated that it couldn't work like that because of R65's behaviors.On 8/12/25 at 1:31 PM, Surveyor asked R65 if SW-J spoke to R65 about R65's new care plan regarding hoarding and an intervention that stated SW-J can enter R65's room to room items. R65 stated Absolutely not.Surveyor noted that R65's right to be involved in R65's care planning process was dismissed by facility staff. On 8/12/25 at 10:32 AM, Surveyor asked UM-D about a list of missing belongings given to UM-D by R65. UM-D stated that UM-D spoke to R65 about the list and reviewed the list with Nursing Home Administrator (NHA)-A. Surveyor asked what was missing from R65's room. UM-D stated that R65 reported missing pens and clips. UM-D stated that there was a [NAME] ball missing which UM-D informed NHA-A about. UM-D stated that there was some shelf food missing as well. On 8/13/25 at 10:31 AM, Surveyor interviewed NHA-A. Surveyor asked if NHA-A had heard about R65's items missing in R65's room. NHA-A stated that NHA-A had heard that R65 wanted to speak to NHA-A, but NHA-A had not had a chance to speak to him yet but will speak to R65 soon. Surveyor asked if UM-D had provided a list of items that R65 was missing. NHA-A stated that UM-D and NHA-A are working to get R65's items back. NHA-A was aware of a [NAME] ball, pens and clips. Surveyor informed NHA-A that according to R65, R65 is also missing a collection of used shopping bags, a reusable tote bag, shelf food, and a paper banner that held sentimental value. NHA-A stated that NHA-A will follow up with that. Surveyor informed NHA-A of the concern that R65 went to a group activity and was not notified before staff entered R65's room to remove items. R65 returned to R65's room and R65 told Surveyor that R65's room was tossed. On the same day that staff removed items without R65's permission, R65 had a care plan intervention entered that SW-J can enter R65's room to remove items. SW-J informed Surveyor that SW-J did not review that care plan with R65 prior to implementation. R65 informed Surveyor that R65 did not know anything about that care plan intervention. Surveyor informed NHA-A that R65 has the right to self-determination about R65's room and the right to be involved in R65's care plan. NHA-A stated that NHA-A understood that R65 has those rights and stated that NHA-A will meet with SW-J and R65 to determine how to move forward.

Based on interview and record review, the facility did not ensure formulated advance directives were documented accurately for 1 (R3) of 20 residents reviewed for code status.Documentation in R3's medical record indicated R3 desired to be a full code (cardiopulmonary resuscitation to be administered) and a do not resuscitate (DNR). Findings include:The facility policy and procedure titled Residents' Rights Regarding Treatment and Advance Directives dated [DATE] documents: Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate and advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.R3 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder characterized by changes in mental and cognitive function), diabetes, chronic obstructive pulmonary disease, dementia, depression, anxiety, and coronary artery disease. R3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. R3's Power of Attorney (POA) was activated.On [DATE], the Resident Code Status form was completed and witnessed by Social Worker (SW)-J and Unit Manager (UM)-D. The form documented R3's POA verbally elected R3 to be a full code. The form was not signed by R3's POA.On [DATE], the State Emergency Care Do Not Resuscitate Order (DNR) form was completed by SW-J and SW Assistant (SWA)-I documenting R3's POA verbally elected R3 to be a DNR. The form was signed by R3's physician.On [DATE], the State Emergency Care Do Not Resuscitate Order (DNR) form was completed by SWA-I documenting R3's POA verbally elected R3 to be a DNR. The form was signed by R3's physician.R3's electronic medical record (EMR) dashboard documents R3 is DNR with a physician order in place.Progress notes entered by R3's physician and nurse practitioner (NP) in R3's EMR document R3 is a full code. Full code was documented by R3's physician and NP from the time of admission with the most recently documented progress note on [DATE] at 7:00 AM by R3's physician.On [DATE] at 4:22 PM in the progress notes, SWA-I documented R3 is a long term resident in facility who chooses CPR as her code status.On [DATE] at 2:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R3's code status was unclear. Surveyor showed NHA-A the documentation in R3's EMR of the verbal consents from R3's POA for the election of full code on [DATE], the State DNR form completed [DATE], the EMR banner indicating DNR, and the documentation in the progress notes by R3's physician, NP, and SWA-I that R3 was a full code. NHA-A agreed the documentation was confusing and was not sure what R3's wishes were. NHA-A stated NHA-A would talk to SWA-I to get clarification.In an interview on [DATE] at 2:51 PM, Surveyor asked Licensed Practical Nurse (LPN)-G where LPN-G would look to find out the code status of a resident. LPN-G stated LPN-G would look at the front of the resident's physical chart. LPN-G stated you can look in the computer, too, but LPN-G would look at the physical chart.Surveyor reviewed R3's physical chart found at the nurses' station on the unit. The first form indicating a code status was the verbal consent code status form from [DATE] indicating R3 was a full code. The State DNR form dated [DATE] was further down in the chart with multiple other papers between. Surveyor did not observe the State DNR form dated [DATE] in the chart. Surveyor noted if staff looked in the physical chart to determine what R3's code status was, the first document indicated full code.On [DATE] at 8:24 AM in the progress notes, SWA-I documented SWA-I confirmed the code status for R3 with R3's POA. R3 is DNR code status.

Based on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 (R5, R34 and R65) of 3 residents. *R5’s wall and heat register in R5’s room was observed to be coated with dirt and a thick layer of dust. R5’s curtains hanging over the heat register was observed to be coated with dirt and black spots. *R34’s window in R34’s room was observed to have a thick white film and appears cloudy. The outside of the window was observed to be dirty. Near R34’s window, there is a cobweb with two dead flies hanging from it. R34’s window blinds appear to be broken and not functional. *R65’s air conditioning and heating unit on R65’s wall in R65’s room was observed to be disconnected and coming off the wall on the left side. On the left side of the unit, Surveyor observed an exposed metal pipe covered in dirt and cobwebs. R65’s shared bathroom flooring is curved up to meet the tile on the walls. The flooring was observed to be peeling off the wall, exposing dirt and the dry wall behind it. Findings include: The facility policy with a reviewed/revised date of 7/1/25 titled “Safe and Homelike Environment” documents, in part: In accordance with residents’ rights, the facility will provide a safe, clean, comfortable and homelike environment… housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment… 1.) R65 was admitted to the facility on [DATE]. R65’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents that R65 is cognitively intact. Surveyor reviewed R65’s electronic medical record. Surveyor noted that R65 had a recent room change at the facility and has been in R65’s current room since July 25, 2025. On 8/6/25 at 10:36 AM, R65 informed Surveyor that the individual air/heating unit in R65’s room is ancient and loud. R65 stated that R65 has hit R65’s leg when walking on that side of the bed due to the way the unit is hanging. Surveyor observed the unit. Surveyor noted the left side of the unit was coming off the wall and hanging down lower than the right side of the unit. Surveyor observed a metal pipe from a previous heating unit/radiator to the left of the current individual air/heating unit in R65’s room. The metal piping is coming up from the floor and is covered with a thick layer of dirt. Surveyor observed cobwebs on the pipe, wall and air/heating unit. R65 directed Surveyor to R65’s bathroom. Surveyor observed what appeared to be laminate flooring covering the floor and curling up about 3 inches to meet the tiled wall. Surveyor observed the laminate flooring is peeling away from the wall in multiple areas. Surveyor noted where the floor is peeling away, there is dirt and dust covering the exposed areas. On 8/13/25 at 11:18 AM, Surveyor interviewed Maintenance Director (MD)-F. Surveyor asked if MD-F had any concerns with R65’s room. MD-F stated that MD-F had not been into R65’s room since R65 moved in there. Surveyor asked if there is any scheduled work to be completed in R65’s room. MD-F stated that MD-F can look. MD-F looked in the computerized system to check. MD-F stated there is nothing scheduled. Surveyor informed MD-F of the concern that R65’s air/heating unit is detached on the left side and not connected flush to R65’s wall. MD-F was willing to enter R65’s room, but R65 had informed Surveyor that R65 did not want to be disturbed and wanted to sleep. MD-F and Surveyor entered a different resident room so that Surveyor could explain Surveyor’s observations. Surveyor informed MD-F of the concern of a metal pipe that is exposed on the left side of R65’s air/heating unit. Surveyor noted that in the current resident’s room, there is a covering noted over the old units’ metal piping. Surveyor pointed to the covering and informed MD-F that the covering observed is not present in R65’s room and R65’s metal pipe is exposed and covered in dirt and cobwebs. Surveyor informed MD-F of the concern that R65’s laminate flooring is peeling off R65’s wall in R65’s shared bathroom. MD-F thanked Surveyor for making MD-F aware. On 8/13/25 at 11:30 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the concerns that R65’s air/heating unit is detached on the left side and not connected flush to R65’s wall, that there is an exposed metal pipe coming up from the floor on the left side of the unit that is covered in dirt and cobwebs, and that the laminate flooring in R65’s bathroom is peeling off the wall exposing dirt. NHA-A stated that the maintenance department has ordered more new air/heating units in case they were needed, and they are waiting for them to come in. NHA-A indicated that NHA-A will address Surveyor’s concerns with MD-F. 2.) On 8/11/25, at 8:21 AM, Surveyor observed R5’s wall to the left of the bed. Surveyor noted the grids on top of the heat register where the air comes out, to be dirty and coated with thick dust. Surveyor noted the wall above the register grid to be black and coated in heavy dirt. Surveyor also noted, R5’s curtains hanging directly over the heat register to be coated with dirt and black spots scattered on the curtains. On 8/13/25, at 9:01 AM, Surveyor interviewed Concierge Coordinator (CC)-K who indicates housekeeping, maintenance and herself make observations of resident rooms to ensure cleanliness and ensure equipment is working, prior to residents being admitted into the facility. CC-K states the facility has a couple resident rooms that require touch ups, and the facility avoids putting residents in these rooms. Surveyor notified CC-K of concerns with R5’s heat register, wall, and curtain being coated in dirt with multiple black spots. CC-K walked Surveyor down to R5’s room for observation. CC-K acknowledged these concerns and states she will be putting in a work order to have maintenance and housekeeping address these concerns. CC-K states R5 was recently admitted to the facility and the previous resident was in that room long term. CC-K states the facility is discarding curtains and placing blinds in resident rooms which tells her the previous resident was in R5’s room for a long time prior to R5 being admitted . On 8/13/25, at 10:35 AM, Surveyor notified Director of Nursing (DON)-B of concerns above. DON-B acknowledged these concerns. 3.) R34 was admitted to the facility on [DATE]. On 8/13/25, at 10:16 AM, Surveyor observed R34’s windows. Both windows have a very thick white film on the inside, appearing very cloudy like, the window on the right is slightly up with a cobweb hanging from it with two dead flies hanging from it. The outside windows are very dirty on the outside. The windowsill in between the inside and outside windows are very dirty with debris. There is no cord on the right side to pull up the blinds on the windows. On 8/13/25, at 10:28 AM, Surveyor interviewed Housekeeping (HK)-T in regard to the process of cleaning Resident rooms. HK-T explained there is daily cleaning expectations and then every Resident room is deep cleaned on a monthly basis. HK-T explained a monthly calendar is maintained to schedule the deep cleans. With a deep clean, one of the expectations is that the windows are cleaned including the frame, inside windows, and windowsills. HK-T stated if the staff notice something is not working right or appears to be broke it would be passed on to maintenance. HK-T stated HK-T does not know why HK-T’s staff can’t clean the outside windows. HK-T does not if it is the maintenance department or an outside company responsibility to clean the outside windows. HK-T has sometimes asked permission from the facility to clean the outside windows. HK-T informed Surveyor that R34’s window was last deep cleaned on 7/28/25 and 8/26/25 is the next scheduled deep clean. On 8/13/25, at 10:44 AM, Surveyor and HK-T went to R34’s room. Surveyor received permission from R34 to enter and observe R34’s windows. It was determined the windows are extremely dirty on the outside. HK-T agreed that the inside sills should have been cleaned by the housekeeper and will follow up. HK-T agreed there is no pull strip to raise up the blind. HK-T had to pull the blind to the side to observe the extremely dirty window and the dirty windowsills. HK-T stated the windowsills between the inside and outside windows should have been cleaned in the deep clean and got missed. HK-T stated maybe it is because the blind would not open. On 8/13/2025, at 11:18 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A regarding R34’s dirty windows and broken blind. Surveyor shared with NHA-A that HK-T agreed the windows were extremely dirty, the sills between the inside and outside windows are very dirty with cobwebs and two dead flies and the blind is broken and cannot be raised up. NHA-A acknowledged the concern and has no further information to provide at this time.

Based on interview and record review, the facility did not ensure 1 (R53) of 2 residents with allegations of abuse were reported to the Nursing Home Administrator (NHA)-A per facility policy, the state agency and one or more law enforcement entities.*On 7/2/25, R59 informed 3 different facility staff members that CNA-FF was rough with R59. This allegation was not reported to the Nursing Home Administrator (NHA)-A, the state agency and one or more law enforcement entities. Findings include:The facility policy, with a last reviewed/revised date of 7/1/25, titled Abuse, Neglect and Exploitation documents, in part: It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property. Reporting/Response: . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. It is important staff feel comfortable to report all concerns by assuring that reporters are free from retaliation or reprisal. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.R59 was admitted to the facility on [DATE] with diagnosis that includes Cerebral Palsy.R59's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documents that R59 is cognitively intact. R59 uses a wheelchair and is dependent for transfers.On 8/7/25 at 8:48 AM, Surveyor interviewed R59. R59 informed Surveyor that a few weeks ago, R59's CNA, CNA-L, needed help getting R59 into the wheelchair. CNA-L went to get help from CNA-FF. Both CNA-L and CNA-FF returned to R59's room. R59 stated that during the transfer, CNA-FF was really, really rough. R59 stated that when R59 was put in R59's wheelchair, R59's feet got caught in some plastic on the wheelchair footrests. While CNA-L was trying to gently guide R59's feet, CNA-FF yanked the chair back hard. R59 stated that the yanking did not cause R59's skin to break but stated that the action really hurt. R59 stated that on other occasions, CNA-FF had been very rough with cares and was bossy and intimidating. Surveyor asked if R59 told anyone about what happened. R59 stated that R59 told CNA-L, a nurse and R59's Occupational Therapist (OT)-GG. R59 stated that OT-GG helped R59 fill out a grievance form. R59 stated that after [R59] informed staff about the concern, CNA-FF came back to R59's room and started apologizing. R59 stated that R59 thinks that administration told the staff member of R59's concern and that is why CNA-FF returned to R59's room. R59 stated that R59 felt intimidated.Surveyor reviewed the grievance log for the last 6 months and noted that there was no grievance logged about CNA-FF being rough with R59.Surveyor reviewed the Facility Reported Incident folders for the last 6 months and noted that there were no incidents documented about CNA-FF being rough with R59. On 8/7/25 at 9:01 AM, Surveyor interviewed CNA-L. Surveyor asked about the incident with CNA-FF. CNA-L stated that R59 is very sore when R59 wakes up in the AM. CNA-L stated that CNA-L works slower with R59 because of that. CNA-L stated that CNA-FF was helping get R59 into R59's wheelchair via the Hoyer lift. CNA-L indicated that CNA-FF yanked R59 from behind and caused R59 to start yelling about R59's feet. CNA-L indicated that CNA-L could not believe how CNA-FF was treating R59. CNA-L stated that CNA-L felt like CNA-FF was rough with R59 and many other residents during cares and transfers. CNA-L stated that other residents had complained about CNA-FF. Surveyor asked what residents complained. CNA-L indicated that CNA-L cannot recall specific names, but the residents are no longer at the facility. Surveyor asked when CNA-L last saw CNA-FF working at the facility. CNA-L stated that CNA-L had not seen CNA-FF in a while and stated, I hope [CNA-FF] doesn't come back for there [the residents] sake. Surveyor asked if CNA-L told anyone about the incident. CNA-L stated that it is a hard position to be in CNA-L was not sure what to do. CNA-L indicated that R59 told the Social Worker.Surveyor noted that CNA-L had concerns about CNA-FF being rough with R59 and other residents and did not report this allegation of abuse to NHA-A per facility policy.On 8/7/25 at 10:40 AM, Surveyor interviewed OT-GG. Surveyor asked if OT-GG recalled a time that R59 reported a CNA being rough. OT-GG stated that a few weeks ago, R59 reported to OT-GG that CNA-FF was rough during cares and a transfer. OT-GG stated that CNA-FF can be rough. OT-GG stated that R59 told OT-GG that CNA-FF pulled too hard during a transfer and hurt R59. R59 asked OT-GG for help writing a grievance. OT-GG indicated that OT-GG told R59 that they could write it out and contact the Social Worker. Surveyor asked who OT-GG gave the grievance to. OT-GG indicated that OT-GG would normally give it to the Unit Manager or the Social Worker, but OT-GG is not sure who OT-GG gave the grievance form to. On 8/7/25 at 1:10 PM, Surveyor returned to OT-GG and asked about the grievance form. OT-GG stated that OT-GG thinks that OT-GG helped R59 fill out the grievance form because R59 has such a hard time writing. OT-GG unsure where it ended up. OT-GG stated that OT-GG usually takes copies of everything. OT-GG began looking in office. After looking, OT-GG stated that OT-GG could not find the form and thinks maybe R59 handed it in. OT-GG stated that Surveyor should check with Unit Manager (UM)-D. OT-GG stated that a lot of times, the Unit Mangers will address the concern with the resident and then feel like that concern is complete and maybe that is the case with this, but OT-GG was not sure.Surveyor noted OT-GG was told by R59 that CNA-FF was rough with cares and transfers and did not report this allegation of abuse NHA-A per facility policy.On 8/7/25 at 1:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who was the nurse working on R59's unit on 7/2/25. Surveyor asked if R59 talked to LPN-G about another staff member. LPN-G stated that R59 informed LPN-G that CNA-FF was rough with cares and R59 does not like having CNA-FF as an aide and did not want CNA-FF as R59's aide. Surveyor asked if LPN-G informed anyone about R59's concerns. LPN-G stated that LPN-G told the Unit Manager. Surveyor asked if any documentation was completed after being told that by R59. LPN-G stated that LPN-G was not sure but stated that residents/staff usually have to fill out a grievance or incident report when something like that happens.Surveyor noted that on 7/2/25, a third staff member was told by R59 about CNA-FF being rough and this allegation of abuse was not reported to NHA-A per facility policy.On 8/7/25 at 11:20 AM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is if a staff member is told by a resident that another staff member was rough and hurt them. NHA-A stated that they should follow the abuse policy and report it to me. Surveyor asked if NHA-A was informed about a CNA being rough with R59. NHA-A stated that NHA-A did not recall the incident of the top of NHA-A's head. NHA-A stated that NHA-A would get back to Surveyor.On 8/7/25 at 12:22 PM, NHA-A returned to Surveyor and provided Surveyor with a note completed and signed by UM-D regarding the incident. NHA-A stated that the incident occurred about 2 months ago. NHA-A indicated that the incident was not a report of rough with cares or transport but more of a preference that R59 had for transferring. NHA-A indicated that UM-D provided education to CNA-FF and watched CNA-FF and CNA-L complete a transfer after the fact. UM-D did ask R59 if UM-D could bring CNA-FF back to R59's room before allowing CNA-FF to return to R59's room. NHA-A stated that there is no documentation of the event aside from the note that given to Surveyor.The undated word document signed by UM-D documents: CNA came to get writer regarding resident [R59] and a transfer that happened. [R59] stated that CNA-L and CNA-FF were transferring [R59] and pushed on [R59's] leg when the transfer occurred. Writer asked [R59] to show [UM-D] where they pushed on [R59's] leg. [R59] stated [R59] was fine now just during the transfer it hurt. [R59] has chronic discomfort with transfers due to [R59's] cerebral palsy and leg pain in which [R59] is on pain medication for. [R59] stated [R59 has never had issues with [CNA-FF or CNA-L] but the transfer felt different today. Writer asked if [writer] could bring [CNA-FF] in to speak with us. [R59] agreed. [CNA-FF] apologized that [R59] experienced pain with the transfer. [R59] stated that [R59] understood that it was not done purposeful just wants everyone to be very careful when putting [R59] from Hoyer into chair due to the pain. Writer watched a transfer with staff and saw no issues. Staff is aware of not pushing on residents' leg to position [R59] into the chair.On 8/7/25 at 1:08 PM, Surveyor returned to UM-D and asked when UM-D signed the note regarding CNA-FF and R59. UM-D indicated that the transfer occurred on 7/2/25 and that is when the note was signed.On 8/11/25 at 8:53 AM, Surveyor interviewed SW-J who is R59's social worker. Surveyor asked if SW-J received a grievance from R59 on 7/2/25. SW-J stated that there is no grievance for that. Surveyor asked if SW-J had heard from R59 or another staff member that a CNA was rough. SW-J stated that SW-J never heard from any staff about another staff member being rough with R59. Surveyor asked what the protocol is if a resident reports that a staff member was rough. SW-J stated that SW-J would report that to the unit manager.Surveyor noted that SW-J told Surveyor that SW-J would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/7/25 at 10:43 AM, Surveyor interviewed CNA-S. Surveyor asked what CNA-S would do if a resident reported that a different staff member was rough with cares or a transfer. CNA-S stated that CNA-S would report that to a manager right away so they can start investigating.Surveyor noted that CNA-S told Surveyor that CNA-S would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/11/25 at 8:58 AM, Surveyor interviewed DON-B. Surveyor asked what DON-B would expect a staff member to do if a resident reported that a different staff member was rough with cares. DON-B stated that staff should report it to DON-B or NHA-A.On 8/13/25 at 2:50 PM, Surveyor informed NHA-A and DON-B of the concern that on 7/2/25, 3 staff members were informed by R59 that CNA-FF was rough. This allegation of abuse was not reported to the NHA-A per facility policy, was not reported to the state agency and was not reported to one or more law enforcement entities.

Based on interviews and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 (R59) of 2 residents reviewed.R59 informed Surveyor that Certified Nursing Assistant (CNA)-FF was rough when caring for R59. On 7/2/25, R59 informed 3 different facility staff members of the alleged abuse incident. The allegation of abuse was not reported to Nursing Home Administrator (NHA)-A and the facility did not complete a thorough investigation into R59's allegation of abuse.Findings include:The facility policy, with a last reviewed/revised date of 7/1/25, titled Abuse, Neglect and Exploitation documents, in part: It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: Identifying staff responsible for the investigation . Investigating different types of alleged violations, Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect exploitation, and/or mistreatment has occurred, the extent, and cause: and providing complete and thorough documentation of the investigation . The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation-This should include staying with the alleged perpetrator to ensure no further contact (verbal or physical) until removal from the facility/environment . Increased supervision of the alleged victim and residents, Room or staffing changes, if necessary, to protect the resident from the alleged perpetrator .R59 was admitted to the facility on [DATE] with diagnosis that includes Cerebral Palsy.R59's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documents that R59 is cognitively intact. R59 uses a wheelchair and is dependent for transfers.On 8/7/25 at 8:48 AM, Surveyor interviewed R59. R59 informed Surveyor that a few weeks ago, R59's CNA, CNA-L, needed help getting R59 into the wheelchair. CNA-L went to get help from CNA-FF. Both CNA-L and CNA-FF returned to R59's room. R59 stated that during the transfer, CNA-FF was really, really rough. R59 stated that when R59 was put in R59's wheelchair, R59's feet got caught in some plastic on the wheelchair footrests. While CNA-L was trying to gently guide R59's feet, CNA-FF yanked the chair back hard. R59 stated that the yanking did not cause R59's skin to break but stated that the action really hurt. R59 stated that on other occasions, CNA-FF had been very rough with cares and was bossy and intimidating. Surveyor asked if R59 told anyone about what happened. R59 stated that R59 told CNA-L, a nurse and R59's Occupational Therapist (OT)-GG. R59 stated that OT-GG helped R59 fill out a grievance form. R59 stated that after [R59] informed staff about the concern, CNA-FF came back to R59's room and started apologizing. R59 stated that R59 thinks that administration told the staff member of R59's concern and that is why CNA-FF returned to R59's room. R59 stated that R59 felt intimidated.On 8/7/25 at 9:01 AM, Surveyor interviewed CNA-L. Surveyor asked about the incident with CNA-FF. CNA-L stated that R59 is very sore when R59 wakes up in the AM. CNA-L stated that CNA-L works slower with R59 because of that. CNA-L stated that CNA-FF was helping get R59 into R59's wheelchair via the Hoyer lift. CNA-L indicated that CNA-FF yanked R59 from behind and caused R59 to start yelling about R59's feet. CNA-L indicated that CNA-L could not believe how CNA-FF was treating R59. CNA-L stated that CNA-L felt like CNA-FF was rough with R59 and many other residents during cares and transfers. CNA-L stated that other residents had complained about CNA-FF. Surveyor asked what residents complained. CNA-L indicated that CNA-L cannot recall specific names, but the residents are no longer at the facility. Surveyor asked when CNA-L last saw CNA-FF working at the facility. CNA-L stated that CNA-L had not seen CNA-FF in a while and stated, I hope [CNA-FF] doesn't come back for there [the residents] sake. Surveyor asked if CNA-L told anyone about the incident. CNA-L stated that it is a hard position to be in CNA-L was not sure what to do. CNA-L indicated that R59 told the Social Worker.On 8/7/25 at 10:40 AM, Surveyor interviewed OT-GG. Surveyor asked if OT-GG recalled a time that R59 reported a CNA being rough. OT-GG stated that a few weeks ago, R59 reported to OT-GG that CNA-FF was rough during cares and a transfer. OT-GG stated that CNA-FF can be rough. OT-GG stated that R59 told OT-GG that CNA-FF pulled too hard during a transfer and hurt R59. R59 asked OT-GG for help writing a grievance. OT-GG indicated that OT-GG told R59 that they could write it out and contact the Social Worker. Surveyor asked who OT-GG gave the grievance to. OT-GG indicated that OT-GG would normally give it to the Unit Manager (UM) or the Social Worker (SW), but OT-GG is not sure who OT-GG gave the grievance form to. On 8/7/25 at 1:10 PM, Surveyor returned to OT-GG and asked about the grievance form. OT-GG stated that OT-GG thinks that OT-GG helped R59 fill out the grievance form because R59 has such a hard time writing. OT-GG unsure where it ended up. OT-GG stated that OT-GG usually takes copies of everything. OT-GG began looking in office. After looking, OT-GG stated that OT-GG could not find the form and thinks maybe R59 handed it in. OT-GG stated that Surveyor should check with Unit Manager (UM)-D. OT-GG stated that a lot of times, the Unit Mangers will address the concern with the resident and then feel like that concern is complete and maybe that is the case with this, but OT-GG was not sure.On 8/7/25 at 1:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who was the nurse working on R59's unit on 7/2/25 when the allegation of abuse occurred. Surveyor asked if R59 talked to LPN-G about another staff member. LPN-G stated that R59 informed LPN-G that CNA-FF was rough with cares and R59 does not like having CNA-FF as an aide and did not want CNA-FF as R59's aide. Surveyor asked if LPN-G informed anyone about R59's concerns. LPN-G stated that LPN-G told the Unit Manager. Surveyor asked if any documentation was completed after being told that by R59. LPN-G stated that LPN-G was not sure but stated that residents/staff usually have to fill out a grievance or incident report when something like that happens.Surveyor reviewed the grievance log for the last 6 months and noted that there was no grievance logged, or investigation completed about CNA-FF being rough with R59.Surveyor reviewed the Facility Reported Incident folders for the last 6 months and noted that there were no incidents documented, or investigation completed about CNA-FF being rough with R59.Surveyor noted that CNA-L, OT-GG and LPN-G all had concerns about CNA-FF being rough with R59 and this allegation was not thoroughly investigated by the facility.On 8/7/25 at 10:58 AM, Surveyor interviewed UM-D. Surveyor asked if UM-D had received a grievance from R59 or heard about a concern that R59 had about a CNA staff member. UM-D stated that about a month ago, CNA-L and CNA-FF were transferring R59 and R59 was upset with the transfer. UM-D stated that CNA-FF did not push where R59 prefers to be pushed when completing a transfer. UM-D stated that there was not a formal grievance placed. UM-D stated that UM-D took CNA-FF back to R59's room after asking R59's permission. UM-D stated that they all talked, and everything was ok after that. UM-D stated that CNA-FF even took care of R59 after that incident. Surveyor asked if any other residents had concerns about CNA-FF cares. UM-D stated no. UM-D indicated that residents like CNA-FF. Surveyor asked if UM-D received a filled-out grievance form from OT-GG or from R59. UM-D stated that R59 did not want to do a grievance and UM-D did not receive a grievance from OT-GG.On 8/7/25 at 11:20 AM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is if a staff member is told by a resident that another staff member was rough and hurt them. NHA-A stated that they should follow the abuse policy and report it to me. An investigation would follow.On 8/7/25 at 12:22 PM, NHA-A provided Surveyor with a note completed and signed by UM-D regarding the incident. NHA-A stated that the incident occurred about 2 months ago. NHA-A indicated that the incident was not a report of rough with cares or transport but more of a preference that R59 had for transferring. NHA-A indicated that UM-D provided education to CNA-FF and watched CNA-FF and CNA-L complete a transfer after the fact. UM-D did ask R59 if UM-D could bring CNA-FF back to R59's room before allowing CNA-FF to return to R59's room. NHA-A stated that there is no other documentation of the event aside from the note given to Surveyor.The undated word document signed by UM-D documents: CNA came to get writer regarding resident [R59] and a transfer that happened. [R59] stated that CNA-L and CNA-FF were transferring [R59] and pushed on [R59's] leg when the transfer occurred. Writer asked [R59] to show [UM-D] where they pushed on [R59's] leg. [R59] stated [R59] was fine now just during the transfer it hurt. [R59] has chronic discomfort with transfers due to [R59's] cerebral palsy and leg pain in which [R59] is on pain medication for. [R59] stated [R59 has never had issues with [CNA-FF or CNA-L] but the transfer felt different today. Writer asked if [writer] could bring [CNA-FF] in to speak with us. [R59] agreed. [CNA-FF] apologized that [R59] experienced pain with the transfer. [R59] stated that [R59] understood that it was not done purposeful just wants everyone to be very careful when putting [R59] from Hoyer into chair due to the pain. Writer watched a transfer with staff and saw no issues. Staff is aware of not pushing on residents' leg to position [R59] into the chair.On 8/7/25 at 1:08 PM, Surveyor returned to UM-D and asked when UM-D signed the note regarding CNA-FF and R59. UM-D indicated that the transfer occurred on 7/2/25 and that is when the note was signed.Surveyor noted that the above document signed by UM-D is the only documentation provided to Surveyor by the facility about the incident on 7/2/25.On 8/13/25 at 2:50 PM, Surveyor informed NHA-A and DON-B of the following concern: R59 reported to 3 different facility staff that CNA-FF was rough on 7/2/25. The facility did not interview other staff members involved. The facility did not interview other residents in the facility about their cares. The facility did not complete a thorough investigation into the allegation of abuse that R59 told to facility staff on 7/2/25.

Based on record review and interview, the facility did not accurately screen residents for a mental disorder for 2 (R4 and R9) of 2 residents reviewed for Preadmission Screen and Resident Review (PASARR) Level I and requiring a Level II screening.R4 was admitted to the facility with diagnoses of mental disorders and was not evaluated on the PASARR Level I screen as having any mental disorders. The Level II PASARR was never completed due to the inaccurate PASARR Level I screen.R9 was admitted to the facility with diagnoses of mental disorders and was evaluated as having a serious mental disorder on the PASARR Level I screen. R9 did not have a completed Level II PASARR screen when identified as having a positive Level I PASARR screen.Findings include:The facility's policy and procedure entitled, Resident Assessment - Coordination with PASARR Program dated 9/18/24, documents:The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.Explanation and Compliance GuidelinesAll applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.PASARR Level I - initial pre-screening that is completed prior to admissionPositive Level I Screen - necessitates a PASARR Level II evaluation prior to admission.PASARR Level II - comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.R4 was admitted to the facility on [DATE], with diagnoses of bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and activity levels). R4's PASARR Level I screen was completed on 5/21/24, documenting R4 was not suspected of having a serious mental illness or a developmental disability. Surveyor notes, R4 has a diagnosis of bipolar disorder which is a serious mental illness. Surveyor notes, R4's Level I PASARR being completed incorrectly indicating R4 did not have a serious mental illness. Surveyor also notes, R4 does not have a PASARR Level II in the Electronic Medical Record (EMR).R9 was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder (a severe chronic mental health disorder that affects how a person thinks, feels, and behaves) and bipolar disorder. R9's PASARR Level I screen was completed on 3/6/25. Surveyor notes R9 was documented as having a serious mental illness on the PASARR Level I. This document was signed by SW-J. Surveyor notes R9 does not have a PASARR Level II in the EMR.On 8/11/25, at 1:11 PM, Surveyor interviewed SW-J regarding the screening process for PASARR Level I and PASARR Level II. SW-J states she is responsible for completing PASARR's for residents within the facility. Surveyor asked about R4 and R9's PASARRs. SW-J states R9 had a PASARR Level I completed and doesn't understand why it doesn't come back indicating R9 requires a Level II PASARR. SW-J acknowledged R9 having a diagnosis of schizophrenia and stated, not everyone with schizophrenia requires a Level II PASARR. SW-J then stated a diagnosis of bipolar does not always require a Level II PASARR as well. SW-J states R9 would have to be displaying symptoms such as self-harm in order to qualify for a Level II PASARR. Surveyor asked about R4's Level I PASARR and why R4's PASARR Level I indicates R4 does not have a serious mental illness. SW-J stated R4 would have to display symptoms or have a major change in condition. SW-J then stated again, bipolar is not automatic for a Level II PASARR.On 8/11/25, at 3:36 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concerns with R4 and R9 not having PASARR Level II completed when R4's EMR and R9's EMR document them as having a serious mental illness. Surveyor notified NHA-A and DON-B of concerns with R4's Level I PASARR indicating R4 does not have a serious mental illness when having a diagnosis of bipolar disorder. NHA-A and DON-B acknowledged these concerns. Surveyor requested additional information if available.

Based on observation, interview, and a comprehensive record review, the facility did not ensure that a resident with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new injuries from developing for 1 of 3 (R13) residents reviewed for pressure injuries. R13 developed a facility acquired Suspected Deep Tissue Injury (SDTI) on the left heel. Subsequent staging of the pressure injury included staging of the pressure injury as unstageable and a stage 3. While on survey, Surveyor had observations of R13's care plan interventions not implemented, including offloading of R13's heel. Findings include: R13 admitted to the facility on [DATE]. R13's face sheet documents diagnoses that include Paraplegia, Chronic Obstructive Pulmonary Disease, neuromuscular dysfunction of bladder, heart failure, chronic Atrial Fibrillation, pressure ulcer of sacral region stage 4, major depressive disorder, unspecified open wound left foot, colostomy, autonomic dysreflexia, hypertension, and acquired absence of right leg above knee. R13's History and Physical dated 12/25/22 includes diagnoses of Peripheral Vascular Disease, severe protein calorie malnutrition, and osteomyelitis. The facility policy titled Pressure Injury Prevention Guidelines and dated as implemented on 2/14/23 documents: .To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. Preventative Skin Care: 1. Inspect skin while providing care, paying close attention to bony prominences. 3. Avoid positioning the resident on an area of redness whenever possible. Repositioning: 1. Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition. Utilize small shifts in repositioning, if otherwise contraindicated. 2. Routine repositioning schedule: Every 2-3 hours, using both side-lying and back positions. Reposition when in bed and out of bed. Repositioning techniques: a. Avoid positioning the resident on bony prominence's/turning surfaces with existing pressure injuries, including stage 1. f. Ensure that heels are floated off the surface of the bed, using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. g. When in chair, provide adequate seat tile to prevent sliding forward. Ensure the feet are properly supported. Pressure Re-Distribution Devices: 1. Support surfaces do not eliminate the need for turning and repositioning. 2. Pillows and wedges may be utilized to maintain proper positioning. 3. Apply heel suspension devices according to the manufacturer's instructions: a. For prevention, stage 1 or stage 2: Use pillows or heel suspension devices. If using heel protectors, will still need to utilize pillows for floatation. b. For stage 3, 4, unstageable or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury. Check the skin each shift and PRN (as needed) for signs of redness or skin breakdown related to the boot. R13's Annual Minimum Data Set, dated dated dated [DATE] documents: Functional Limitation in Range of Motion: Lower extremity (hip, knee, ankle, foot) - impairment on 1 side. Mobility: Roll left and right - substantial/maximal assistance. Is this resident at risk of developing pressure ulcers? Yes. Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? Yes. Brief Interview for Mental Status score: 15, indicating no cognitive impairment. Rejection of Care - Presence & Frequency: Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Behavior not exhibited. Surveyor was able to view R13's care plan in Point Click Care (PCC) but was unable to view all revisions. The facility provided a printed copy of R13's care plan. Self-care deficit r/t (related to) decreased mobility, generalized weakness - initiated 6/8/21. Interventions include Bed Mobility: Assist of 1. Uses trapeze over bed and enabler bars x 2. Resident has Potential for impaired skin integrity r/t: Altered nutritional status, assist needed with turning and/or repositioning, decreased mobility, dry skin, History of pressure injuries - 10/24/23. Interventions include: Cushion in wheelchair - 2/10/23 Encourage side to side positioning- 12/11/23 Float heels while in bed - 10/24/2023 Assist to reposition side to side approximately q 2-3 hours and prn - 10/24/23 Elevate feet while in wheelchair - 11/7/23 Wheelchair cushion - 10/24/23 Weekly skin assessment - 10/24/23 Resident has Impaired Skin integrity. Pressure Injury Sacrum, Heel, Ischium initiated 6/9/21, revised 5/9/24. Interventions include: Float heels - 6/9/21 Soft boots on in bed - 6/9/21 Specialty air mattress - 6/9/21 (Resolved) encourage to turn and reposition every 2-3 hours - 6/9/21 (Resolved) ensure ROHO cushion is inflated and fill if not - 6/30/21 Resident may be up as he prefers, encourage to lay down after 2 hours - 4/18/22 Ensure proper footwear while up in chair - 8/4/22 Foot buddy to wheelchair - 7/11/23 Heel lift cushion placed between foot board and patient's feet. Foot board extension - 8/29/23 Soft boot Left foot on in bed at all times; float heels - 10/24/23 Shoes/slippers on to left foot when up - 10/24/23 Encourage side to side positioning (resident needs encouragement as resident often refuses)- 1/19/24 R13's June 2023 TAR (Treatment Administration Record) documents: Check skin and edema weekly with shower day Wednesday AM shift. Foot checks every HS (hour of sleep) one time a day - 6/21/23. Surveyor asked for a list of residents with pressure injuries. R13's name was on the list which documented: Sacrum stage IV (4) POA (present on admission), Right ischium FA (facility acquired), Left heel FA. Surveyor review of R13's medical record revealed the following pressure injuries: Sacrum stage 4 POA 6/8/21, Left plantar FA SDTI (suspected deep tissue injury) identified 6/21/23. R13 underwent a transmetatarsal amputation of his toes. R13 subsequently developed a FA Left plantar SDTI identified on 10/24/23, FA Right lateral and right medial gluteal fold stage 4's identified on 11/7/23 and a FA Left heel SDTI identified 1/9/24. On 5/8/24 at 9:40 AM, Surveyor noted R13 was not in his room, the nurse reported he was getting a shower. On 5/8/24 at 10:25 AM, Surveyor observed R13 was back in his room, lying in bed which had an air mattress. Surveyor spoke with R13. R13 reported he gets out of bed for a couple hours a day which is all he is allowed because of a big sore on his butt. R13 reported he has had the pressure sore for at least 3 years, prior to admission to the facility. R13 reported the wound is slowly getting better, the facility is doing a good job, but it takes a long time to heal. Surveyor observed R13 had a right leg amputation. Surveyor observed R13's left heel resting directly on the mattress, not offloaded. Surveyor observed a mepilex dressing on his left heel. Surveyor asked R13 if he wears anything on his foot for protection when in bed. R13 stated, No, but they usually put my leg on a pillow. R13 was observed not wearing a heel suspension boot according to facility policy (for stage 3, 4, unstageable, or deep tissue injury) and his heel was not offloaded according to his care plan. Surveyor noted R13's care plan interventions of a heel lift cushion placed between foot board and patient's feet, soft boot left foot on in bed at all times, and float heels when in bed were not observed as implemented. On 5/9/24 at 9:00 AM, Surveyor observed R13 lying in bed on his back, watching TV. The head of bed was elevated 30 degrees. Surveyor observed R13's left heel wrapped with Kerlix gauze dated 5/9. Surveyor observed R13's left heel resting directly on the mattress, not offloaded. Surveyor asked R13 how he thought his wounds developed. R13 stated, Well, I'm paralyzed from the waist down, so I'm not really able to move much. Surveyor noted grab bars on both sides of the bed and a trapeze. Surveyor asked R13 if he was able to use the trapeze. R13 stated, Yeah, I can grab it to boost myself up a little. Surveyor asked R13 if he can turn and reposition himself with the grab bars. R13 stated, No, I'm not strong enough to turn myself all the way over on my side. Surveyor asked if staff offers to turn and reposition him. R13 stated, No, I don't know why. Surveyor asked R13 if he asks to be turned and repositioned. R13 stated, No, but I probably should. Surveyor asked R13 if he is able to move his leg or lift his leg off the bed. R13 reported he cannot lift his leg off the bed. R13 was observed not wearing a heel suspension boot according to facility policy (for stage 3, 4, unstageable, or deep tissue injury) and his heel was not offloaded according to the care plan. Surveyor noted R13's care plan interventions of a heel lift cushion placed between foot board and patient's feet, soft boot left foot on in bed at all times, and float heels were not observed as implemented. On 5/9/24 at 11:00 AM, Surveyor observed R13 lying in bed on his back watching TV. Surveyor noted the bed was tilted downward on an angle with his head higher than his legs. Surveyor observed R13's left heel resting directly on the mattress, not offloaded. Surveyor observed several dried dark stains on the sheet in the area where R13's left heel would rest, indicating the heel was previously resting on the mattress. R13 was not wearing a heel suspension boot according to facility policy (for stage 3, 4, unstageable, or deep tissue injury) and his heel was not offloaded according to his care plan. Surveyor noted R13's care plan interventions of a heel lift cushion placed between foot board and patient's feet, soft boot left foot on in bed at all times, and float heels were not observed as implemented. On 5/9/24 at 12:54 PM, Surveyor observed R13 sitting up in his wheelchair watching TV. R13 was wearing a gripper sock on his left foot. Surveyor noted a blue pad covering R13's wheelchair footrests. R13's heel was resting directly on the blue pad. There was no pillow under his leg and his heel was not offloaded. R13's care plan intervention to elevate feet while in wheelchair was not observed as implemented. On 5/13/24 at 9:14 AM, Surveyor observed R13 lying in bed on his back with the head of bed elevated, watching TV. Surveyor observed R13's left heel offloaded on a pillow. Surveyor observed a Mepilex dressing peeling halfway off the heel. Surveyor observed dark drainage on the dressing which was dated 5/12. Surveyor noted dried dark stains on the sheet in area where R13's heel previously rested, indicating the heel had previously been resting directed on the mattress. Review of R13's medical record documented: The facility's initial wound assessment dated [DATE] documents: Left lateral foot pressure 2.5 x 2.6 x 0.2 cm (centimeters) unstageable. 100% eschar. Resident exhibits two or more conditions that increase the likelihood of the development of an unavoidable wound? NO. R13's pressure injuries to be followed by Wound Doctor-I. The left foot plantar pressure injury subsequently healed. Surveyor was advised Wound Doctor-I stopped working for the facility in December 2023, and wounds were then followed by Director of Nursing (DON)-B. On 5/14/24 at 11:01 AM, Surveyor met with RN (Registered Nurse) Consultant-C. She reported having spent the whole weekend reviewing R13's medical record which revealed R13 admitted in 2021 with a right gluteal fold stage 3 pressure injury and vascular wound left lateral foot. IV (intravenous) antibiotics were ordered for osteomyelitis of the left foot and ankle. The gluteal fold did progress to a stage 4 and did eventually heal. In August 2021, the left gluteal opened related to wound vac tape, and eventually healed. Surveyor reviewed Wound Doctor-I's documentation regarding R13's current gluteal pressure injuries. Surveyor asked why the wounds were staged as stage 4. RN Consultant-C reported Wound Doctor-I had been following R13 for years, at another facility prior to admission. Wound Doctor-I advised once a wound is staged, like a stage 4, if it heals and re-opens at any time, it is then still staged at a stage 4. DON-B (present in room) stated, I guess I can understand that logic, but his assessment and documentation indicates stage 3, but that's why he classified it as stage 4. The facility's weekly skin assessment dated [DATE] documents: Sacrum, right thigh (rear,) Left heel - tx (treatment) continues. Surveyor noted there was no documentation of an assessment or measurements of a left heel wound and no treatment implemented on 1/3/24. The left heel SDTI was not documented as identified until 1/9/24. On 1/9/24, R13 developed a Facility Acquired SDTI on his left heel. The initial wound assessment documents: Left heel pressure 2.0 x 2.0 x 0 cm. Suspected Deep Tissue Injury. Area has 2 small discolored areas inside of it. Resident exhibits two or more conditions that increase the likelihood of the development of an unavoidable wound? Yes. Resident exhibits the following conditions (check all that apply) - Diabetes, Severe PVD. Surveyor reviewed R13's medical record, including the face sheet, hospital discharge summary, and History and Physical. Surveyor located no diagnosis of Diabetes in R13's medical record. R13's prior assessment of the left lateral foot pressure injury dated 6/21/23 of resident exhibits two or more conditions that increase the likelihood of the development of an unavoidable wound documented No. Subsequent documentation and weekly measurements of the left heel: 1/16/24 3 x 2 x UTD (unable to determine) SDTI 1/23/24 2.8 x 2.0 x 0 SDTI 1/30/24 2 x 2 x 0 SDTI. Area has become 1 area but is not open 2/6/24 3.8 x 2 x UTD unstageable. DTI reabsorbed 2/13/24 2.5 x 1.5 unstageable. 100% eschar. 2/20/24 2 x 1 x 0 SDTI 100% eschar 2/27/24 4 x 1 unstageable 100% eschar 3/5/24 4 x 1 SDTI 100% eschar 3/12/24 2 x 2.2 unstageable, 100% eschar 3/19/24 2 x 1.5 SDTI 100% slough 3/26/24 2 x 1 SDTI 100% slough 4/2/24 1.8 x 1.8 unstageable 100% slough 4/9/24 1.5 x 1.8 unstageable 100% eschar 4/16/24 2 x 3 unstageable 100% slough 4/23/24 3 x 3.5 unstageable - no percentages documented 4/30/24 4 x 2.5 stage 3 75% granulation, 25% slough 5/7/24 2.4 x 3.5 unstageable 75% granulation, 25% slough Surveyor noted inconsistent and/or inaccurate documentation of staging and wound characteristics. Documentation varies from week to week, indicating SDTI 100% eschar, then unstageable 100% eschar, then SDTI 100% slough. A SDTI would not include slough. When the wound progressed to stage 3 with 75% granulation and 25% slough, which indicates only 25% of the wound is obscured with slough, no depth is measured or documented. On 5/14/24 at 9:10 AM, Surveyor spoke with RN (Registered Nurse)/MDS (Minimum Data Set) Coordinator-D who reported she was the prior DON (Director of Nursing.) Surveyor advised of observations of R13's heels not offloaded while on survey. RN/MDS Coordinator-D rolled her eyes and stated OK, that's a problem. On 5/14/24 at 10:41 AM, Surveyor observed R13's wound care with Assistant Director of Nursing (ADON)-J. Surveyor noted several dark stains on R13's sheet in area where his heel would rest, indicating the heel was previously resting directly on the mattress. Surveyor noted no wound or discoloration to the left foot plantar area. R13's left heel revealed a stage 3 pressure injury approximate size of a half dollar. The center of the wound was necrotic surrounded by a rim of slough, surrounded by maceration. R13's entire heel was reddened. There was no active drainage or odor noted. On 5/14/24 at 11:30 AM, Surveyor advised DON-B of the concern that R13 admitted to the facility with pressure injuries and a long history of wounds, including RLE amputation. Weekly skin checks were implemented, however, although R13 had current pressure injuries and was at increased risk, daily foot checks were not implemented until after R13 developed a facility acquired pressure injury on his foot. Surveyor advised of multiple observations R13's care plan interventions, including offloading of heels, which were observed to not be implemented while on survey. On 5/14/24, during the daily exit meeting with the facility, DON-B voiced she did not agree with recommended citation for R13's heel pressure injury. DON-B reported the reason the heel wound was staged as stage 3 is because it was an SDTI and, there is no way to know how deep it would be, it could go as deep as the bone, therefore stage 3 would actually indicate healing. Surveyor advised DON-B Surveyor would be happy to review any additional information the facility chooses to provide. RN Consultant-C then reported the facility has evidence from the doctor that the pressure injury was unavoidable. This was the first time the facility alleged the pressure injury was unavoidable. Surveyor had asked previously if there was any documentation as such, and was not provided any information. Surveyor reminded the facility of multiple observations on survey of care plan interventions not implemented and R13's heel not offloaded. After Surveyors left the facility, the facility provided a form titled Community Acquired Pressure Injury Investigation Form. The form did not document anything about R13's FA left heel pressure injury or that it was specific to said pressure injury. At the bottom of the form was a typed statement with a check mark: Based on this review, it is unavoidable. Unavoidable, per NPUAP means that the individual developed a pressure injury even though the community had evaluated the individual's clinical condition and pressure risk factors, defined and implemented interventions that are consistent with the individual's needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions and revised the approach as appropriate. If unavoidable, has the physician documented this? (Check mark next to yes). Surveyor noted the form was dated 2/23/24 and signed by a physician (not Wound Doctor-I.) Surveyor located no evidence or other documentation by a physician that indicated the pressure injury was unavoidable.

This is an uncorrected deficiency from Survey Event: VLJH11 Based on interview and record review the facility did not ensure 4 (R2, R4, R5, & R32) of 4 residents received necessary behavioral health care to attain their highest practicable mental health well-being. * R2 is a long-term resident with a history of substance abuse, behavioral and mental health concerns. R2 had an extensive history of taking Clonazepam multiple times daily to address an anxiety disorder. In May of 2023, the facility became aware of treatment concerns in the relationship between R2 and the psychiatric Nurse Practitioner who had been addressing his anxiety disorder and prescribing his Clonazepam. The facility did not work with R2 or address the discontinuation of services with R2's prescriber and facilitate a solution to address R2's behavioral and mental health needs. The facility continued to seek out the Psychiatric Nurse Practitioner, despite knowing services had been ended, and asking for extensions of the prescription. On 09/01/2023 R2 received his last prescribed dose of 1 mg of Clonazepam in the morning. R2's previous history of orders for this medication was to receive Clonazepam 1 mg TID (three times daily). Clonazepam is a medication that cannot be discontinued abruptly. Shortly after receiving this last dose on 09/01/2023, R2 started demonstrating withdrawal symptoms from not receiving the medication. R2 was noted during a hospitalization , for a different issue, to be experiencing withdrawal from the medication. Facility staff noted and documented R2 was experiencing withdrawal and was actively asking for the medication due to anxiety. The facility also documented awareness of R2 seeking out drugs to self-medicate. There was no active facilitation and coordination of care and addressing R2's behavioral and mental health care needs during this time. R2 turned to illicit drugs including methamphetamine and was found to be in possession of other illicit drugs including fentanyl. On multiple dates R2 was found to be hallucinating and engaging in other behaviors that were not typical for R2. R2 was found to be experiencing an overdose requiring 911 transport, admission to the intensive care unit (ICU) and intubation. When R2 returned to the facility, hedid not have the services of a behavioral/mental health professional or services from a qualified individual to address R2's substance abuse issues. The facility failure to ensure R2 received the appropriate behavioral health services to allow R2 to reach his highest practicable well being created a finding of immediate jeopardy that began on 9/1/23. Surveyor notified NHA (Nursing Home Administrator)-A, Assistant Administrator-L, Interim DON (Director of Nursing)-B, and RN (Registered Nurse) Consultant-H of the immediate jeopardy on 11/2/23 at 4:47 p.m. As of the facility exit on 11/2/23, the immediate jeopardy was not removed. The survey also identified noncompliance at a severity level of E (potential for more than minimal harm that is not immediate jeopardy/pattern), as evidenced by the following: * R4's behavior contract and care plan have not been updated to reflect person-centered interventions with specific behaviors. The trauma and substance abuse assessments have been completed, but interpreting the results and implementing a person-centered care plan with interventions has not been completed by the facility. R4's physician orders have not been updated to reflect medications should be held with suspected use of alcohol. * R5's behavior contract and care plan have not been updated to reflect person-centered interventions with specific behaviors. The trauma and substance abuse assessments have been completed, but interpreting the results and implementing a person-centered care plan with interventions has not been completed by the facility. R5's physician orders have not been updated to reflect medications should be held with suspected alcohol use. * R32 has a long history of alcohol abuse, remains at high risk and the care plan has not been updated to reflect person-centered interventions. The trauma and substance abuse assessments have been completed, but interpreting the results and implementing a person-centered care plan with interventions has not been completed by the facility. An Intimacy and Relationship evaluation had not been completed on a quarterly basis or with the 10/2/23 incident. Findings include: The Behavioral Health Services policy with a date implemented of 09/06/2023 under policy documents It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. Under definitions documents Substance Use Disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Under Policy Explanation and Compliance Guidelines documents 1. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders. 2. The facility will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUDs) and those with a history of trauma and/or post-traumatic stress disorder (PTSD), as reflected in the facility assessment. 3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. 4. The facility will ensure that a resident who, upon admission was not assessed or diagnosed with a mental or psychosocial adjustment difficulty or documented history of trauma and/or PTSD does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors while residing in the facility. 7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will: b. Obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health. c. Monitor the resident closely for expressions or indications of distress. d. Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable. f. Assess and develop a person-centered care plan for concerns identified in the resident's assessment. g. Share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis. h. Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record. i. Ensure appropriate follow-up assessment, if needed. j. Discuss potential modifications to the care plan. k. Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident. 8. The resident, and as appropriate the resident's family, are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall: a. Have interventions that are person-centered, evidenced-based, culturally competent, trauma-informed and in accordance with professional standards of practice. b. Provide for meaningful activities which promote engagement and positive, meaningful relationships. Residents living with mental health and SUDs may require different activities than other nursing home residents. The facility will ensure that activities are provided to meet the needs of these residents. c. Reflect the resident's goals of care. d. Account for the resident's experiences and preferences. e. Maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety. f. Use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated. g. Address any other individualized needs the resident may have related to the mental disorder or the SUD. h. Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. 9. If a behavioral contact is used, it will only be used with residents who have the capacity to understand it. A contract will only be used as a method of encouraging the resident to follow their plan of care, and not as system of reward and punishment. The contract will not conflict with resident rights or other requirement of participation. The Safety for Residents with Substance Use Disorder policy not dated documents It is the policy of this facility to create an environment as free of accident hazards as possible for residents with a history of substance use disorder. Under Policy Explanation and Compliance Guidelines documents, 1. Residents with a history of SUD will be assessed for risk including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 2. When substance use is suspected, (in the facility or upon return from an absence from the facility) which could lead to overdose, facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner. 3. Care plan interventions will address risk by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety. 6. Residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to: a. Frequent leaves of absence with or without facility knowledge b. Odors c. New needle marks. d. Changes in resident behaviors, especially after interaction with visitors or absences from facility: i. Unexplained drowsiness ii. Slurred speech iii. Lack of coordination iv. Mood changes 7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision. The Facility Assessment Tool updated 10/16/23 documents the Facility is licensed for 123 beds with an average census of 80-90. Common diagnosis includes substance use disorder. The average number of residents with active or current substance use disorders is 15. Under Other section 1.7 for describe other pertinent facts or descriptions of the resident population that must be taken into account when determining staff and resource needs (e.g. resident's preferences with regard to daily schedules, waking, bathing, activities, naps, food, going to bed, behaviors, etc.) documents Facility has residents with current/history of Substance Abuse Disorder. Social Services has attended specialized education to support Substance Use Disorders. The facility staff has been trained on and has resources and processes in place to care for residents with current Substance Use Disorders with risk for overdose. Under section 2.1 mental health and behavior for specific care or practices documents Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, substance abuse disorder, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities, substance abuse and ETOH (alcohol) abuse, Alcohol Anonymous weekly meetings held at [NAME] Health and Rehabilitation, access to virtual Narcotics Anonymous meetings, a list of all resources are attached to this document. Part 3 Facility resources needed to provide competent support and care for our resident population every day and during emergencies section 3.1 includes Behavioral and mental health providers, AODA (alcohol and other drug abuse) services, SAMHSA (substance abuse and mental health services administration), AA/NA (alcoholics anonymous/narcotics anonymous). Section 3.2 staffing plan documents 2 social service & 3 activities staff for other staff needed for behavioral healthcare and services. 1.) R2 was originally admitted to the facility on [DATE] with a readmitted [DATE]. Diagnoses includes paraplegia, anxiety disorder, other psychoactive substance abuse, depressive disorder, diabetes mellitus and hypertension. R2 is [AGE] years old, does not have an activated power of attorney for healthcare and has been receiving Clonazepam in the facility since admission in 2020. R2 verbally reports many years of receiving Clonazepam for anxiety even prior to admission. The history of substance abuse/chemical dependency related to drug addition, erratic behaviors, hallucinations, diaphoretic care plan created 2/5/20 and initiated & revised on 10/19/23 documents the following interventions: * If you suspect resident has been using non-prescription substances, notify supervisor immediately. Created 2/5/20 and initiated & revised 10/19/23. * Provide leisure counseling to resident to help him/her use free time in productive ways. Created 2/5/20 and initiated & revised 10/19/23. * Psych consult. Created 6/18/23 and initiated & revised 10/19/23. * 6/7/22 Orders received to obtain Ethyl Glucuronide Urine test-Urine positive. NP (nurse practitioner) aware NOR (new order received). Created & initiated 6/7/22. This intervention was resolved on 12/22/22. * 9/25/23 lab work ordered (CBC (complete blood count) and drug screen) (+) (positive) for barbiturates. Created 9/26/23 & initiated 10/19/23. This intervention was canceled on 10/19/23. * 9/26/23 15-minute checks placed d/t (due to) hallucinations + (blood sample barbiturates). Created 9/26/23 & initiated 10/19/23. This intervention was canceled on 10/19/23. * 10/5/23 UA (urinalysis) collected 10/6/23 (+) amphetamines/opiates. Created 10/9/23 and initiated 10/19/23. This intervention was canceled on 10/19/23. * 911 called due to hallucinations refused to go to ER (emergency room ). Created 10/9/23 & initiated 10/19/23. This intervention was canceled on 10/19/23. The history of substance use disorder r/t use of/addiction to prescription drugs. My drug(s) of choice is/was: pain medications created 5/3/23 and initiated & revised 10/19/23 documents the following interventions: * Assist me in attending support groups with others who also have substance use disorder. Created 5/3/23 and initiated & revised 10/19/23. * Account for any traumas in my past that may influence my substance use and help me avoid triggers. Created 5/3/23 and initiated & revised 10/19/23. * Encourage and allow me to openly express my feelings and to express fears and worries. Created 5/3/23 and initiated & revised 10/19/23. * Report any changes in my mood status to my physician. Created 5/3/23 and initiated & revised 10/19/23. * Report any suspected use of substances to my physician. Created 5/3/23 and initiated & revised 10/19/23. * Educate resident on ways to utilize coping skills to deal with feelings of desire for my preferred substance of choice. Created 5/3/23 and initiated & revised 10/19/23. * Resident can attend in house AA (alcoholics anonymous) meeting as desired. Created 8/11/23 and initiated 10/19/23 and revised 10/31/23. * 9/26/23 15-minute checks started d/t (due to) substance monitoring. Created 10/9/23 and initiated 10/19/23. This intervention was canceled on 10/19/23. * Behavioral contract in place r/t hx (history) of SUD (pain medications). Created, initiated & revised on 10/31/23. * Contact emergency services immediately if I exhibit any signs of overdose and administer opioid reversal agents as indicated. Created & initiated 10/31/23. * Educate me on the risk of leaving the facility to seek out substances and/or early unplanned discharge. Created & initiated 10/31/23. * Encourage frequent contact with my family and friends that are supportive of my recovery and do not encourage substance use, as desired by me. Created & initiated 10/31/23. * Encourage my family to be an active part in my care plan and discharge planning process so that I have an active support system in the community as desired by me. Created & initiated 10/31/23. * Provide homelike environment, when possible, use familiar objects from home or objects with sentimental value, family pictures, etc. Created & initiated 10/31/23. * Provide regular opportunities for: physical activity, daily decision making, socialization, leisure activities consistent with my interests. Created & initiated 10/31/23. * Support my strengths and provide me with positive affirmations. Created & initiated 10/31/23. * Upon discharge, provide appropriate referrals and discharge instructions. Created & initiated 10/31/23. R2's initial consult with Psychologist-M was on 1/11/23 with the next consultation on 1/26/23. On 3/2/23 Psychologist-M's note documents: Patient was seen for session, chart reviewed, and status discussed with staff who report the medication list in the chart is accurate He was alert and oriented to self, place, and time. He appears to be more irritable and indicated he wanted his anxiety medication increased and was not interested in counseling unless his meds would be increased. Attempted to discuss with him but he was not amenable and declined further psychology services. Will recommence if patient reconsiders. Surveyor noted Psychologist-M did not provide services to R2 after 3/2/23. R2 did not receive psychological services after 3/2/23. Psych Nurse Practitioner (NP)-N's note dated 5/1/23 under narrative documents: Staff report pt (patient) willing to be seen by psych practitioner again after patient recently terminated psych services. Pt stated, I need you to prescribe my Clonazepam until I can find another provider. Pt became upset when this practitioner stated she would provide only a one-month supply which will allow him time to secure another provider. Under treatment recommendations no change is checked with documentation of no change, pt reports he is looking for another provider for psychiatric medications, will cover one month supply Clonazepam to allow pt time to secure new provider. For follow up appointment it is documented PRN (as needed). Also checked is due to history of past failed GDR (gradual dose reduction) on going baseline sx (symptoms) reduction of psych meds is clinically contraindicated. R2 did not receive psych services after 5/1/23. The quarterly MDS (Minimum Data Set) with an assessment reference date of 7/25/23 has a BIMS (brief interview mental status) score of 15, which indicates R2 is cognitively intact. Under psychosis R2 is checked for having hallucinations and delusions. No behavioral symptoms are checked. R2 is independent for bed mobility, transfer, ambulation, eating & toilet use. R2 is continent of urine and bowel. Surveyor reviewed R2's July eMAR (electronic medication administration record) and noted a start date of 10/9/22 for Clonazepam tablet 0.5 mg (milligrams) Give 0.5 mg by mouth three times a day for anxiety. R2's Clonazepam was discontinued on 7/24/23. The nurses note dated 7/24/23 documents: Resident Clonazepam has been d/c (discontinued) by NP. Resident was to have appointment with outside provider that he missed. Resident no longer wanted to see psych NP [Name] at facility. [Psych NP first name] covered his medication until the 18th when he was supposed to see his new doctor. NP [Name] will no longer prescribe the Clonazepam. This was explained to the resident, and he stated that he understands. Resident is in process of making another appointment for MD outside of facility. The physician order dated 7/27/23 documents Referral to [Name] psychiatric [Hospital name] for anxiety disorder and major depressive disorder. On 11/1/23 at 12:58 p.m. Surveyor asked SW (Social Worker)-D if R2 was seen by psychiatrist at [Hospital name] which was ordered on 7/27/23. SW-D informed Surveyor R2 did not see the psychiatrist as NP-O is an independent practitioner and they wouldn't take the referral; they only take referrals from their hospital. R2 did not receive Clonazepam 0.5 three times a day from 7/24/23 until 8/1/23. The nurses note dated 8/1/23 documents: Writer spoke to NP [Name] regarding resident Clonazepam. Resident is not able to get into the new psych MD until September. Resident will be restarted on Clonazepam and the script will be filled for 60 days until resident sees his new psych NP. Resident is his own person and declines family update. On 8/10/23 a substance abuse assessment was completed for R2. This assessment does not indicate who in the Facility completed this assessment and has the assessor answer yes/no for family history of substance abuse for alcohol, illegal drugs, & Rx (prescription) drugs. 1 is circled indicating yes for alcohol, all other categories are no. For personal history of substance abuse 0 indicating no is circled for alcohol, illegal drugs, Rx, and age between 16-45. Under psychological disease 1 indicating yes is circled for depression. Scoring total is not documented. On 11/1/23 at 12:27 p.m. Surveyors met with SSD (Social Service Director)-C and SW (Social Worker)-D. Surveyor asked who completed the 8/10/23 substance abuse assessment for R2. SW-D informed Surveyor they don't know who completed it and that department heads completed the assessments. Surveyor asked what the intent of this assessment was. SW-D replied she thinks it was paper compliance. Surveyor asked about R2's assessment indicating no for illegal drugs. SW-D informed Surveyor that may be what R2 said but can't answer for that because she doesn't know who did it. The nurses note dated 8/14/23 at 3:10 a.m. documents: Writer and another staff member entered resident's room at 0310 (3:10 a.m.) to administer resident's scheduled medications, resident (R2) noted to be lying on the bed with legs slightly over the edge of the bed, resident was shaking, having involuntary muscle movements, crying and anxious, writer asked resident what is wrong and resident stated he was scared, he also stated he feels like someone is touching him all over but no one is there, resident also stated that if staff keeps seeing him like this he will end up in the loony bin, writer asked staff member to stay with resident while I went to get my units and obtain residents vital signs, when I returned I obtained residents VS (vital signs) and all were WNL (within normal limits) except for an elevated HR (heart rate) of 102, writer again asked resident if he consumed any substances, resident denies any substance use, this time resident did not become agitated with writer, writer asked resident if he would like to go to the ER for evaluation by MD, resident is responsible for self and refused to go to the ER, writer notified resident that I would call the MD and update on residents change in condition, writer called MD and left message, writer also called NP [Name] and left message as no one answered the calls, writer notified RN (Registered Nurse) on staff and updated her on residents condition, staff RN came to assess resident and attempted to get resident to agree to go to the ER for evaluation, resident continues to decline going to the ER, resident again stated he was scared to the RN staff member, RN asked what he was scared of and resident stated he can't say, RN asked if he was scared of anyone in the building and resident stated no and that we wouldn't understand, resident again stated he was scared of going to the loony bin, resident states he won't tell us what he is scared of but it's not anyone in the building or of himself being in the building, writer updated DON (Director of Nursing) [Name] and ADON (Assistant Director of Nursing) [Name] on residents current condition and notified them that writer placed resident on 15 minute monitoring until NP[Name] or MD returns my call, writer monitoring resident closely. The nurses note dated 8/14/23 at 10:38 p.m. documents: Resident confused this shift. Writer knocked on resident door to give resident his 5pm meds. I went to open the door and resident closed the door on me. He then told me I could come in. Upon entering resident was diaphoretic. Writer asked resident what's wrong and resident was very confused with answering. Resident stated he could not explain what was wrong. Resident was very agitated and anxious. Writer made it very clear I was concerned about him, and I could not leave him in the state he was in. He was talking about a conversation with a police officer that never took place today. Resident stated that staff was bothering him by constantly coming in his room. I writer informed NP [Name] of the situation. NP ordered labs and stated to try to encourage resident to go get labs drawn. Writer let resident know that I did not feel comfortable giving him any more medication without him getting checked out. Resident stated himself that something was wrong, but he did not know how to explain what the issue was. Resident agree (sic) to go to ER (emergency room ) after dinner while waiting for him to have dinner writer was told resident was on the floor. Writer called 911. Resident was clearly having some altered mental status and weakness. When EMS (emergency medical services) arrived, resident was competent enough to not have to go to ER. Resident refused neuros done r/t fall. DON (Director of Nursing) aware. Writer held HS (hour sleep) meds. Resident has not called for any staff assistance. Writer went in to check resident before end of shift and resident was laying vertically on the edge of bed. Writer and another nurse attempted to place resident in bed correctly and he was hollering from pain. He was in the room talking to himself upon entering. Staff asked resident if we could assist him of any kind, he denied our assistance. Resident still declining for staff to check vitals. NP-O's note dated 8/15/23 under HPI (history present illness) documents [AGE] year-old male seen today for reports from nursing of bizarre behaviors from patient x (times) 2 days. ER (emergency room ) offered for altered mental status, patient refused. Nursing staff reports periods of yelling, crying, confusion, standing on his bed, and crawling on the floor. Patient reports recall of events as poor but denies any illicit drug use. Patient is stable in no acute distress. Under assessment/plan includes documentation of 2. history of substance abuse, urine drug screen ordered, monitor behaviors and symptoms of impairment, hold medications if altered. The nurses note dated 8/16/23 at 4:00 a.m. documents: Resident A&Ox4 (alert and orientated times four), VSS (vital signs stable), writer attempted to collect urine for UA (urinalysis) order, resident refused. Surveyor noted the following eMAR (electronic medication administration record) notes for Clonazepam oral tablet 0.5 mg (milligram) Give 1 tablet by mouth three times a day for anxiety: 9/1/23 at 1:13 p.m. documents do not have, reported to nurse manager, nurse manager stated that the unit manager would be taking care of this. 9/2/23 at 3:30 a.m. documents needs to be reordered none in cart. 9/2/23 at 1:07 p.m. documents on order. 9/3/23 at 2:23 a.m. documents none in cart. 9/4/23 at 1:04 p.m. documents on order. 9/4/23 at 2:36 a.m. documents none in the cart. 9/5/23 at 1:35 a.m. documents not available on order. Called pharmacy and they stated they put note out to [Psych NP (nurse practitioner) name] for approval to fill script. Will update am (morning) shift to reach out. 9/5/23 at 1:39 a.m. documents on order. 9/5/23 at 8:08 p.m. documents on order awaiting new rx (prescription). 9/6/23 at 2:42 a.m. documents none in the cart. 9/6/23 at 1:00 p.m. documents on order. 9/6/23 at 8:01 p.m. documents on order. 9/7/23 at 1:57 a.m. documents none available. 9/7/23 at 1:11 p.m. documents Medication is on order. 9/7/23 at 7:14 p.m. documents on order. 9/8/23 at 1:09 p.m. documents Drug not available. 9/8/23 at 8:25 p.m. documents on order. 9/9/23 at 8:00 p.m. documents on order. 9/10/23 at 1:27 p.m. documents on order. 9/10/23 at 8:08 p.m. documents on order. 9/11/23 at 1:50 a.m. documents not available on order. 9/11/23 at 2:31 p.m. documents requested script from psych NP. 9/12/23 at 2:15 a.m. documents on reorder. 9/12/23 at 1:08 p.m. documents not available. The substance abuse risk evaluation dated 9/8/23 documents R2 is at high risk. On 11/1/23 at 12:29 a.m. Surveyor informed SSD-C R2's substance abuse assessment dated [DATE] indicates he is at high risk. Surveyor inquired if a Resident is considered at high risk for substance abuse what occurs. SSD-C replied we care plan. Surveyor inquired if there is already a care plan, is the care plan updated. SSD-C informed Surveyor R2's care plan should have been updated. Surveyor informed SSD-C R2's care plan was not updated after the substance abuse assessment was completed. SSD-C informed Surveyor if there was already a care plan in there, she would have left it the same. The nurses note dated 9/12/23 documents: NP ordered for residents Clonazepam to be discontinued. Resident fired psych NP and is still pending to see new provider. [Name] NP agreed with decision of psych NP to discontinue Clonazepam until resident sees his new provider. Resident is his own person and declines family update. Surveyor reviewed September 2023 MAR (Medication Administration Record) and noted Clonazepam 0.5 mg is initialed as being administered on 9/1/23 at 0200 (2:00 a.m.) & 2000 (8:00 p.m.), 9/2/23 & 9/3/23 at 2000, 9/9/23 at 1400 (2:00 p.m.), 9/10/23 at 0200 (2:00 a.m.), and 9/11/23 at 2000 (8:00 p.m.) On 11/2/23 at 8:37 a.m. Surveyor informed Interim DON-B Surveyor had reviewed R2's September 2023 MAR for Clonazepam and noted there are times from 9/1/23 to 9/12/23 when the MAR was initialed as the medication being administered. Surveyor inquired if Clonazepam is in contingency. Interim DON-B informed Surveyor it is, but they would have to call pharmacy & get a code, but pharmacy would only give the code if they had a script. Interim DON-B informed Surveyor she didn't believe during this time they had a script and would check. Interim DON-B later informed Surveyor the [TRUNCATED]

Based on interview and record review, the Facility failed to utilize the services of the Facility's Medical Director to ensure 1 (R2) of 1 Residents received the appropriate behavioral health services, including ensuring R2 received medications and health services as assessed. R2 had been receiving Clonazepam since being admitted in 2020. In May of 2023, the facility became aware that the psychiatric nurse practitioner (psych NP) that was seeing R2 and actively prescribing R2's antianxiety medication would no longer see R2. The psych nurse practitioner did not help refer R2 to an alternate provider and the psychiatrist supervising the psych nurse practitioner did not step in to assess R2 or help refer R2 to an alternate provider. The facility's medical director did not communicate with the behavioral practitioners to facilitate services for R2. On 7/24/23 R2's Clonazepam was discontinued. The Facility did not utilize the services of the medical director to ensure R2 had a qualified mental health practitioner to continue to see R2 to address R2's behavioral/mental healthcare needs including coordination of prescribing medications (Clonazepam). This medication was not reordered until 8 days later. On 9/1/23 R2's Clonazepam ran out with the last dose being received at 2:00 a.m. and then was discontinued on 9/12/23. R2's previous history of orders for this medication was to receive Clonazepam 1 mg three times daily. Clonazepam is a medication that cannot be abruptly discontinued. Shortly after receiving this last dose, R2 started demonstrating withdrawal symptoms from not receiving the medication. Facility staff noted and documented R2 was experiencing withdrawal and was actively asking for medications due to anxiety. There was no active facilitation and coordination of care and addressing R2's behavioral and mental health care needs during this time by the medical director. R2 turned to illicit drugs to self-medicate including methamphetamine and was found to be in possession of other illicit drugs including fentanyl. On multiple dates R2 was found to be hallucinating and engaging in other behaviors not typical for R2. On 10/11/23 R2 was found to be experiencing an overdose requiring 911 transport, admission to the intensive care unit and intubation. R2 returned to the facility and still does not have the services of a behavioral/mental health professional or services from a qualified individual to address R2's substance abuse issues. The failure of the facility to utilize the medical director to coordinate medical care when R2's Clonazepam was abruptly stopped & did not intervene with other medical practitioners to facilitate R2's medical care created a finding of immediate jeopardy that began on 7/24/23. Surveyor notified NHA (Nursing Home Administrator)-A, Assistant Administrator-L, Interim DON (Director of Nursing)-B, and RN (Registered Nurse) Consultant-H of the immediate jeopardy on 11/2/23 at 4:47 p.m. The immediate jeopardy was not removed at the time of the facility exit. Findings include: The Duties and Responsibilities of the Medical Director signed on 5/20/22 under Duties and Responsibilities: The Essential Functions documents 1. Provide medical direction and support to the Managers and Governing Body. 1.1 Participate in meetings with the administration and/or professional staff to discuss and resolve clinical or administrative issues and specific resident care concerns. 2. Provide on-going guidance in developing, establishing, and implementing polices and procedures to enhance and promote the quality of life and care for residents. This involves collaborating with the facility regarding the policies and protocols that guide clinical decision making to help assure that they address the needs of the residents. 2.1 Examples of resident care policies include, but are not limited to: 2.1.1 Admission policies and care practices that address the types of residents that may be admitted and retained based upon the ability of the facility to provide the services and care to meet their needs. 2.1.7 Mechanisms for communicating and resolving issues related to medical care; 3. Coordinate medical care and treatment through the facility's quality assessment and assurance committee and quality assurance program. This includes, but is not limited to, assisting the facility: 3.4 Address and resolve concerns and issues between the physicians, health care practitioners and facility staff. R2 was originally admitted to the facility on [DATE] with a readmitted [DATE]. Diagnoses includes paraplegia, anxiety disorder, other psychoactive substance abuse, depressive disorder, diabetes mellitus and hypertension. Psych NP-N note dated 5/1/23 under narrative documents Staff report pt (patient) willing to be seen by psych practitioner again after patient recently terminated psych services. Pt stated, I need you to prescribe my Clonazepam until I can find another provider. Pt became upset when this practitioner stated she would provide only a one month supply which will allow him time to secure another provider. Under treatment recommendations no change is checked with documentation of no change, pt reports he is looking for another provider for psychiatric medications, will cover one month supply Clonazepam to allow pt time to secure new provider. For follow up appointment documents PRN (as needed). Also checked is due to history of past failed GDR (gradual dose reduction) on going baseline sx (symptoms) reduction of psych meds is clinically contraindicated. R2 did not receive psych services after 5/1/23. Psych NP-N did not help refer R2 to an alternate provider and the Psychiatrist supervising Psych NP-N did not step in to assess R2 or help refer to another provider. The Facility did not utilize the medical director to ensure R2 had a qualified mental health practitioner to continue to see R2 to address R2's behavioral & mental healthcare needs. Surveyor reviewed R2's July eMAR (electronic medication administration record) and noted a start date of 10/9/22 for Clonazepam tablet 0.5 mg (milligrams) Give 0.5 mg by mouth three times a day for anxiety. R2's Clonazepam was discontinued on 7/24/23. The nurses note dated 7/24/23 documents Resident Clonazepam has been d/c (discontinued) by NP. Resident was to have appointment with outside provider that he missed. Resident no longer wanted to see psych NP [Name] at facility. [Psych NP first name] covered his medication until the 18th when he was supposed to see his new doctor. NP [Name] will no longer prescribe the Clonazepam. This was explained to the resident, and he stated that he understands. Resident is in process of making another appointment for MD outside of facility. The Facility did ensure the medical director became involved with assessing R2's healthcare needs or assisting with R2 locating an alternative provider for behavioral health services and mental health services for R2. R2 did not receive Clonazepam 0.5 three times a day from 7/24/23 until 8/1/23. The nurses note dated 8/1/23 documents Writer spoke to NP [Name] regarding resident Clonazepam. Resident is not able to get into the new psych MD until September. Resident will be restarted on Clonazepam and the script will be filled for 60 days until resident sees his new psych NP. Resident is his own person and declines family update. Surveyor noted the following eMAR (electronic medication administration record) notes for Clonazepam oral tablet 0.5 mg (milligram) Give 1 tablet by mouth three times a day for anxiety: 9/1/23 at 1:13 p.m. documents do not have, reported to nurse manager, nurse manager stated that the unit manager would be taking care of this. 9/2/23 at 3:30 a.m. documents needs to be reordered none in cart. 9/2/23 at 1:07 p.m. documents an order. 9/3/23 at 2:23 a.m. documents none in cart. 9/4/23 at 1:04 p.m. documents on order. 9/4/23 at 2:36 a.m. documents none in the cart. 9/5/23 at 1:35 a.m. documents not available on order. Called pharmacy and they stated they put note out to [Psych NP (nurse practitioner) name] for approval to fill script. Will update am (morning) shift to reach out. 9/5/23 at 1:39 a.m. documents on order. 9/5/23 at 8:08 p.m. documents on order awaiting new rx (prescription). 9/6/23 at 2:42 a.m. documents none in the cart. 9/6/23 at 1:00 p.m. documents on order. 9/6/23 at 8:01 p.m. documents on order. 9/7/23 at 1:57 a.m. documents none available. 9/7/23 at 1:11 p.m. documents Medication is on order. 9/7/23 at 7:14 p.m. documents on order. 9/8/23 at 1:09 p.m. documents Drug not available. 9/8/23 at 8:25 p.m. documents on order. 9/9/23 at 8:00 p.m. documents on order. 9/10/23 at 1:27 p.m. documents on order. 9/10/23 at 8:08 p.m. documents on order. 9/11/23 at 1:50 a.m. documents not available on order. 9/11/23 at 2:31 p.m. documents requested script from psych NP. 9/12/23 at 2:15 a.m. documents on reorder. 9/12/23 at 1:08 p.m. documents not available. The nurses note dated 9/12/23 documents NP ordered resident's Clonazepam to be discontinued. Resident fired psych NP and is still pending to see new provider. [Name] NP agreed with decision of psych NP to discontinue Clonazepam until resident sees his new provider. Resident is his own person and declines family update. Surveyor reviewed September 2023 MAR (medication administration record) and noted Clonazepam 0.5 mg is initialed as being administered on 9/1/23 at 0200 (2:00 a.m.) & 2000 (8:00 p.m.), 9/2/23 & 9/3/23 at 2000, 9/9/23 at 1400 (2:00 p.m.), 9/10/23 at 0200 (2:00 a.m.), and 9/11/23 at 2000 (8:00 p.m.). On 11/2/23 at 8:37 a.m. Surveyor informed Interim DON-B Surveyor had reviewed R2's September 2023 MAR for Clonazepam and noted there are times from 9/1/23 to 9/12/23 when the MAR was initialed as the medication being administered. Surveyor inquired if Clonazepam is in contingency. Interim DON-B informed Surveyor it is but they would have to call pharmacy & get a code but pharmacy would only give the code if they had a script. Interim DON-B informed Surveyor she didn't believe during this time they had a script and would check. Interim DON-B later informed Surveyor they did not have a script and the only time R2 received Clonazepam during this time was the first dose (2:00 a.m.) on 9/1/23. Interim DON-B informed Surveyor she is going to speak with the nurses and find out why they initialed the medication as being administered. According to https://medlineplus.gov/druginfo/meds/a682279.html for Clonazepam documents Clonazepam may cause a physical dependence (a condition in which unpleasant physical symptoms occur if a medication is suddenly stopped or taken in smaller doses), especially if you take it for several days to several weeks. Do not stop taking this medication or take fewer doses without talking to your doctor. Stopping Clonazepam suddenly can worsen your condition and cause withdrawal symptoms that may last for several weeks to more than 12 months. Your doctor probably will decrease your Clonazepam dose gradually. Call your doctor or get emergency medical treatment if you experience any of the following symptoms: unusual movements; ringing in your ears; anxiety; memory problems; difficulty concentrating; sleep problems; seizures; shaking; muscle twitching; changes in mental health; depression; burning or prickling feeling in your hands, arms, legs or feet; seeing or hearing things that others do not see or hear; thoughts of harming or killing yourself or others; over excitement; or losing touch with reality. The nurses note dated 9/23/23 at 2:00 a.m. documents Writer entered resident's (R2) room at 0200 (2:00 a.m.) to administer medication, resident (R2) was sitting on his buttock on the floor with his legs extended out in front of him and his back leaning against the bed, resident was wearing a long sleeve shirt and shorts, resident had tennis shoes on, walker was right in front of resident, writer noted that resident was very anxious the more questions that were asked, writer also noted resident was jittery, resident states he's been having panic attacks on and off the past few weeks because he has not had his Clonazepam, Resident states he did not fall, resident states he sat himself on to the floor to stretch his legs out because he has been having cramps in his legs, Resident upset at writer when writer notified resident that being found on the floor is considered an unwitnessed fall and I have to update the MD of the fall, resident refused writer to assess vital signs and assess for injuries, resident denied injury or pain from sitting on the floor, but does claim to have his normal everyday pain, writer updated NP [Name], ADON [Name], and DON [Name], resident responsible for self and denies family update. The nurses note dated 9/23/23 at 5:00 a.m. documents Writer entered resident's (R2) room for neuro assessment, resident standing with walker in the middle of his room, writer noted resident was diaphoretic and shaky, writer asked resident to have a seat so that I may obtain his vitals, resident was agreeable and sat in his recliner, writer took resident blood pressure with automatic unit, residents BP (blood pressure) was very high (155/124) so writer notified resident that I needed to obtain residents BP manually, resident became agitated with writer and stated that I am making him anxious, writer updated co-nurse the RN to see if resident would allow her to obtain his vitals, resident refused and said all he want to do is go have a cigarette at the fence line on the residents smoking patio and that he would allow us to obtain his vitals after, writer reapproached resident approximately 15 to 20 minutes later and resident began yelling at writer that I gave him no time to smoke a cigarette, writer explained to resident that I needed to verify his blood pressure due to the last reading was so high and my concerns with waiting any longer, resident began screaming at writer about having panic attacks and I am making him more anxious, resident refusing to allow writer to obtain VS, writer updated NP [Name], ADON [Name] and DON [Name]. The nurses note dated 9/23/23 at 7:26 a.m. documents Author arrived at 6:30 and was informed resident was having an issue. Resident was found on the floor. Resident states he was having muscle cramps and was on the floor to stretch. Fall report initiated. Resident shivering and sweating. Hypertensive and tachycardic. Resident describing cramping in his hands and feet that may be r/t (related to) hyperventilation. Pupils are constricted but reactive; note that resident takes prescribed scheduled narcotic pain relief every three hours. RN suspects the resident may be going through withdrawals. Resident normally takes TID (three times daily) Clonazepam but has not had it for weeks as he seeks a provider to replace one the sic (that) retired. Resident aggressively denies taking any non prescribed substances and invites a search of his room if staff does not believe him. Resident anxious, fidgeting, shivering and talking extremely fast without allowing staff to respond. All staff would very much like to see resident go to the hospital in hopes that something could be given to relax resident. Resident has just returned from a short stay at [Hospital Name] and is agitated with the care he was given while hospitalized . At this time resident is refusing transport to the hospital. Resident is pleading with staff to be left alone for a couple hours. Author has a good rapport with this resident; resident agrees at this time to go to the hospital if the episode does not pass within the next couple hours. Staff to monitor. NP to be updated. The nurses note dated 9/23/23 at 12:57 p.m. documents RN spoke with resident, and he is willing to comply with urine drug screen at this time. Test scheduled for Monday. The nurses note dated 9/23/23 at 10:25 p.m. documents Resident continues on ABT (antibiotic) for tooth extraction. No A/R (adverse reactions). Resident has been sweating, restless, hallucinating, with delusions this shift. Resident seen by Director of Nursing (DON) [Name] for assessment. Noted was hallucinating, restlessness with arms and legs were constantly moving. Requested urine from resident and he refused. 911 was called for altered mental status. 911 arrived and assessed resident whom then refused to go to the ER for further evaluation, as he is his own person. Hydroxyzine 25 mg was administered po (by mouth) x 1 for anxiety as per order NP [Name]. The nurses note dated 9/24/23 at 4:07 a.m. documents Resident remains on ABT for tooth abscess/extraction, no AR noted, resident has been sitting on his floor this entire shift, resident talking to himself and moving personal articles around, when staff was checking on resident he asked staff to leave because he was having private conversation with his shampoo bottle, resident has food all over the floor and personal items all on the floor, when staff asked to assist resident he refused any assistance, resident slept on this floor for a short time, staff monitoring resident every 15 minutes this shift, resident refusing vital signs. The nurses note dated 9/24/23 at 10:41 p.m. documents Resident on 1 hour checks due to change in condition. Resident slurring his words, has thrown things everywhere around his room, verbally aggressive. Continue to monitor. Medications held. The nurses note dated 9/25/23 at 5:46 a.m. documents Resident continues with AMS (altered mental status), resident did allow writer to obtain VS, VSS this shift, resident pupils dilated (approximately 5 mm (millimeter)) and sluggish, resident alert and communicating, some speech understood by writer and some speech in incomprehensible, resident talking with jaw clenched, resident asked for narcotic for pain, writer informed resident that due to AMS I am holding all medications at this time, writer offered resident to go to the ER and resident refused, writer performed assessment with CNA as witness to residents behavior, will continue to monitor. The social service late entry note dated 9/25/23 documents Writer Crisis was called and informed of resident current state, hallucination, weight loss and major change in behavior. The nurses note dated 9/25/23 at 2:03 p.m. documents Resident continues to have AMS this shift. Resident speech continues to be understandable at times but most times it is a lot of gibberish. Writer turned on residents light in room to assess him and resident was screaming and putting the cover over and off his face continuously. Resident was diaphoretic drenching in sweat and the blanket was soaked as well. Resident was found in the shower room running the water over him with his clothes on. Writer helped resident with shower. Resident was yelling with the water touching him was put back into bed after shower and resident has been sleep since. Staff was able to clean room with resident sleep and staff found a bottle of butane and ETOH (alcohol) in room. Resident resting at this time. Will continue to monitor. The nurses note dated 9/25/23 at 3:00 p.m. documents Writer went into residents room this AM to discuss recent behaviors. Upon entering the room resident was sitting on the floor on a blanket and had a pillow next to him with an additional blanket wrapped around him tightly. He had no shirt on and shorts on the bottom. He has a large bruise on the top of his right hand and scattered bruises all over bilateral legs. He also had scabs on the right leg that he was picking at. Writer asked resident how he was feeling he said ok and then started talking about his brother and looking over at the window. He had wrappers, cat food all over the floor. The garbage was knocked over. Typically resident is very clean and organized with everything in place and orderly. Writer asked to obtain vitals. He agreed. BP 127/78, heart rate 82, O2 (oxygen) 98 on room air, temperature 97.8. Resident is very diaphoretic and is not making sense with speech but is answering more appropriately. Writer asked to obtain a drug screen lab draw and CBC (complete blood count) to check for infection from his previous tooth extraction which he is currently on antibiotics for. He agreed. Labs drawn, CBC results sent to NP. NNO (no new orders). Resident agreed to let CNA (Certified Nursing Assistant) and writer clean up his room. Upon cleaning we found a bottle of butane as well as a large vodka bottle. Staff took this from his room with his permission. Soon after cleaning staff found resident in shower room spraying himself with shower head fully clothed. Staff assisted him in taking off his clothes, finish his shower and getting clean clothes on. After shower resident went and laid in bed and took around a two hour nap. Later in the afternoon around 3pm writer and social worker went to check back in with resident and he was again on the floor trying to climb underneath his bed. He stated that he needed to get warm. Writer provided him with more blankets and asked him to please get off of floor and move back to the bed where it would be more comfortable. Resident refused. Writer asked resident if he would be willing to get sent out to ER for evaluation so that we could get him feeling better, he refused. Social worker contact crisis to come out and evaluate resident. He has been refusing meals and lost close to 40 lbs (pounds) in two months. Continues to be extremely anxious and keeps looking at window saying he is waiting for his brother and friends. Resident is currently on hourly checks. Resident is his own person and declines family update. NP is aware of situation. Writer will be reaching out to psych NP and [Psychologist Name] to see in what ways we are able to further assist resident. The social service note dated 9/25/23 documents [Name] county crisis came out to eval resident. Updates given to her regarding resident. She went to meet with resident, continues to talk non-sense told writer and worker to get out of the room before his friends come back from a holiday party. Crisis told writer that resident at this time, is safe they cannot chapter him or do much at this time. Stated if resident becomes combative towards himself, staff or peers to call 911 and then crisis will follow up if needed. IDT updated and aware. The lab report collected on 9/25/23 and verified on 9/28/23 is positive for barbiturates and methamphetamine. The nurses note dated 9/26/23 at 12:52 p.m. documents Resident's drug screen back positive for barbiturates in which he does not have a prescription for. NP updated. NNO (no new order). Resident is his own person and declines family update. Resident is being put on 15 minute checks d/t recent hallucinations, erratic behavior and positive UA drug screen. The social service note dated 9/26/23 documents Resident is on 15 minute checks for behaviors. Behavior contract to be established and signed when resident is coherent. The nurses note dated 9/28/23 at 6:22 a.m. includes documentation of .staff member came to writer and stated resident was very diaphoretic in his room, and his pupils were very large and that the resident was talking very fast and kept moving his arms and legs around like he couldn't sit still, resident stated that he doesn't want writer to come check on him for his 15 minute checks, he only wanted the CNA to check on him, writer informed the CNA to notify writer if resident is in need of my assistance at anytime during checks, writer updated NP [Name], ADON [Name] and DON [Name] on residents current behavior. The nurses note dated 9/28/23 at 1:52 p.m. documents Lab results sent to NP for CBC. NOR (new order received) to obtain a repeat CBC 10/2/23. Writer went into resident room this AM to follow up on how things are going and to discuss the hallucinations that were again occurring over night shift. NP [Name] went into room with writer to talk with resident. Upon entering room resident was sitting on the edge of his bed. When NP asked if he could scoot back further onto the bed resident got angry quick and snapped back that he is [AGE] years old and knows how to sit on a bed. We explained to him why he is on 15 minutes and asked if he remembers the conversation he had with writer 2 days previously about being on the 15 minute checks and understanding why. He dismissed that conversation and did not want to talk about it. Resident very upset about not receiving pain medication over night or this morning from nurses due to having suspected drug use from his own source. It was explained to him yet again why the pain medication is being held. Writer contacted [Physician's Name] who prescribes residents Oxycodone to see what his thoughts were on decreasing medication and a more effective pain regimen. Writer was instructed to have our NP give [Physician's Name] a call so they can discuss a plan of action. Awaiting a response to that meeting between the two providers. [Name] NP from psych was also emailed asking if she can take [R2's first name] back as a resident as he has many factors occurring recently that he needs addressed. She stated that she needs to be in contact with her boss and will get back to me early next week. Resident did refuse to go to his CT scan this morning. Initially resident was refusing his antibiotics for his tooth abscess. Resident did end up accepting antibiotic from writer after two attempts. Writer asked if there was anyone she could call for resident to talk to since he was so upset and anxious with staff here. Residents aunt and him have a very good relationship. He declined to call her. Resident has been resting in bed today throughout first shift. The nurses note dated 9/28/23 at 2:41 p.m. documents Meds. withheld this shift due to res. behaviors. Speech noted to be fast and garbled, difficult to understand at times. Refused assessment but pupils noted to be dilated and skin appears moist. Told writer not to do 15 min. (minute) checks. Did answer when writer knocked on door. Refused writer to open door to check on him. The nurses note dated 9/29/23 at 3:49 p.m. documents resident lab results received, resident tested positive for methamphetamine, [Name] DON and [Name] NP updated. The Facility investigated R2's illegal drug use. Facility staff determined the root cause dated 9/29/23 as [R2's first name] was possibly self-medicating because he did not have a Rx (prescription) for the Clonazepam. The Facility did not utilize the medical director after R2's Clonazepam was abruptly stopped & R2 started to self medicate with illegal drug to assist with locating a qualified mental health practitioner to address R2's behavioral and mental health needs. The nurses note dated 10/3/23 at 10:30 p.m. documents Held resident's HS medications, as resident was difficult to arouse, bilateral legs moving rapidly, and staff notice he was slurring his words or was just staring at you with no response. The eMAR note dated 10/4/23 at 2:31 a.m. documents 15 min checks being completed he is in his room sleeping he has not come out of his room none the previous shifts 10/3/23 each check he seems very drowsy nodding, his room is unkept he has things everywhere which is unusual for him he usually has a very clean room, he was found sitting on the floor said he just got down there to sit he didn't fall, he has some slurred speech as well. The nurses note dated 10/4/23 at 2:39 p.m. documents Resident has been very jittery this shift. Upon arrival pupils were dilated. Writer held everything but his ABT and antiviral's. Resident has been in room all shift. He was stating he was cleaning a 3x but it was more of a mess. Resident confused this shift. He dropped his breakfast plate on the floor. Writer asked him to move in center of bed a 3x this shift. Resident compliant. Resident has stated that he is ok and has no concerns. Resident has not c/o (complained of) pain this shift and has not been out to smoke. The nurses note dated 10/4/23 at 4:13 p.m. documents Writer asked resident if we could draw labs due to current anxious behaviors, staying in room and throwing things all over room that have started up again. Resident had previously tested positive for methamphetamine so we are trying to monitor use. Resident declined. NP updated. Resident is his own person and declines family update. The nurses note dated 10/5/23 at 12:28 p.m. documents Resident alert and oriented x4 this shift. No signs of paranoia. Resident jittery. Room continues to be messy and resident states that he starts to clean but becomes anxious and starts to drop stuff. Resident denied assistance to help clean. Resident meds given this shift per NP [Name]. NP stated that [Name of Medical Director-F] is still waiting to speak with [Physician's name] that prescribes his narcotics. No confusion noted this shift pain rate 10/10 oxy given. Resident continues to be 15 min checks due to abnormal drug panel. No signs of illicit drug use this shift. No VS (vital signs) taken this shift as writer did not want to upset resident due to him asking for a pain pill and writer wanted to wait until NP assessed resident. Resident did not go out to smoke this shift. Resident laying in bed at this time awaiting lunch. Will continue to monitor. The lab report collected on 10/5/23 and verified on 10/7/23 is positive for amphetamines and opiates. There is handwritten notation next to opiates which documents prescribed oxycodone. The nurses note dated 10/11/23 at 6:57 a.m. documents Resident was noted to have normal behavior most of the shift, resident went to smoke x1 this shift and was supervised the whole time, towards the end of the shift resident began to behave abnormally, writer and [Name] (Administrator) went to assess resident in his room and noted resident to be anxious, fidgety, speaking rapidly with jaw clenching, writer assessed residents pupils and they were noted to be 4mm in size with a sluggish response, resident denied using any substance when asked, 15 minute checks were completed this shift. The nurses note dated 10/11/23 at 2:12 p.m. documents Resident has not left room all shift. Upon arrival Administrator and DON assessing resident. Writer noticed resident sweating profusely. Writer could not understand resident, his speech was not coherent. Resident was jittery and could not stop moving. Writer asked resident to get in the middle of the bed because he was on the edge resident compliant. Resident did not eat breakfast and a few bites of lunch. Resident stated he was in pain and writer got him Tylenol. Meds held except antivirals and Tylenol due to AMS. NP [Name] updated. Resident continues 15 min checks due abnormal drug screen. By end of shift resident was more understandable in speech but he was talking about things that had nothing to do with anything. Resident refused for staff to take vitals this shift. Will continue to monitor. The nurses note dated 10/11/23 at 10:02 p.m. documents Entered resident's room at 1945 (7:45 p.m.), resident legs between heater and head off the side of the side of bed. Attempted to assess LOC (level of consciousness), resident sleeping very soundly. Requested assistance of wing 1 nurse, she and CNA [Name] moved resident's legs from side of bed by heater and resident moved his head. He was speaking noncoherently and moving bilateral upper and lower extremities rapidly, which I was unable to do vital signs. Resident agreed to be assessed by 911. Resident left with wing 1 nurse in attendance. 911 was called at 1950 (7:50 p.m.) and police officer arrived at 1955 (7:55 p.m.). Resident was assessed by EMT's (emergency medical technicians) and gave medication to resident for anxiety. EMS left with resident via stretcher at 2040 (8:40 p.m.). NP [Name] notified, [Name] DON notified and [Name] Admin. was notified. R2 was hospitalized from 10/11/23 to 10/19/23. The hospital discharge summary for admitted [DATE] and discharge date of [DATE] under final discharge diagnoses documents methamphetamine overdose, acute hypoxic respiratory failure due to above, AKI (acute k [TRUNCATED]

Based on record review and interview, the facility did not have an effective system to ensure residents' advanced directives for emergency end-of-life care/code status were accurate and carried out as the resident wished and did not follow facility policies to call a Code Blue when a resident was found pulseless and non-breathing. This affected 1 of 1 residents (R1) who expired while at the facility and 11 of 16 sampled residents (R11, R30, R27, R28, R29, R20, R7, R22, R23, R24, R25) whose code statuses identified delays in obtaining resident/responsible party signatures, witness signatures, signatures of the physician/nurse practitioner and at times issues with code status orders. R1's code status election forms were documented as follows: The first one was for a full code status election signed by R1 on [DATE] and Nurse Practitioner (NP)-FF on [DATE]. A second full code status election was signed by R1 on [DATE] with NP-FF signing this form on [DATE]. A third code status election form was completed however, R1 elected a no code status. This form was signed by R1 on [DATE] with NP-FF's signature dated [DATE]. R1's last expressed wish on [DATE] was to be no code; however, the last signed order on [DATE] was to be full code. Staff did not identify this discrepancy, making it unclear what staff should do if the resident became pulseless and non-breathing. On [DATE], staff found R1 unresponsive outside the facility. Staff did not assess R1, did not call a Code Blue, and did not begin cardiopulmonary resuscitation (CPR); staff did call 911 even though facility policies direct staff to call 911 only if full code. Emergency responders began CPR when they arrived and were not shown R1's wishes and orders until 20 minutes after arriving. The Emergency Paramedic report states: Facility did produce a DNR order approximately 20 minutes into resuscitation efforts. Resuscitation efforts were discontinued at that time. Patient remained in asystole (flat line) during entire resuscitation. During interviews with Director of Nursing (DON)-B Surveyor was informed of the facility expectation that a code blue would be called for a cardiac/unresponsive resident. DON-B shared the facility has code blue instructions noted on the back of employee identification badges that identify if dealing with a situation involving Cardiac/Unresponsive: staff are to announce Code Blue & Location X3 (3 times), DNR/Full Code? (determine if), (obtain) Crash Cart, CPR- Nurse Only (provide), 911 Called (If Full Code). The steps of this Code Blue procedure were not carried out fully/timely by facility staff during this change in condition for R1. DON-B shared the facility did not have a specific facility policy and procedure regarding the expectations for calling a code in emergency situations. DON-B indicated they were providing the code expectations on the back of the facility staff badges as they were replacing staff badges. DON-B indicated the facility had completed mock code drills regarding CPR and provided Surveyors with the facility drill form. It was noted this form indicated facility staff should initiate CPR while verifying code status which would not be appropriate. During survey, facility staff identified different locations in the medical records (paper and electronic) where they would go to in order to locate a resident's code status. On [DATE] DON-B stated the place she expected staff to go to for this information was the front of the resident paper medical record and review the red or green form located in the paper medical record. This expectation was not clearly designated in a facility policy and procedure. The facility's failure to have an effective system, to include policy and procedures, to ensure residents code status is reflected in the medical record and through orders, that staff know where to obtain the resident's code status information, how to alert other staff of the need for assistance with an unresponsive resident, and to convey accurate, timely assessment and code status information to first responders culminated into a situation of an immediate jeopardy that started on [DATE]. Nursing Home Administrator (NHA) - A, Director of Nursing (DON)- B, Regional Director of Operations-GG, Senior Director of Clinical Services RN-OO was notified of the immediate jeopardy on [DATE] at 11:00 am. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity level of F (potential for harm/widespread) as the facility continues to implement and monitor their action plan, for the 37 residents who have chosen to be full code and the 49 residents who have chosen a Do Not Resuscitate code status. Findings include: 1. R1's medical record reviewed on [DATE] and [DATE] indicates R1 was admitted to the facility on [DATE]. R1 was responsible for himself, with no activated power of attorney for health care. R1's admitting diagnoses consisted of fracture of orbit, unspecified, subsequent encounter for fracture with routine healing, fracture of one rib, anxiety disorder, major depressive disorder, recurrent, mild other asthma, gout, unspecified injury of spleen, chronic obstructive pulmonary disease, alcohol abuse with alcohol-induced mood disorder, type 2 diabetes mellitus . R1's Admission Minimum Data Set (MDS) dated [DATE] assessed R1 to be cognitively intact with daily decision-making skills scoring a 15 of the Brief Interview for Mental Status. R1 was assessed to have moderate depression with a mood score of 10. The MDS indicates R1 had little interest or pleasure doing things, feeling down, depressed or hopeless, trouble falling asleep, trouble concentrating, feeling tired or having little energy, R1's advanced directives: On [DATE], at 17:27 (5:27 PM), R1's medical record documents, admitted to room [room number] per ambulance with belongings and attendants.Friendly and cooperative. Surveyor notes there is no documentation facility staff discussed or obtained R1's code status preference upon admission to the facility. On [DATE], R1's medical record documents R1 signed the facility Resident Code Status form identifying the Code Status Protocol R1 selected was a full code status. R1 signed this form via electronic signature. A facility witness electronically signed the form on [DATE] and Nurse Practitioner (NP)-FF electronically signed on [DATE]. Surveyor notes R1's code status form dated [DATE] was completed 2 days after R1's admission to the facility and was scanned into R1's electronic medical record on green paper (green paper indicated a full code status). On [DATE], R1's medical record documents [R1] arrived at the facility at 0530 (5:30 AM), VVS (vital signs stable) left BKNA [sic] (Below the Knee Amputation), splint on left stump, splint on right ankle, BKNA [sic] site ace wrapped with cam boot on, no excessive drainage, no s/s (signs/symptoms) of infection, resident was in good spirits. On [DATE], R1's medical record documents R1 signed the facility Resident Code Status form and again elected a full code status. The facility witness signed on [DATE]. NP-FF signed on [DATE], 142 days after R1 signed and the form was scanned into R1's electronic medical record on green paper. R1's care plan dated [DATE] documents: [R1] has elected a full code status. Interventions include: -maintain [R1]'s chart to include notation of Full Code status. Date initiated: [DATE]; revision on: [DATE]. -Provide all life sustaining measures (i.e., CPR (Cardiopulmonary Resuscitation), Dated initiated: [DATE], revision on: [DATE] . - Update physician and responsible party, if [Preferred Name] [sic] elects to change code status as indicated by change in [his/her] [sic] preference. Date initiated: [DATE], revision on: [DATE]. Surveyor notes R1 was admitted to the facility on [DATE] and R1's care plan was not updated to include R1's elected code status preference until [DATE]. On [DATE], at 14:23 (2:23 PM), R1's medical record documents, res (resident) out at [name of hospital] for surgery early this shift. R1's Orthopedic Surgery (Hospital) Discharge Summary dated [DATE], documents, Major Procedures: [DATE]: Targeted Muscle Reinnervation for pain control nerve transfers. Code Status at discharge: Full Code. On [DATE], at 15:57 (3:57 PM), R1's medical record documents, resident readmitted to facility post-surgical procedure on left stump. resident alert able to make needs known. denies pain/discomfort. non removal dressing in place to left stump. pain pump in place to left mid-thigh. ortho (orthopedic) to be called in am (morning) for clarification on removal of pump when completed. no further skin issues noted. resident independent with ADLs (Activities of Daily Living). medications reviewed and signed by [NP-FF]. resident code status DNR (Do Not Resuscitate) per his request. consent to tx. (treat) signed. Surveyor notes there is no documentation R1's physician was informed of R1's desired change in code status upon return to the facility. Surveyor notes R1's prior code status was a full code and R1's code status upon discharge from the hospital, on the same day, was documented as a full code. Surveyor notes R1's medical record does not include a signed no code status form in R1's paper chart or electronic medical record. R1's care plan dated [DATE] documents: [R1] and/or responsible party have elected a DNR-CC (Do Not Resuscitate) code status. Interventions include: -Maintain [R1]'s chart to include order and notation of code status. Date initiated: [DATE] . -Update physician and responsible party if [R1] and/or responsible party elect to change code status as indicated by change in condition/treatment or [his/her] [sic] preference. Date initiated: [DATE]. Surveyor notes R1's medical record progress notes document R1 elected a no code status on [DATE] however, R1's care plan was not updated to reflect the change in code status until [DATE]. On [DATE], at 1:42 PM, Surveyor interviewed DON-B who stated the expectation is the nurses will review a resident's code status with the resident upon admission and readmission and at that time a new code status form would be signed by the resident and facility staff if there was a change in code status. DON-B stated she believed R1 changed their code status after returning from the hospital following the (BKA) amputation. DON-B stated the code status election forms are copied on to colored paper. Red for no code/stop and green for full code/go. Surveyor shared that a red no code form could be located in R1's charts. DON-B stated she would look for R1's no code status form since it was not located in R1's electronic medical record or in the overflow paper chart provided to this Surveyor. On [DATE], at 2:12 PM, DON-B provided Surveyor with a photocopy of R1's DNR code status form signed on [DATE] by R1 and a facility witness. The area where R1's physician signed was completed however this Surveyor noted the date appeared to be filled in on the photocopy provided by DON-B. DON-B stated she believed it was dated [DATE]. On [DATE], at 3:17 PM, Surveyor interviewed Medical Records (MR)-II and asked if she could locate the original code status forms signed by R1 on [DATE] and [DATE]. Surveyor observed MR-II go into in the room attached to MR-II's office and came back out and stated she was unable to locate the originals of R1's code status forms signed on [DATE] and [DATE]. MR-II stated the procedure for obtaining a resident's code status was the original signed copy by the resident would be faxed to the physician for a signature, a copy would go into the resident's paper chart on the unit and the original would go into a book at the nurse's station for the NP to sign. When the faxed copy is signed and returned by the physician it is placed in the paper chart and then the faxed copy is replaced when the original is signed by the NP later. MR-II states she believes if the code status order is changed the code status paperwork goes to the NP for signature. MR-II stated if MR-II identifies a discrepancy she will notify the unit managers. MR-II stated any time a resident leaves the facility for more than 24 hours a new code status form is signed by the resident, the facility witness, and NP. MR-II stated when a resident leaves the facility all the paperwork from the paper chart is scanned into the electronic medical record and the originals are shredded. MR-II stated the original signed code status forms dated by R1 on [DATE] and [DATE] were scanned into R1's electronic medical record then shredded. Surveyor informed MR-II that R1's DNR form dated [DATE] could not be located in R1's electronic medical record. MR-II stated she was trained that the original of any document that was scanned into the medical record could be shredded after scanned. On [DATE], at 11:19 AM, MR-II informed Surveyor they were unable to locate the original, hard copies, of R1's code status forms signed by R1 on [DATE] and [DATE]. MR-II stated she was closing out R1's medical record and only half of the paper chart has been scanned into the EMR at this time. Surveyor informed MR-II R1's code status form signed on [DATE] is not scanned into the EMR. MR-II states she would have to check and would get back to Surveyor. On [DATE], at 11:53 AM, MR-II provided Surveyor with an original code status form signed by R1 and facility witness on [DATE]. This form was on red paper and did not have a physician signature or date. This original copy was creased and appeared to have been folded into quarters at one time. MR-II informed Surveyor Social Work Assistant (SWA)-H had the original form and MR-II stated she was not sure why SWA-H had the original form or why it was folded. MR-II stated the original form was not signed because it was never faxed to R1's physician for signature. Surveyor asked MR-II what part SWA-A or the Social Work Department plays in the code status process. MR-II stated she could not answer that. On [DATE], at 12:04 PM, Surveyor interviewed SWA-H who stated, the nursing staff goes over the code status forms with the residents and faxes the form to the NP for signature. SWA-H stated if a resident decides to change their code status SWA-H would have a nurse get the signature of the resident, the physician order and update the doctor. SWA-H stated she was R1's assigned Social Worker from the time of R1's admission and did not recall having any conversations with R1 related to desired code status as that is a nursing function. SWA-H stated she located R1's original DNR form downstairs in medical records in the bins that are used to store paperwork before it is scanned into the EMR or filed in overflow. SWA-H stated the original DNR form was to be scanned into the EMR. SWA-H states she did work in medical records in the past and does continue to help in medical records from time to time. SWA-H stated when she assists in medical records, she does not shred any original documents once scanned into the EMR. SWA-H verified the signatures on R1's code status forms is of NP-FF. On [DATE], at 2:24 PM, Surveyor interviewed Registered Nurse (RN)-JJ who stated she did not recall readmitting R1 to the facility on [DATE]. RN-JJ stated she did not recall having a conversation with R1 related to code status or R1's election for a change in code status from a full code to a no code. RN-JJ stated the usual protocol is for RN-JJ to sign the code status form with a resident that is admitted or readmitted , fax the form to the physician for signature and put a note into the medical record. RN-JJ stated she would then change the physician's order to reflect the code status and put the unsigned (by physician) form into the resident's paper chart. RN-JJ stated she would review the code status with the physician when she verifies the orders. RN-JJ stated it depends on the time of the admission if the physician will fax back the code status form signed right away. RN-JJ again stated she did not recall readmitting R1 on [DATE]. On [DATE], at 12:26 PM, DON-B provided Surveyor with a copy of a progress note written by SWA-H. The progress noted dated [DATE], at 14:07 (2:07 PM), documented as a late entry entered on [DATE], at 14:12 (2:12 PM), documents, Care plan held, resident and facility IDT (Interdisciplinary Team) in attendance. resident currently own person, and is remaining a DNR code status. has sister as emergency contact. Resident residing at the facility until prosthesis is fitted and able to be worn, and resident able to walk. which therapy will pick up once resident receives his prosthesis. spoke briefly about living arrangements, resident unsure at this time, but will keep writer updated. at this time resident does not have any additional questions writer will follow up as needed. On [DATE], at 12:34 PM, Surveyor interviewed SWA-H related to the progress noted written as a late entry for [DATE]. SWA-H reviewed a copy of the progress note and stated if she wrote she reviewed R1's code status with R1 then she did. SWA-H stated that she did not pull out the code status form and review it with R1 during the care conference. Surveyor asked SWA-H if she knew why R1 elected a no code status after previous election of a full code status. SWA-H stated she believed the change in code status was related to R1's leg amputation. SWA-H stated before R1 had the amputation they had a lot going on and believe R1's amputation changed things. On [DATE], at 1:02 PM, Surveyor interviewed DON-B. Surveyor reviewed R1's three code status forms with DON-B. Surveyor reviewed R1's initial full code status form dated [DATE], signed by NP-FF on [DATE], the second full code status from signed by R1 on [DATE], signed by NP-FF on [DATE], the third code status form, the change to a no code status, signed by R1 on [DATE]. Initially the no code status form provided to this Surveyor dated [DATE] was a photocopy with a date for the physician signature appearing to be added to the photocopy, dated [DATE]. The second copy provided of the [DATE] no code, code status form was on red paper and was unsigned and undated by R1's physician or NP. DON-B stated her expectation for a completed code status form would be signed by the resident, facility witness and within a week of those signatures the physician or NP signature would be obtained. DON-B stated a resident's code status election would be considered complete when the physician or NP signed the code status form. DON-B stated it is possible the discrepancy in the physician signature dates could be due to an audit completed by the physician or someone else and while the audit was completed the physician or NP was signing with the current date of the audit, but DON-B could not be sure. Surveyor explained the concern for the discrepancy in the physician signature on R1's code status form and if the code status forms are considered complete once the physician or NP signs the form then R1 would be considered a full code status since the form with the most recent signature from NP-FF was the full code status signed by the NP as of [DATE]. DON-B stated she understood this Surveyor's concern. R1's progress notes state: [DATE] 12:54 (12:54 pm) nurses note: No A/E (adverse effects) to increased K+ (potassium) and Prednisone. Awaiting BMP (basic metabolic panel) results. [DATE] 03:10 (3:10 am) nurses note: No adverse effected [sic] noted to increase in potassium and prednisone. Pt. (patient) in bed has slept this shift. Afebrile. [DATE] 19:58 (7:58 pm) nurses note: Late Entry: RN was passing out PM (evening) medications, when a nurse, (LPN-NN) came up to me and asked me to come outside, because (R1's name) is out front and he is dead. I ran outside with her and found him sitting in his wheelchair, not breathing. I called 911 at approximately 1930 (7:30 pm) to report this and asked (LPN- NN) to stay with him. I ran inside to be certain he was a DNR (Do not Resuscitate). I grabbed the crash cart, looked up his code status and began running outside. I did take the crash cart. When I arrived back out front, on the scene, police officers and paramedics were there. I helped get him out of his wheelchair and once he was on the ground, a police officer started chest compressions. I told the officer he was a DNR. He stopped after what seemed like a couple of minutes. Another officer took me and (LPN-NN) aside. Told us to stay with him and not talk to anyone else. We stayed outside with him, for approximately 45 minutes, before he let us return inside. He came with us inside. I began handing out medication to my residents. Signed by RN-KK As of [DATE] there are no further progress notes in R1's record after the above note dated [DATE] 7:58 pm. On [DATE] at 3:50 pm, Surveyors interviewed RN-KK who shared she was getting ready to pass out medication, that she (RN-KK) was on unit 4. LPN-NN came and said R1 was outside, I think he is dead. RN-KK stated, R1 was outside in the front slumped over in his wheelchair. RN-KK stated at the time she was 99% sure he was DNR. RN-KK stated, she called 911 reported it as she ran in to check his DNR status and to get the crash cart. RN-KK reported she immediately called 911 and then called DON-B before running in to get the crash cart and to confirm R1's code status. RN-KK stated she spoke to DON-B for about a minute. RN-KK stated she looked at R1's medication administration record for R1's code status and then went to get the crash cart. RN-KK stated by the time she got outside the paramedics and police were there. R1 was pulled out of the wheelchair, and she thought the police officer did chest compressions. RN-KK told Surveyor she stated, No he's a DNR. When asked, RN-KK indicated they did not show the first responder R1's code status that was in writing. RN-KK stated the police then pulled us aside to ask questions and wanted to know when the last time was that we saw R1. RN-KK stated that around dinner time she spoke to R1 who was in the best mood and at that time, he went outside, and I started passing medications. RN-KK stated that was the last time she saw R1 until LPN-NN came to get her. On [DATE] at 4:35 pm, Surveyors interviewed LPN-NN regarding R1's change in condition on [DATE]. LPN-NN reported on [DATE] at about 7:25 pm she walked out front and had a jacket on. She looked to the right and saw R1 in his wheelchair leaning to the left and from a distance he appeared to be sleeping. LPN-NN stated she decided to walk over to R1 and wake him to come into the building as he was still wearing short sleeves and shorts. LPN-NN stated the closer she got to R1 she noticed everything was blue, his face, both arms, right leg all blue. LPN-NN stated she shook R1 and no response. LPN-NN stated she had no phone on her, so she left R1 to come into the building. LPN-NN stated she went to wing 4 and got nurse RN-KK. LPN-NN reported to RN-KK there was an emergency out front, I knew he (R1) was not alive, she needed to come with me. LPN-NN stated we both went out the front door together walked up to R1. RN-KK shook R1 with no response, so she (RN-KK) called DON-B first and then called 911. LPN-NN stated, we never had someone pass away outside and was not sure about the policy. LPN-NN stated she should have announced (referring to overhead paging code blue) but that is when (the resident) is in the building. LPN-NN stated the way he (R1) looked and how cold he was, he was gone for a while, didn't just happen. LPN-NN stated (RN-KK) was standing next to me talking to 911. LPN-NN reported that they were told by 911 to start CPR. LPN-NN stated, I think they thought we would do the CPR, but we didn't have a crash cart and between the two of us there was no way to get R1 out of the wheelchair. LPN-NN stated RN-KK had to get the equipment and by the time RN-KK came back the police were there and asking for help. LPN-NN reported she did not have a conversation with RN-KK regarding what R1's code status was. RN-KK then went to get the crash cart because R1 was a heavy man and there was no way the 2 of us were going to get R1 out of the chair. 911 was there within minutes before she (RN-KK) was out there with the crash cart. LPN-NN stated by the time RN-KK came back with the crash cart, that is when they (police) started doing CPR. Once police came, they started CPR, and the ambulance came and took over for the police officers. LPN-NN stated I had no idea what his (R1's) code status was, he wasn't my resident. 3 police officers and male Certified Nursing Assistants (CNAs) (CNA -QQ and RR) assisted R1 out of the wheelchair and onto a board. The police determined R1 was not breathing and had no pulse, which we determined that too. LPN-NN stated when the police came, I could step aside, the ambulance showed up within a minute and the EMTs came out and started working on him. LPN-NN stated no one asked us (referring to the police and EMTs) about R1's code status. LPN-NN stated she could not speak for RN-KK if RN-KK told them R1's code status. LPN-NN reported the paramedic went into the facility to get R1's code status form, to check on R1's code status. I don't know who helped him (paramedic). The paramedic came back with a red sheet to visually show co-workers in writing R1's code status. This is when they stopped CPR on R1. Surveyor noted on [DATE], LPN-NN did not announce an overhead Code Blue page upon leaving R1 and entering the facility to find RN-KK on wing 4. Together LPN-NN and RN-KK went back outside to check on R1. LPN-NN and RN-KK did not bring R1's hard medical record and/or code status form to present it to the first responders. RN-KK did not conduct a physical assessment of R1. Surveyor noted while outside with LPN-NN, RN-KK then called the Director of Nursing (DON)-B to convey the situation. DON-B informed RN-KK to call 911 in which RN-KK did call 911. 911 instructed RN-KK to start CPR. RN-KK and LPN-NN did not have a crash cart, so RN-KK went back into the facility to find out R1's code status and to obtain a back board. RN-KK did not overhead page a code blue upon her reentry into the facility. Surveyor spoke to Sergeant-MM on [DATE] at 1:55 pm who stated, when he arrived on [DATE], there were ,d+[DATE] people/staff standing in a circle around (R1) but no one did anything to help. It was like they were in a panic. I said let's start life saving measures and they brought out a board we didn't use. (R1) was in a wheelchair. 2 males helped (Sergeant-MM) get resident out of the wheelchair and onto the ground. No one at the facility did CPR. Sergeant-MM stated he was the only officer to conduct CPR while another office put AED (automated external defibrillator) pads on R1's chest. When the fire/rescue department came they took over the CPR and Sergeant-MM was relieved from doing the CPR. Sergeant-MM then gave instructions to his staff to start an investigation. It was the Fire/Rescue team who ultimately stopped the CPR. After (R1) was pronounced deceased , Sergeant-MM spoke to the staff member who found (R1). Sergeant-MM stated he was told (R1) went outside about an hour prior to passing away. (R1) was blue and found with a burning cigarette in his right hand. Sergeant-MM stated the facility never relayed (R1's) code status upon Sergeant-MM's arrival or while Sergeant-MM was conducting CPR on (R1). Surveyor reviewed the Police Incident Report dated, [DATE] 19:31 (7:31 pm) which indicated in part; On [DATE] at approximately 7:31 pm, I (Sergeant-MM) along with Officer SS, TT, and UU, were dispatched to the [name of facility] [address of facility] for a report of a male not breathing. [Name of county] County Communications (RCC) advised a male was currently slumped over in his wheelchair and was unresponsive. Upon arrival, I observed a male sitting in his wheelchair on the front sidewalk of the main entrance slumped over and blue. I identified the male as (R1) from previous law enforcement contacts. I further observed several nurses/aids surrounding him in a circle, but no life saving measures being performed. I approached (R1) and asked two unidentified males to help me lift (R1) off of his wheelchair and onto the ground. Once complete, I started CPR until the [name of city] Rescue members relieved me of my duties. I then instructed Officer SS, TT, and UU to canvass the area and begin their investigation . Surveyor reviewed the Patient Care Report Narrative documented: [Name of city] .dispatched for PNB (pulseless non-breathing) at [name of facility].responded to location lights and sirens without delay. According to dispatch information, patient was found unresponsive in front of the building in his wheelchair. Patient was said to have gone outside an hour prior. PD (police department) was first to arrive on scene. They started CPR and placed AEDs advising no shock. Patient was moved to the ground by PD. Upon EMS (Emergency Medical Services) arrival patient was found supine on the ground unresponsive, cold, and pale. CPR was continued by PD until LUCAS ([NAME] University Cardiac Assist System) (device)) was placed and started. Rapid assessment of patient was completed. Pupils were fixed non constricted. Patient was cool to the touch with no rigor or mottling. Patient smells of alcohol, there was a bottle found near him. There were no other obvious abnormalities. Patient was placed on our monitor using PD pads. The monitor showed asystole. Compressions were continued. Ventilation via BMV (bag mask ventilation) was started along with placement of an [NAME] (ventilating device). O2 (oxygen) was started at 15 liters per minute (LPM). Patient bagged easily monitoring showing an Etco2 (End-tidal carbon dioxide - the level of carbon dioxide released at the end of an exhaled breath) in the 50's. Patient airway was suctioned to clear secretions. There was vomiting. Chest rise was good with each ventilation. IV access was attempted X2 in patient left hand but unsuccessful .all subsequent pulse was asystole. Facility did produce a DNR order approximately 20 minutes into resuscitation efforts. Resuscitation efforts were discontinued at that time. Patient remained in asystole during the entire resuscitation. Patient was left with PD, ME (medical examiner) was contacted. Arrest witnessed by: Not witnessed CPR Care provided prior to EMS arrival: Yes Who Provided CPR Prior to EMS arrival: First responder (Fire, Law, EMS) AED use prior to EMS arrival: Yes, applied without defibrillation. Date/Time resuscitation discontinued: [DATE] 19:57:00 (7:57 pm). Reason CPR/Resuscitation Discontinued: Protocol Requirements Complete End of EMS Cardiac Arrest Event: Expired in the field On [DATE] at 1:52 pm, Surveyor interviewed DON-B regarding R1's change in condition on [DATE] DON-B stated, Registered Nurse (RN)-KK called her on [DATE] at 7:29 pm and it was reported R1 was deceased . Surveyor noted this call to DON-B from RN-KK was prior to RN-KK calling 911 for emergency assistance for R1. On [DATE] at 8:00 am, 8:45 am, 8:50 am, and at 2:15 pm, Surveyor interviewed DON-B. During these conversations, DON-B informed Surveyors the facility's CPR policy does not have specific instructions on how to implement the facility's use of a red/no code form or a green/full code form. On [DATE] at 8:45 am, DON-B reported the facility has a code blue expectation staff are to carry out for a resident who may not be breathing and/or is pulseless. DON-B stated staff would page over head a code blue 3 times for all available staff, call 911 if full code, and that the facility conducts monthly mock code blue drills. DON-B reported once a code blue is called, all available staff are to go to the designated location of where the code blue is being called, staff are to grab the crash cart and resident's chart. DON-B was asked for a policy and procedure regarding the code blue expectations. DON-B indicated she would have to see if they have one. DON-B reported not having an in-house defibrillator. DON-B stated the nurse takes charge and directs the staff as to who should call 911 etc. in an emergency situation. On [DATE] at 2:15 pm, DON-B [TRUNCATED]

Based on interview and record review the facility failed to protect 1 of 6 residents (R10) right to be free from sexual and mental abuse by Dietary Aide (DA)-O. (DA)-O failed to maintain caregiver boundaries by engaging in a personal/sexual relationship with R10. DA-O became overly involved with R10 which included spending inappropriate amounts of time while off duty with R10, directing staff that she was providing 1:1 supervision and cares of R10, such as doing dressing changes, allowing R10 to call her for support when R10 wanted to get high, allowing R10 to watch movies at her home, assisting R10 with detoxing by providing R10 with narcotics (such as Heroin and/or Fentanyl). The facility was aware of the relationship and dynamics that were developing between DA-O and R10. On 6/28/23 the facility questioned DA-O about this relationship but did not take the steps to protect R10 from abuse from a caregiver as DA-O would be defined in her capacity as an employee of the facility. DA-O conveyed in her statements to the facility and interview that she implied to R10 and others, DA-O was the only one that could help R10, creating a situation of authority over R10. R10 was noted to overdose on Fentanyl on 8/8/23 after DA-O was observed providing unofficial (determined as needed by DA-O and not assessed as needed by the facility) 1:1 supervision of R10. DA-O admitted having a sexual relationship with R10 to the police/detective. The facility's failure to ensure staff maintained caregiver boundaries with R10 created a finding of immediate jeopardy that began on 6/28/23. Surveyor notified NHA-A and Director of Nursing (DON)-B of the Immediate Jeopardy on 8/22/23 at 3:07 PM. The immediate jeopardy was removed on 8/11/23, however; the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor their removal plan. This is evidenced by: Wisconsin Statute Chapter 50.065 (1) (ag) 1. Caregiver means any of the following: a. A person who is, or is expected to be, an employee or contractor of an entity, who is or is expected to be under the control of an entity, as defined by the department rule, and who has, or is expected to have, regular, direct contact with clients of the entity . The Wisconsin Administrative Code Chapter Division of Health Services (DHS) 13.03 (3) (a) Caregiver means a person who is all of the following: 1. A person who has received regulatory approval from an agency or is employed by or under contract with an entity. 2. A person who has access to the entity's clients. 3. A person who is under the entity's control. According to the State Operations Manual: F600 Freedom from Abuse, Neglect and Exploitation. Under Guidance 483.12 (a) (1); Allegations of Staff to Resident Sexual Abuse: Nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. Also, for some health care professionals, it is prohibited by licensure or certification requirements for professionals to have a relationship with a resident (or patient.) According to Observing Professional Boundaries for Caregivers developed by UW Oshkosh Center for Community Development, Engagement and Training and Wisconsin Department of Heath Services, Division of Quality Assurance, February 2016: Professional boundaries are guidelines for maintaining a positive and helpful relationship with your residents. Understanding boundaries helps caregivers avoid stress and misconduct, recognize boundary crossings and provide the best possible care. The caregiver has a powerful role in the relationship between caregiver and client. This power comes from: 1. Control over the services provided to the client and 2. Access to private knowledge about the client . Maintaining professional boundaries helps the caregiver maintain a helpful or therapeutic relationship with the client. Crossing Boundaries: Type of Boundary Crossing: Sharing Personal Information Not seeing behavior as symptomatic, Over-involvement: signs may include spending inappropriate amounts of time with a particular client, visiting the client when off duty, thinking you are the only caregiver who can meet the client's needs. Romantic or Sexual Relationships: A caregiver is never permitted to have a romantic or sexual relationship with a client. Sexual contact with a client is against the law in Wisconsin because residents of many facilities are not viewed as being able to give consent under the law. Secrets: Secrets between you and a client are different than client confidentiality . Personal secrets compromise boundaries and can result in abuse or neglect of a client. https://wss.ccdet.uwosh.edu/stc/CAREGIVER/_WebRedesign/Documents/Keys/ObsProfBoundariesCgvrs-ParticipantGuide.pdf Prior to 8/9/23, the facility's Employee Handbook and facility education did not address professional boundaries of staff and did not indicate staff to resident sexual relationships were prohibited. R10 was admitted to the facility 9/27/22 with diagnoses that included Metabolic Encephalopathy, Lower Extremity Wounds, Sepsis, Opioid Dependency, Diabetes Mellitus 2 and Psychoactive Substance Abuse. Surveyor reviewed R10's Minimum Data Set (MDS) Assessment with an assessment reference date of 7/7/23. Documented under Cognition was a brief interview mental status (BIMS) score of 15 which indicated cognitively intact. Surveyor reviewed employee documents for staff member DA-O. DA-O was hired on 10/11/21 as a Temporary Certified Nursing Assistant (CNA) under the Covid 19 waiver, then in September of 2022 switched positions to a Hospitality Aide. In December 2022 DA-O switched positions to a Dietary Aide. According to the facility, Dietary Aide (DA)-O was involved in a relationship with another Resident (R1) prior to R1 being admitted into the facility and DA-O being employed at the facility. The facility allowed for this relationship to continue despite both having affiliations with the facility. Nursing Home Administrator (NHA)-A created special rules for DA-O's relationship/friendship with R1. On 6/22/23 R1 and R10 had an altercation in the facility. An investigation was completed including interviews, interventions and follow-up. There is no mention of DA-O in the report. On 6/28/23 NHA-A interviewed DA-O about R10 and R1. Documented was: Discussion with [DA-O] regarding [R10] and [R1] 6-28-23 Present: [Food Services Director (FSD)-Q] [NHA-A] I [NHA-A] entered [FSD-Q's] office and asked to speak with [DA-O], [FSD-Q] went to get [DA-O]. [NHA-A]: What is going on with you and [R10]? [DA-O]: What do you mean? [NHA-A]: You seem to be hanging around [R10] much more than you used to, and you do not seem to be paying attention to [R1] anymore. [DA-O]: Yes, I am [NHA-A]: Are you with [R1] anymore? [DA-O]: No, he is an [expletive]. I tried to help him, and he continues to drink and act like an [expletive] to everyone. [NHA-A]: Are you and [R10] dating? [DA-O]: (laughed) Oh no! I am just trying to help him [NHA-A]: Help him with what? [DA-O]: Get clean, off of drugs so he can go be with his wife. [NHA-A]: What do you do to help him? [DA-O]: When he is frustrated and angry we talk, he opens up to me a lot. When he feels he wants to get high he calls me and we talk, I talk him down. [NHA-A]: That is a huge responsibility [DA-O], have you asked him to see a professional to help him? [DA-O]: tried but he doesn't trust anyone but me. [NHA-A]: I need to discuss with you hanging around [R10] in front of [R1], this is a very big issue as I am sure you know. You were very large support for [R1] and in a relationship prior to [R1] coming to [facility] and now you dumped him to be with [R10], who we all know [R1] and [R10] do not get along. This is causing many altercations between [R1] and [R10]. [DA-O]: Yea, I know. I don't mean to make [R1] mad but [R10] wants my help, and he listens to me. [NHA-A]: I want to make it clear that you are not to have any contact with [R10] while you are on the clock working in the kitchen, the same rules apply when you were with [R1]. [DA-O]: It is not like that, I am just talking with [R10] to help him, he wants to get better and be with his wife. There were no other interviews with staff and residents into the allegation of abuse between DA-O and R10. (Cross reference F610). During this interview on 6/28/23, NHA-A became aware that DA-O was taking on responsibilities beyond DA-O's qualifications and position within the facility. NH-A became aware R10 was calling DA-O to talk to DA-O when upset and opening up to DA-O when wanting to get high. NH-A became aware of DA-O's attempts to help R10 get clean and off drugs. NH-A acknowledged to DA-O as taking on a huge responsibility and asked if DA-O asked R10 to seek professional help. DA-O informed NH-A that R10 did not trust anyone other than DA-O. NHA-A, FSD-Q and DA-O should have recognized from this interview, DA-O's relationship with R10 was beyond professional boundaries and should have intervened with R10's need for professional intervention in regard to his substance abuse disorder. DA-O continued to develop an abusive relationship with R10 creating a situation of mental anguish for R10 by fostering feelings of fright and anxiety related to their drug addiction and overall well-being by encouraging R10 to not trust anyone but DA-O. This progressed to sexual abuse as a caregiver. On 7/2/23 R1 and R10 had another altercation in the facility. An investigation was completed including interviews, interventions and follow-up. There is no mention of DA-O in the investigative report even though NHA-A stated in the 6/28/23 interview with DA-O that she (DA-O) was the reason for the resident to resident incidents. On 7/22/23 Certified Nursing Assistant (CNA)-J observed DA-O in R10's room. CNA-J wrote a statement that documented: On Saturday July 22, 2023, I walked by [R10's] room and witnessed [DA-O] in the bathroom with the resident. I notified [SW-L]. On 7/22/23 SW-L wrote a statement about DA-O in R10's room. Documented was: I, [SW-L], was doing rounds around 10:40 AM. I witnessed [DA-O] in [R10's] bathroom with [R10]. I asked if everything was OK and [R10] replied yes. [DA-O] then walked out of the bathroom. On 7/25/23 DA-O wrote a statement about the event on 7/22/23. Documented was: On the day in question, I came in at 6 AM to bring Dietary Aide [DA-BB] to work. When I came in I saw [R10] and we conversed (sic) a little while. I then went and ran some errands and came back. When I came back [R10] told me he was about to go wash his leg and rewrap it. He said he wanted me to see how good they healed. When I got to [R10's] room he was in the bathroom washing his leg so I walked in and stood in the doorway of his bathroom as he showed me how good his legs looked. All doors remained open. Then [SW-L] walked in and asked him if he was OK. He replied yes at this time I was gathering some items he asked me to get for when he was done and was going to rewrap them. We at that point realized [R10] needed more rolled gauze so I walked down to the nurses' station and asked [Licensed Practical Nurse (LPN)-S] for some . When [LPN-S] came back up I took the roll of gauze to [R10] and asked him if he needed anything else before I walked away. He said no so I left and went and clocked in and started doing my job. NHA-A prepared the following summary about above the event on 7/22/23. Documented was: Investigation on complaint 7-22-23 On 7-24-23 [SW-L] brought to my attention that [DA-O] was in [R10's] bathroom. This occurred at approx. 10:30 a.m. [R10] had the door open to the bathroom; [DA-O] was bending over helping with his bandage. [SW-L] stated that [DA-O] shortly went to the kitchen to work. The administrator looked up [DA-O's] work hours for 7-22-23. She clocked in at 11:00 (AM) and clocked out at 7:05 PM [DA-O] was not in working hours when she was with [R10]. There were no other interviews completed with staff and residents (such as frequency of DA-O visiting with R10, what DA-O was doing for R10 etc.) and no investigation into the relationship between DA-O and R10. On 8/21/23 at 9:57 AM Surveyor interviewed SW-L. Surveyor asked if anyone had reported anything inappropriate between R10 and DA-O to her. SW-L stated on 7/22/23 CNA-J came to her office and stated that a kitchen staff member was in R10's room. SW-L stated she went to R10's room and DA-O and R10 were in his bathroom. SW-L stated DA-O was hunched over his legs with a white towel in her hand. SW-L stated she asked DA-O what she was doing. SW-L stated DA-O responded just wiping his legs. SW-L stated she wrote a statement and had CNA-J write a statement. On 8/17/23 at 3:43 PM Surveyor interviewed FSD-Q. Surveyor asked if she knew about the relationship between DA-O and R10. FSD-Q stated she knew that she (DA-O) was spending a lot of time with him after her shifts. Surveyor asked if she heard anything inappropriate between the two of them. FSD-Q stated a couple of CNAs, who she does not remember their names, told her DA-O should not be in R10's room. Surveyor asked when this was reported to her. FSD-Q stated 2 to 3 weeks before the last overdose [of R10] on 8/8/23. Surveyor asked what she did with the information. FSD-Q stated she asked DA-O what was going on and DA-O stated nothing, she was just helping R10 with his bandage changes to his legs. Surveyor asked if she reported this to anyone. FSD-Q stated the CNAs had already reported it to SW-L [noting the incident on 7/22/23]. Surveyor noted FSD-Q became aware DA-O was assisting R10 with his bandage changes to R10's legs. This was beyond DA-O's position responsibilities and DA-O had no qualifications to be performing dressing changes on R10's legs or cares. Surveyor noted FSD-Q was aware of DA-O spending a lot of time with R10 after her shifts and did not recognize DA-O's behaviors as crossing caregiver boundaries which can lead to abuse. FSD-Q did not report this to anyone as FSD-Q stated the CNAs had already reported it to SW-L. R10's Progress Notes dated 8/7/2023 at 9:49 PM by Licensed Practical Nurse-U documents Resident did sober up somewhat but meds were held because of earlier under the influence. Narcan was given for one dose to right nostril. Sleeping with a chaperone at the bedside. On 8/21/23 at 9:49 AM Surveyor interviewed LPN-U. Surveyor asked who the chaperone was. LPN-U stated the chaperone was DA-O. LPN-U stated she approached DA-O and asked her what she was doing there. LPN-U shared DA-O stated the facility asked her to do a 1:1 with R10 and she was just there to watch him. On 8/17/23 at 10:41 AM Surveyor interviewed CNA-N who was working 8/7/23 through 8/8/23 on night shift on R10's unit. Surveyor asked if she saw DA-O in R10's room. CNA-N stated yes, she was doing a 1:1 supervision. CNA-N stated she did not know why though, because she (DA-O) is not a CNA anymore. Surveyor asked if the door was open. CNA-N stated no, it was closed. On 8/17/23 at 12:33 PM Surveyor interviewed LPN-R who was working 8/7/23 through 8/8/23 on night shift on R10's unit. Surveyor asked if she saw DA-O in R10's room. LPN-R stated yes, she talked to her and DA-O told her she was doing a 1:1 supervision because of the overdose on 8/7/23. Surveyor asked if the door was open. LPN-R stated throughout the night the door was both open and closed. Surveyor asked if she saw anything inappropriate. LPN-R stated DA-O was massaging his (R10's) feet and legs around 11:30 PM on 8/7/23. Surveyor asked if she was aware if they were in a relationship. LPN-R stated she had heard that and had seen them together after her [DA-O's] shifts were over. Documented in Progress Notes on 8/8/23 at 2:44 PM by DON-B was This writer was contacted by nurse on duty at facility around 5:35 this AM stating that resident was unresponsive. This writer told nurse to administer Narcan due to resident's history of OD (overdose) and drug abuse and call 911. Upon arrival to facility at 5:45AM this writer went to resident's room where police and paramedics were already with resident and staff. EMT [emergency medical transport] tried to get resident to arouse and answer questions but resident was not able to answer any questions, he was moaning and spitting everywhere. At approximately 6:20 (am) resident was taken to local ER by ambulance. A staff member reported to this writer around 9:40 (am) that resident called her and stated he needed a ride back to facility because he had been discharged . The staff member was identified as DA-O. On 8/8/23, NHA-A interviewed DA-O with Detective-V after the R10's overdose. The facility was concerned DA-O was giving R10 drugs since she was with him (R10) for both the overdoses on 8/7/23 and 8/8/23. Documented by NHA-A was: Interview between [Police] and [DA-O] August 8, 2023 Interviewer: [Detective-V] [Detective-V]: Introduced herself to [DA-O]. [Detective-V]: How do you know [R10]? [DA-O]: He is a resident here [Detective-V]: What kind of relationship do you have with [R10]? [DA-O]: We don't have sex it is not like that [Detective-V]: I was not referring to that I just asked what kind of relationship with [R10] do you have [DA-O]: We are friends that is it. We talk about his wife. [Detective-V]: This morning you told my officer to look in [R10]s wallet because there may be drugs in it, how did you know that? [DA-O]: I didn't know that [Detective-V]: Then why did you tell the officer to look in his wallet? [DA-O]: He is always protective of his wallet, he sleeps with it. [Detective-V]: What position do you do? [DA-O]: I work in the kitchen, I am a dietary aide [Detective-V]: How do you know he sleeps with his wallet? [DA-O]: He usually has a lot of money in his wallet and he is very protective of his money, I assumed he slept with it. [Detective-V]: I was told that you helped [R10] Detox from drugs, how did you do that [DA-O]: Yes, I did. I was his support, I would just talk to him about his wife and that he wants to get out of here. [Detective-V]: Did you provide anything else? [DA-O]: No, we would just talk about him getting clean and getting out of here and be with his wife. [Detective-V]: Do you have a relationship with [R10] outside of the facility? [DA-O]: No [NHA-A]: Has [R10] ever been to your house? [DA-O]: No [NHA-A]: It has been reported by staff that [R10] was seen at your house, has [R10] been to your house? [DA-O]: Puts her head down and stated, yes, I made a bad decision and had him come over. [Detective-V]: What did you and [R10] do when he was in your house? [DA-O]: We just watched movies. [Detective-V]: Is that the only time he has been at your house? [DA-O]: Yes [Detective-V]: Is there anything else you need to tell me before we end? [DA-O]: No, that is pretty much it [Detective-V]: Ok, I need you to know I found three phones in [R10's] room, we will be getting a search warrant for them, I will be dumping these phones, so if there is anything you need to tell me or you are not telling me it will show up on the phone. Let me ask again, is there anything you need to tell me that may be on the phones? [DA-O]: No, I cannot think of anything. Included in the report was the follow-up phone call made to the facility by Detective-V. Documented by NHA-A was: Discussion with [Detective-V] August 9, 2023 [at 9:15 AM] On August 9, 2023, [Detective-V] called and stated that [DA-O] came into the police station to speak with her. [Detective-V] stated that [DA-O] admitted to lying to the [Detective-V] at the interview the day before. [DA-O] stated that she has sex with resident [R10]. She also confessed that she has given [R10] Illegal drugs, Fentanyl while in the facility. [Detective-V] stated that she called me immediately due to the danger of [DA-O] bringing in illegal drugs into the facility and giving them to a resident . On 8/15/23 at 10:40 AM Surveyor interviewed DA-O. Surveyor asked if she was having a sexual relationship with R10. DA-O stated yes. Surveyor asked if she had ever had training on having relationships with residents. DA-O stated she was told that as long as both people are their own person, it is consensual, and the resident is not coerced it is fine. Surveyor asked if she told anyone at the facility about the relationship. DA-O stated no. Surveyor asked how the facility knew about the relationship. DA-O stated she spent a lot of time there after her shift and people talk. Surveyor asked about the night of 8/7/23 through 8/8/23. DA-O stated she spent the night with R10 but the door was kept open. DA-O stated she did not trust the staff on the floor to take care of him overnight since his overdose on 8/7/23. Surveyor asked when R10 was at her house. DA-O stated she thought it was sometime in July and it was only that once. Surveyor asked if she told anyone about R10 being at her house. DA-O stated no. Surveyor asked if she had ever given R10 illegal drugs. DA-O stated yes, a little bit of heroin over the course of 30 days to help him detox and get off drugs. Surveyor reviewed the facility's undated Policy and Procedure Abuse and Neglect Reporting and Investigating portion of the Employee Handbook Documented was .4. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Any non-consensual of any type with a resident . The procedure did not state staff to resident sexual relationships were not permitted. After the incident on 8/8/23 and information received on 8/9/23 from Detective-V, the facility completed a Quality Assurance and Performance Improvement (QAPI) Plan and a Root Cause Analysis. The facility determined that DA-O crossed therapeutic thresholds and ended up in an inappropriate relationship with R10 because she thought she was helping him detox from an illegal substance. They determined the root cause to be that the employee thought she was helping the resident. After this, the facility developed a new policy, Workplace Relationships, with an implementation date of 8/9/23. Documented on the new policy was: Policy: Work-place relationships are a mandatory disclosure to the Administrator. The Administrator will review on a case-by-case basis if the relationship poses violation to our code of ethics policy, including and not-limiting to a relationship between an employee and a resident. Definition: Ethical standards in the workplace acknowledging human values such as respect, responsibility, integrity, and the personal behavioral standards a person holds. Purpose: To re-enforce the code of ethics in the employee handbook. Consensual and serious relationships disclosed to the Administrator will require a signed disclosure by both parties. Personal relationships (including romantic and/or sexual) between individuals in inherently unequal positions, where one party has real or perceived authority over the other in their professional roles, may be inappropriate in the workplace and are strongly discouraged. Employee may not be defined as the direct report over the other. Employees must always possess professional conduct so as not to affect job performance for either party, public displays of affection are prohibited. Employee may not be assigned as caregiver during hours of work, unless approved by the Administrator and written within the Residents' care plan. Employee must refrain from the Resident area during work hours unless on authorized breaks or during their assigned meal period. Reporting of a relationship to the Administrator needs to occur prior to employment. If the Relationship is established within the employment period, then the employee must come forward within 24 hours of the established relationship. Witnessing a relationship is also reportable to the Administrator, when an employee identifies a relationship with a co-worker or resident that is defined as romantic and or sexual, bringing it to the attention of the Administrator. Acknowledgement of Work-place relationship DATE [Name and Title of Employee 1 to be filled in] [Name and Title of Employee 2 to be filled in] o Acknowledgement that the relationship is consensual. o Acknowledgement that the relationship was never a term of employment. o Acknowledgement that the (Employee/Resident) relationship, although an employee of the facility will abide by family/visitor rights, unless authorized by the Administrator. I.e., staying in the facility during non-visiting hours. o Agreement public displays of affection are forbidden in the workplace. o Agreement that the relationship will not affect job performance. o Agreement that transfers and promotions may be affected by policies that prohibit employees to work in the same department or prohibit supervisor/subordinate relationships. [signature lines] Cc: employee file(s) and or resident care plan Surveyor noted this policy includes that any relationship needs to be reported prior to employment and that witnessing a relationship is reportable to the NHA and when a relationship develops between a coworker or a resident, that is reportable to the NHA as well. The policy does not define whether the relationship is between staff and staff or staff and a resident. The policy acknowledges if the relationship is consensual, (employee/resident relationship,) they will abide by the family visitor rights, for example, staying in the facility after business hours and the relationship will not affect job performance. The policy does state that personal relationships can provide a real or perceived position of authority and may be inappropriate in the workplace and are strongly discouraged. This policy also states, If the relationship is established within the employment period, then the employee must come forward within 24 hours of the established relationship. On 8/21/23 at 12:18 PM Surveyor interviewed NHA-A and DON-B. Surveyor asked about the employee handbook and why it does not specify that staff are not permitted to have sexual relationships with residents, nor does it address staff boundaries. NHA-A stated Corporate creates those policies. Surveyor asked why the new policy does not address that employees are not permitted to have sexual relationships with residents and does not specify staff or residents on the form. NHA-A stated she will investigate this. Surveyor asked when NHA-A was aware of the relationship between DA-O and R10. NHA-A stated 8/9/23 when Detective-V told her. Surveyor asked about the incidents/events on 6/28/23, 7/22/23 and the knowledge that R10 had been to DA-O's house. Surveyor asked why these incidents were not investigated further with interviews with other staff, residents, and with R10. NHA-A stated that these were just rumors and she cannot look into all rumors. Surveyor asked how does she know they are just rumors and not facts if she does not investigate? NHA-A stated I guess I can't. Surveyor asked about the altercations between R1 and R10. NHA-A stated they stemmed from fighting over DA-O. Surveyor noted this is not documented anywhere in the investigation. Surveyor asked what were the rules that were in place for DA-O and R1 and subsequently R10. NHA-A stated DA-O could only visit after work hours, never during; all meetings would be in a common area or in the room with the door open. Surveyor asked when she was made aware that DA-O stayed the night 8/7/23 through 8/8/23. NHA-A stated not until 8/8/23 in the morning. Surveyor asked if DA-O staying overnight in R10's room was appropriate. NHA-A stated no. Surveyor asked if she ever had a conversation with DA-O about not having a relationship with R10. NHA-A stated no. Surveyor asked if NHA-A thought the sexual relationship between DA-O and R10 was OK. NHA-A stated no. Surveyor also reviewed an additional Work-Place Relationships policy dated 8/9/23. This policy addresses Romantic Relationships which states, Romantic or sexual relationships, consenting or otherwise, between an employee and a facility resident is strictly prohibited and will lead to the immediate termination of the employee's employment Surveyor noted although this policy prohibits a romantic or sexual relationship with residents the facility has developed 2 policies both dated 8/9/23 pertaining to Work-Place Relationships. One policy states . The Administrator will review on a case-by-case basis if the relationship poses violation to our code of ethics policy, including and not-limiting to a relationship between an employee and a resident with the requirement to come forward within 24 hours of the established relationship. The second policy references a romantic or sexual relationship between and employee and a facility resident as strictly prohibited leading to the immediate termination of employment. Neither policy addresses crossing professional/caregiver boundaries which is an abuse of power a staff member has over a resident. This can lead to abuse, including resident to resident abuse such as the altercations between R1 and R10 as a result of their relationships with DA-O. The facility's failure to investigate and recognize that DA-O was crossing caregiver boundaries and to prevent abuse including sexual abuse of R10 created a a finding of immediate jeopardy. The immediate jeopardy was removed on 8/11/23 when the facility completed the following: RESIDENTS DIRECTLY INVOLVED: 1.) [R10] no longer resides in the facility. However, facility did complete the following steps upon his return to the facility on [DATE]; a. 1:1 staff supervision in place upon his return to facility. Staff trained on specific guidelines for his care and monitoring. b. Resident was educated on expectation and new supervision guidelines of 1:1 prior to his return. ACTIONS FOR POTENTIALLY AFFECTED RESIDENTS: 1) Police were notified and interviewed on 8/8/2023 2) Identified resident received medical care outside of the facility on 8/8/2023 3) Interview with the resident and administrator on 8/8/2023 at the outside facility 4) Police interviewed identified staff member on 8/8/2023 5) Staff member was removed from the facility on 8/8/2023 and suspended pending investigation on 8/9/2023. Staff member no longer employed at facility at this time. SYSTEMIC ACTIONS: 1) Systemic changes to include; a. Residents and staff were interviewed regarding exploitation and relationships with staff starting 8/8/2023. b. Residents without the ability to speak or communicate were monitored for any changes in condition to include mood or behaviors without known root cause or changes in normal mood or behavior on 8/9/2023. (Any resident with changes had an investigation for root cause) c. Workplace Relationship Policy that addressed employee/resident romantic or sexual relationships, consensual or not, are strictly prohibited, reviewed, revised and trained on 8/9/2023. Addendum to policy completed on 8/23/2023 to include the responsibility to protect and care for the residents and potential abuse of power when policy is violated, training on professional boundaries to include post-test for competency. Ad Hoc QAPI held on 8/23/2023 with Medical Director/Designee for review of policy update. d. Resident Council held on 8/10/2023 with Administrator; topics discussed around resident relationships and substance abuse guidelines. Additional Resident Council to be held on 8/24/2023 to include review of revised Workplace Relationship policy on 8/23/2023. e. QA Meetings with Governing Body held on August 9th, 10th & 11th to review QAPI Plan. f. Care Plan audit of those with known Substance Abuse Disorder completed by DON on [TRUNCATED]

Based on interview and record review, the facility did not ensure that 3 (R10, R11 and R8) of 7 sampled residents' environment was as free as possible of accident hazards and provided with the supervision necessary to prevent accidents. * R10 was admitted to the facility with a history of drug abuse. On [DATE], [DATE], [DATE] and [DATE], R10 overdosed on drugs and had to have Narcan administered. The facility did not investigate or monitor the resident and did not put effective interventions, including increased supervision, in place to prevent subsequent overdoses. On [DATE], the facility did not notify the MD or call 911 after administering Narcan for R10's overdose. * R11 was admitted to the facility with a history of drug abuse. On [DATE] and [DATE], R11 overdosed on drugs and had to have Narcan administered. The facility did not investigate or monitor the resident and did not put effective interventions in place to prevent subsequent overdoses. The facility's failure to provide a safe environment by failing to monitor, supervise, and prevent residents from subsequent overdoses on illegal drugs created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the Immediate Jeopardy on [DATE] at 3:07 PM. The immediate jeopardy was removed on [DATE], however; the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor the effectiveness of their action plan and as evidenced by: * R8 eloped from the facility on [DATE] and was put on one-to-one for supervision. On [DATE] R8 was found outside on the smoking patio without the supervision of a one-to-one staff person, there was no investigation into how R8 was able to get out on the smoking patio and if R8 was supposed to be under one-to-one supervision with a staff member. Findings include: Surveyor reviewed facility's Safety for Residents with Substance Use Disorder policy with an implementation date of [DATE]. Documented was: Policy: It is the policy of this facility to create an environment as free of accident hazards as possible for residents with a history of substance use disorder. Definitions: Substance Use Disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Policy Explanation and Compliance Guidelines: 1. Residents with a history of SUD will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 2. When substance use is suspected, (in the facility or upon return from an absence from the facility) which could lead to overdose, facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner. 3. Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety . 6. Residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to: a. Frequent leaves of absence with or without facility knowledge b. Odors c. New needle marks d. Changes in resident behaviors, especially after interaction with visitors of absences from facility: i. Unexplained drowsiness ii. Slurred speech iii. Lack of coordination iv. Mood changes Surveyor reviewed the facility's Resident Possession and Use of Illegal Substances policy with an implementation date of [DATE]. Documented was: Policy: It is the policy of this facility to uphold the resident's right to retain and use personal possessions, unless to do so would infringe upon the rights or health and safety of other residents. The possession and use of illegal substances by residents will not be tolerated. Policy Explanation and Compliance Guidelines: 1. Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use, which includes but is not limited to: a. Changes in resident behavior b. Increased, unexplained drowsiness c. Lack of coordination d. Slurred speech e. Mood changes f. Loss of consciousness 2. If the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source, the facility will not act as an arm of law enforcement. In accordance with state laws, a referral will be made to local law enforcement. 3. To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility. 4. If facility staff identifies items or substances that pose risks to residents' health and safety and are in plain view, they will confiscate them. 5. Facility staff will not conduct searches of a resident or their personal belongings, unless the resident or resident representative agrees to a voluntary search and understands the reason for the search. Surveyor reviewed facility's Opioid Overdose Management policy with an implementation date of [DATE]. Documented was: Policy: It is the policy of this facility to recognize and treat opioid overdose per current standards of practice. Definitions: Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. Opioids include prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone, hydrocodone, Fentanyl, hydromorphone, and buprenorphine, as well as illegal drugs such as heroin and illicit potent opioids such as Fentanyl analogs (e.g., carfentanil). Opioid Use Disorder (OUD) is a problematic pattern of opioid use leading to clinically significant impairment or distress. Overdose refers to taking more than the normal or recommended amount of something, often a drug. It can result in serious, harmful symptoms, or death. Policy Explanation: Whether intentional, unintentional, or undetermined, opioid overdose continues to be a health crisis in the United States. Recognizing the signs of overdose and quickly responding can prevent brain injury and death. Compliance Guidelines: 1. The facility will review the residents' medications and history to determine if opioids are in use or the have a history of addiction, opioid use disorder (OUD), or are on a medication assisted treatment prof for OUD. 2. The facility will keep naloxone (Narcan) readily available and located in a designated area to be administered as per facility protocol and standing naloxone (Narcan) orders. 3. The facility will periodically check to ensure that naloxone (Narcan) is not expired or changed characteristics and will have the pharmacy replace as needed. 4. The facility will train all staff to recognize the signs of opioid overdose and respond to it according facility policy. 5. If a resident exhibits any of the following overdose symptoms, the facility will call 911, initiate basic life support, if indicated, and administer naloxone as per facility protocol and manufacturer's instructions: a. Extremely pale face or clammy to the touch b. Limp body c. Blue or purplish color to fingernails or lips d. Vomiting or making gurgling noises e. Inability to awaken or speak f. Breathing or heartbeat slows or stops. According to an article at www.medicalnewstoday.com, Narcan can cause certain side effects: More common side effects of Narcan Narcan can cause certain side effects, some of which are more common than others. These side effects are usually temporary, lasting a few days or weeks after the drug is given. These are just a few of the more common side effects reported by people who took Narcan in clinical trials: - nose that's dry, stuffy, painful, or swollen inside - high blood pressure - muscle pain or spasms - headache - opioid withdrawal Mild side effects of Narcan Mild side effects can occur with Narcan use. This list doesn't include all possible mild side effects reported with the drug. Mild side effects of Narcan can include: - bone pain - constipation - nose that's dry, stuffy, painful, or swollen inside - dry skin - high blood pressure - muscle pain or spasms - toothache - headache These side effects are usually temporary, lasting a few days or weeks. https://www.medicalnewstoday.com/articles/drugs-narcan-side-effects#more-common-side-effects 1.) R10 was admitted to the facility [DATE] with diagnoses that included Metabolic Encephalopathy, Lower Extremity Wounds, Sepsis, Opioid Dependency, Diabetes Mellitus 2 and Psychoactive Substance Abuse. Surveyor reviewed R10's Minimum Data Set (MDS) Assessment with an assessment reference date of [DATE]. Documented under Cognition was a brief interview mental status (BIMS) score of 15 which indicated cognitively intact. Surveyor reviewed R10's Progress Notes. Documented on [DATE] at 11:00 PM was Resident was noted laying on the floor beside the bed at 2300. Assisted resident to the [wheelchair (w/c)]. Resident tells writer he placed himself on the floor to cool off. He stated that the floor was cool and he felt hot . Alert x 4 but slowed thought process and noted with lethargy . Risk and benefit given but unable to verbalize understanding due to lethargy . During frequent assessment at [11:20 PM] writer noted resident with increased weakness, unable to hold head up, not arousable, able to communicate intermittently but loses ability due to lethargic state. Eyes noted to be constricted and unable to answer questions appropriately intermittently and displays verbal aggression to staff when cognition is assessed. Writer questioned if the resident is under the influence of illegal drugs or substance and when asked yelled at writer stating you are over reacting, Why are asking me this?'' Paramedics called and arrived around [11:30 - 11:35 PM]. Resident refuses assessment with paramedics. Unable to obtain vitals. Refused transport to the ER for evaluation and treatment. Paramedics stayed in the facility to ensure safety of the resident due to questionable state/change of condition. Writer and paramedics noted a change in residents' mentation. Resident was intermittently unresponsive. Staff nurse noted medication which was not prescribed to the resident laying on the resident's bed (morphine). The paramedics notified police. Police arrived to the facility shortly after. Police spoke to the resident independently without writer present. The police informed writer that the paramedics could not transport the resident due to the resident having the right to refuse ER transport. Police left the facility at [11:55 PM] with paramedics . On [DATE] the facility put a care plan in place for R10's substance use. Documented was: Focus: I have a history of substance use disorder [related to (R/T)] Use of/addiction to illegal drugs. My drug(s) of choice is/was: Prescription analgesics Use of/addiction to illegal drugs. My drug(s) of choice is/was: oxycodone and morphine, Heroin [DATE]- Suspected Overdose Goal: - I will demonstrate an understanding that substance use is not permitted in the facility as evidenced by: Verbally able to state through the next review. Interventions: - [DATE]- Narcan administered per policy Sent to ER for evaluation MD/Family updated Psych Services updated-will see on next facility visit [police] on scene room checked for other illegal substances Social services to follow up with resident - Account for any traumas in my past that may influence my substance use and help me avoid triggers - Administer medications that are prescribed to me as part of my medication assisted treatment (MAT) and observe for side effects. - Assist me in attending support groups with others who also have substance use disorder. - Contact emergency services immediately if I exhibit any signs of overdose and administer opioid reversal agents as indicated. - Educate me on the risks of leaving the facility to seek out substances and/or early unplanned discharge. - Educate resident on ways to utilize coping skills to deal with feelings of desire for my preferred substance of choice. - Encourage and allow me to openly express my feelings, and to express fears and worries - Encourage frequent contact with my family and friends that are supportive of my recovery and do not encourage substance use, as desired by me. - Encourage my family to be an active part in my care plan and discharge planning process so that I have an active support system in the community as desired by me. Surveyor reviewed R10's Progress Notes. Documented on [DATE] at 4:18 AM was Writer noted the resident in the dining room sitting in his w/c near a table. Resident's head was tilted toward trunk. Writer attempted to arouse resident with tactile and verbal stimuli and resident was unresponsive. Head tilted upward to ensure airway and respirations. Respirations noted, no cyanosis noted or pallor noted, drooling/ secretions noted from mouth, and eyes fixated and constricted- unreactive to light. Pulse noted. Writer called for assistance from co- nurse and facility staff. Transported the resident to the nurse's station while co- nurse called 911. Narcan obtained. paramedics arrived facility and Narcan administered per orders at [4:22 AM]. Resident was arousable and responsive within 2 minutes of administration of Narcan. Resident assessed by paramedics and police at seen (sic). Resident refuses ER transport. Police notified resident that ER services were non optional at this time due to severity of event with plausible/ suspected overdose. Resident departed from the facility at [4:25 AM] with police dispatch and paramedics on stretcher . Prior to departure, another facility resident provided police with a cut straw found on the facility patio where resident was smoking earlier in the evening. Statement provided by this resident to the police. Police kept item. Police noted resident to have a clear plastic bag of white powdery substance in the resident's hand. Police confiscated this item as well. Non- prescribed Morphine tablet taken by police. Resident's personal cell phones (3) taken by police. Alert and responsive at time of the time of departure. R10's care plan was updated after the overdose on [DATE]. Documented was: Focus: [DATE]- overdose-Narcan administered, admitted to hospital taking Heroin daily Intervention: [DATE]- returned from hospital after [against medical advice (AMA)], NP aware new orders received. Surveyor noted there was no resident specific interventions put in place to prevent further overdoses including the root cause to R10's drug use, education on illegal drug use and facility policy of no tolerance for drug use in the facility. After R10 returned from the hospital AMA the incident was not investigated to determine how he came to have narcotics in the building or if R10 was stable to return to the facility. There was no indication the facility investigated as to whether there was a pattern of R10 leaving the facility or having visitors who may have been bringing the narcotics into the building. There was no investigation into the cut straw found on the patio, the clear plastic bag with white powdery substance and the morphine tablet. Surveyor reviewed Progress Notes for R10. Documented on [DATE] at 7:07 PM was Resident returned to facility after being admitted to hospital on [DATE] for possible [overdose]. Facility received call from hospital that resident left hospital AMA and no discharge summary given and would not give one since he left AMA. This writer spoke with [NP] and verified orders for resident. Order was to continue all previous medications but discontinue oxycontin order and start Tylenol 650 mg every 6 hours for pain. R10's care plan was updated after the NP was contacted on [DATE]. Documented was: Interventions: [DATE]- monitor every 15 minutes for [signs and symptoms (s/sx)] of drug use [DATE]- nurse to evaluate for s/sx of substance use and overdose On [DATE], the facility contacted the pain clinic who said there was nothing more they could do for the resident. Surveyor reviewed Progress Notes for R10. Documented on [DATE] at 4:16 PM was [Interdisciplinary Team (IDT)] met to discuss the incident on ,d+[DATE]. Resident has been on 15 min checks. No further incidents since then, resident has not appeared to be lethargic, is mostly cooperative and pleasant. Will take off 15 min checks. Resident will remain on nurse checks every 4 hours. Surveyor reviewed Progress Notes for R10. Documented on [DATE] at 1:54 PM was At approximately 1:05 PM this writer was asked to assess [R10] due to him being lethargic, sweating, not responding well to verbal and tactile stimuli. Upon entering resident's room, resident had bottom on edge of bed, feet on floor with upper body slumped to the left and backwards. Resident did not arouse to verbal stimuli but did open eyes to sternal rub. This writer told floor nurse to call 911 and update facility NP. While waiting for 911 to arrive this writer and 2 other staff members stayed with resident, sitting him up and holding him in a sitting position. Pulse was staying in the upper 70's, O2 would fluctuate from ,d+[DATE]% with him coming in and out as we continued to try to keep him awake. O2 dropped to 62 and resident would not arouse, one dose of Narcan 0.4 mg was being administered nasally as police and paramedics arrived to room. Resident became much more alert and started yelling and swinging on staff when the officer stepped in and told him to stop, he did. Police were questioning resident and he bolted to the bathroom. He continued to deny taking anything, stating he was tired because he had not slept in 2 days. Vital signs were stable, resident alert and slightly confused. Resident refused to go to the ER for evaluation. Resident here continues on 4 hour assessments and closer monitoring due to previous incident [DATE]. Will continue to monitor and offer counseling services, which resident declines. R10's care plan was updated after the overdose on [DATE]. Documented was: Focus: [DATE]- drug overdose-Narcan administered Interventions: [DATE]- Narcan x 1 dose given with positive results [police] responded to 911 call Resident refused to go to the ER for evaluation MD aware, declined any family update social services to follow up with resident [DATE] - over dose- Narcan administered, continues to decline assistance with substance abuse counseling, [police] on the scene. Surveyor noted there was no resident specific interventions put in place to prevent further overdoses on [DATE]. There is no indication the facility assessed the effectiveness of the care planned interventions put in place with the [DATE] care plan. The updates to the care plan on [DATE] was only identifying what happened on [DATE]. Documentation does not indicate what specific services were offered and refused by R10. There was no investigation into how the narcotics came in to the building including identifying visitors who came to the facility to visit R10. The facility also did not utilize an agreeable behavior contract to help R10 to refrain from substance abuse. R10's care plan was updated on [DATE]. Documented was: Interventions: - Ensure that the necessary care and services are person-centered and reflect the residents' goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety Provide meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Those activities that address the residents' customary routines, interests, preferences, etc. and enhance the resident's well-being Counseling by [Alcohol and Other Drug Abuse (AODA)] and therapeutic psychosocial services have been offered with accommodations for coordination of these services. Provide regular opportunities for: physical activity Daily decision making Socialization Leisure activities consistent with my interests - Report any changes in my mood status to my physician. - Report any suspected use of substances to my physician. - Support my strengths and provide me with positive affirmations - Upon discharge, provide appropriate referrals and discharge instructions Documented on [DATE] at 10:00 AM in R10's Progress Notes was Resident noted be acting strangely and sweating excessively. Nurse evaluated, resident noted to have pinpoint pupils, diaphoretic, inability to maintain a conversation, alternating between dozing off and scratching excessively at arms and back. NP notified, order given to have EMS [emergency medical services] evaluate resident. [Oxygen] at 93% and [Heart Rate] 101. unable to obtain [blood pressure (BP)] due to resident unable to sit still long enough for BP to read. EMS called. Documented at 10:35 AM was EMS radioed for police to come and speak with resident. Documented at 10:43 AM was police state resident refuses treatment, stated that there was nothing they can do at this moment. Documented on [DATE] at 3:55 AM in R10's Progress Notes was Resident exhibiting s/sx of substance use at this time, resident alert when spoken to but head bobbing noted, resident noted to be hollering woooo that was good multiple times and staff could hear it all the way down the hall, resident refusing [vital signs (VS)] at this time and any assessments, staff monitoring resident closely for s/sx of overdose. Documented on [DATE] at 5:42 AM in R10's Progress Notes was resident up throughout this shift. resident outside on the patio. resident admitted to being high. no s/sx of overdose noted at this time. Documented at 2:30 PM was resident noted to be drowsy, but resident was alert and able to answer questions appropriately. Resident refused cares and all medications, resident refused all assessments including skin check and blood pressure check. R10's care plan was updated after taking drugs on [DATE]. Documented was: Focus: ,d+[DATE] - S/S drug use Documented on [DATE] at 6:16 AM in R10's Progress Notes was positive for signs and symptoms of impairment. Resident was alert and oriented. Hyperverbal at times and drowsy at others. Staff increased monitoring. Documented at 10:10 PM was The resident was monitored every 4 hours for s/sx of substance use/overdose: There was a sudden changes in mood and behavior, drowsiness, lack of coordination, loss of consciousness observed at the evening 4 pm to 6 pm. He was sitting in the smoking patio and leaning forward for couple of hours confused. The care provider was with him entire time to prevent fall. He was acting funny and confused, later in the evening he went back to the room and was observed continuously going to the smoking area. There were no added resident specific interventions or updates to the care plan for the suspected substance use on [DATE], [DATE] or [DATE]. On [DATE] and [DATE] R10 was suspected of being high on the patio. There was no update to the care plan to identify the need for supervision of R10 when on the patio to monitor his use of substance abuse. There was no investigation into how the narcotics came into the building and education that the facility would not tolerate drug use in the facility. There was no update to the care plan after signs of substance use on [DATE] or any update to the MD. It is noted that much of R10's drug activity happens during the night/early morning hours. There is no indication the facility recognized this pattern and increased supervision during these hours or assessed R10 to determine why R10 was not sleeping at night. R10's care plan was updated on [DATE] and [DATE]. Documented was: Interventions: [DATE] c/o nausea due to withdrawal [DATE] - s/s drug use Surveyor noted there were no Progress Notes or any other documentation about the withdrawal or substance use on [DATE] or [DATE]. There was no assessment of the resident including appearance of what the withdrawal symptoms looked like, and how R10 was acting during withdrawals. The facility did not document what interventions were used (besides medication for his nausea) for R10's withdrawals to keep R10 safe and did not update the MD for R10's withdrawals. Documented on [DATE] at 2:39 AM in R10's Progress Notes was Resident is clearly impaired. He was observed throwing his hat in the air and dancing around. He denied any alcohol or drug use. Eyes are dilated. refused vital signs. resp 17. Documented on [DATE] at 4:21 AM in R10's Progress Notes was Resident sleeping this shift, possible substance use noted earlier but resident is alert and responsive when spoken to, will continue to monitor. Documented on [DATE] at 5:25 AM in R10's Progress Notes was S/Sx of substance use noted this shift, PRN Zofran given for [nausea and vomiting] and effective . Documented on [DATE] at 1:58 AM in R10's Progress Notes was Resident on the board for suspected substance use, resident [alert and orientated (A&O)] x 4, resident awake this shift walking around and out smoking cigarettes' on the resident's smoking patio. Documented on [DATE] at 4:02 PM in R10's Progress Notes was Resident appeared to be high this morning. When nurse brought his AM medications, he was doing sit ups and other exercises, sweating profusely, kept saying he will take his medications in a second but it took him about 20 min to start taking them. Resident kept making strange movements. At one point he took a washcloth, flinged it in the nurse's face, shouted, boo loudly and said that this is an African prayer ritual that he has to do before he can start taking his pills. R10's care plan was updated on [DATE]. Documented was: Focus: [DATE]-Suspected drug use There were no added resident specific interventions or updates to the care plan for the suspected substance use on [DATE], [DATE], [DATE], [DATE] or [DATE]. There was no documentation of update to the MD. There was no plan to increase R10's supervision as R10 continued getting using narcotics. The facility did not investigate how R10 was continuing to show signs of substance use while in the facility. Documented on [DATE] at 4:26 AM in R10's Progress Notes was did checks on patient he appeared high both times he was very drowsy and falling asleep standing up, tried calling the physician twice on third shift did not get through will report to AM nurse. Documented at 12:33 PM was resident demonstrating s/s substance abuse; resident noted to be lethargic with [oxygen] stats dropping from high 90s to low 80s when resident slumps over, resident responsive; NP notified, [new order] given for Vitals [every 4 hours for 1 day]; will continue to monitor, Narcan on hand and readily accessible. Documented at 3:19 PM was resident alert and no longer slumping over in chair, [vital signs stable] will continue to monitor. Documented at 9:49 PM was Resident did sober up somewhat but meds were held because of earlier under the influence. Narcan was given for one dose to right nostril. Sleeping with a chaperone at the bedside. Cross-reference F600. R10's care plan was updated on [DATE] after the overdose. Documented was: Focus: [DATE]-Suspected drug use Intervention: [DATE]-Narcan given There were no resident specific interventions added to the care plan after the overdose on [DATE]. There was no update to the MD and 911 was not called during the overdose. Orders were given by the NP to monitor vitals despite ongoing documentation that R10 refuses monitoring of vitals when taking drugs or coming off of taking drugs. There were no added resident specific interventions or updates to the care plan for the suspected substance use on [DATE], [DATE], [DATE], [DATE] or [DATE]. There was no documentation of update to the MD. There was no plan to increase R10's supervision as R10 continued getting using narcotics with the only reference in progress notes of a chaperone at bedside that was not initiated by the facility. The facility did not investigate how R10 was continuing to show signs of substance use while in the facility. Documented in Progress Notes on [DATE] at 2:44 PM by Director of Nursing (DON)-B was This writer was contacted by nurse on duty at facility around 5:35 this AM stating that resident was unresponsive. This writer told nurse to administer Narcan due to resident's history of overdose (OD) and drug abuse and call 911. Upon arrival to facility at 5:45AM this writer went to resident's room where police and paramedics were already with resident and staff. EMT tried to get resident to arouse and answer questions but resident was not able to answer any questions, he was moaning and spitting everywhere. At approximately 6:20 resident was taken to local ER by ambulance. A staff member reported to this writer around 9:40 that resident called her and stated he needed a ride back to facility because he had been discharged . This writer called ER and was told that resident left AMA. During this entire time police were still in the building waiting to get a search warrant for resident's room. The police did get the search warrant and took evidence from room. Resident took a taxi back to facility and went to his room and was upset looking for his wallet that the police took. The resident was sitting outside near the parking lot, the police went to talk with him around 11:20 and he complained of chest pain. The police called for EMTs and he was taken back to hospital by ambulance. The hospital documentation on [DATE] at 4:49 pm indicates: Patient is a [AGE] year-old male with past medical history detailed below. Patient is a resident at the [name of facility]. Patient came in to the ED [emergency department] this morning for altered mental status. Was thought to be a drug overdose but the patient's drug screen was negative. Patient left AMA and went back to the [name of facility]. Upon returning to the [name of facility] he was met by police who had found Fentanyl in his belongings. Patient began experiencing chest pain and was transported back to hospital. Patient was found to be in hypertensive crisis with elevated troponin. Currently patient is lethargic and diaphoretic. Discussed Fentanyl etc. and patient indicated he was worried that he will be going through significant withdrawal symptoms. After discussing plan to control withdrawal symptoms, patient agreed to be admitted to the ICU [intensive care unit] on Cardene drip. Cardiology will consult. The report goes on to include: Assessment and plan: 2. Fentanyl overdose -patient thinks he may have gotten a bad batch. -rescue,e PTA p.r.n. medications for withdrawal symptoms -Zofran, Compazine as needed -supportive care -close monitoring of symptoms in the ICU 3. Elevated troponin -likely secondary to above R10's care plan was updated on [DATE] after the overdose. Documented was: Focus: [DATE]-Drug overdose Intervention: [DATE]-Narcan given, 911 called, sent to ER- to be 1 to 1 upon return from hospital There was no investigation by the facility to investigate how R10 was obtaining narcotics resulting in overdoses an[TRUNCATED]

Based on interview and record review, the facility did not ensure 1 (R11) of 3 residents reviewed received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. R11 was admitted to the facility with a history of Substance Use Disorder (SUD). On 11/19/22, 3/17/23, 5/4/23 and 8/3/23 R11 overdosed on drugs and had to have Narcan (Naloxone) administered. There is no indication if care planned interventions were followed through on, and whether they were evaluated for effectiveness. The facility did not assess the resident for the need of behavioral health services and specialized drug counseling. The facility did not establish plans to assess for withdrawal symptoms and treatment of those symptoms but rather focused on only monitoring for substance use and overdose. The facility put a Behavioral Contract in place on 9/3/23, 4 months after it was added as an intervention to prevent overdoses. R11's first Substance Abuse Risk Evaluation was on 9/5/23 after R11 already had 4 previous overdoses. This Substance Abuse Risk Evaluation did not address interventions pertaining to counseling or mental health concerns related to SUD. This assessment does not address how far back R11's history of substance abuse goes. It does not address if R11's substance abuse is associated with past traumas, stress and/or triggers. This assessment does not address past meaningful activities or relationships, and/or support systems/treatment which R11 may have been involved with in the past. The lack of evaluating R11's care plan interventions for effectiveness, the lack of assessing R11's history and current substance abuse, and implementing an effective behavioral contract contributed to R11 having another overdose on 9/9/23 requiring the administration of Narcan as a life saving measure. Findings include: According to The National Institute of Mental Health: .When someone has a SUD and another mental health disorder, it is usually better to treat them at the same time rather than separately. People who need help for a SUD and other mental disorders should see a health care provider for each disorder. It can be challenging to make an accurate diagnosis because some symptoms are the same for both disorders, so the provider should use comprehensive assessment tools to reduce the chance of a missed diagnosis and provide the right treatment. It also is essential that the provider tailor treatment, which may include behavioral therapies and medications, to an individual's specific combination of disorders and symptoms. It should also take into account the person's age, the misused substance, and the specific mental disorder(s) . https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health According to the Substance Abuse and Mental Health Services Administration: Naloxone is a temporary treatment and its effects do not last long. Therefore, it is critical to obtain medical intervention as soon as possible after administering/receiving naloxone .Use of naloxone causes symptoms of opioid withdrawal. Medical assistance must be obtained as soon as possible after administering/receiving naloxone. Opioid withdrawal symptoms include: feeling nervous, restless or irritable, body aches, dizziness or weakness, diarrhea, stomach pain, or nausea, fever, chills or goose bumps, sneezing or runny nose in the absence of a cold. Opioid overdose is life-threatening and requires immediate emergency attention .Opioid overdose can happen: .with illicit drug use, if a person takes opioid medications prescribed for someone else, if a person mixes opioids with other medications, alcohol, or over the counter drugs. R11 was admitted to the facility on [DATE] with diagnoses that included Chronic Multifocal Osteomyelitis, Hypertensive Urgency and Anxiety. Surveyor reviewed R11's MDS (Minimum Data Set) Assessment with an assessment reference date of 3/2/23. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. R11 had a history of substance abuse and overdosed on 11/19/22, 3/17/23, 5/4/23 and 8/3/23 under the influence of drugs and alcohol. After each overdose there was no assessment of the resident's mental health and no specialized drug related counseling initiated. Surveyor noted there was no plan or assessment established to monitor R11 for signs/symptoms of possible withdrawal from narcotics or alcohol to provide support. On 10/22/22 the facility put a care plan in place for R11's substance use. Documented was: Focus: - Resident has a history of alcohol abuse/dependency - 11/19/22 drug overdose incident, sent to ER - 3/5/23 [alcohol (ETOH)] use suspected - 3/17/23 - Under the influence of ETOH or drugs Goal: Resident will refrain from using non-prescribed substances and/or alcohol through the next review date. Interventions: - 10/22/22 resident at bar drinking, risk vs benefit given - 11/19/22 - returned from the ER no new recommendations - 11/19/22 administer Narcan if drug overdose suspected - 11/19/22 - social services and psych services to follow up with resident - 3/17/23 - [new order (NOR)]: Obtain [urinalysis (UA)] Drug Screen, [discontinue (DC)] Oxycodone, Hold all medications if under the influence - 3/19/23 - UA [positive] for THC/Opiates - hold medication and update MD if resident is suspected of being under the influence - If you suspect resident has been using non-prescribed substances, notify supervisor immediately. Surveyor noted that psych services should have followed up with R11 as indicated in the 11/19/22 care plan intervention. There was no follow up by psych services documented. There were no added psychosocial interventions or assessments to prevent mental health concerns, potential further drug use and no interventions to monitor for and treatment of withdrawl signs and symptoms. On 5/3/23 the facility put a care plan in place for R11's drug use. Documented was: Focus: I have a [history] of substance use disorder [related to (R/T)] Use of/addiction to prescription drugs. My drug(s) of choice is/was: pain medications Use of/addiction to illegal drugs. My drug(s) of choice is/was: marijuana, fentanyl, cocaine Use of/addiction to alcohol history of drug overdose 7/3/23 ETOH use 8/3/23-Suspected drug use I will not use the substances that I am/was addicted to through the next review. Goal: I will work with a therapist/counselor to help me with my SUD through the next review. (5/3/23) Interventions: - 5/3/23 Account for any traumas in my past that may influence my substance use and help me avoid triggers. - 5/3/23 Assist me in attending support groups with others who also have substance use disorder. - 5/3/23 Encourage and allow me to openly express my feelings, and to express fears and worries. 5/5/23 Counseling by AODA and therapeutic psychosocial services have been offered with accommodations for coordination of these services. - 5/3/23 Offer a behavioral contract if I am cognitively able to consent, and only if it will encourage me to follow this plan of care. - 5/3/23 Report changes in my mood status to my physician. - 5/3/23 Report any suspected use of substances to my physician. - 5/3/23 Support my strengths and provide me with positive affirmations. - 5/4/23 Narcan x 1 administered with positive results [police] at the facility-interviewed by officer MD aware, declined any family update Social services to follow up with resident Monitor resident every 4 hours for [signs and symptoms (s/sx)] of substance use/overdose symptoms and update MD if positive social services to follow up with resident regarding substance abuse education and counseling-resident declined. - 5/5/23 Ensure that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Ensure that the direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. Provide meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Those activities that address the residents' customary routines, interests, preferences, etc. and enhance the resident's well-being. - 5/5/23 Counseling by AODA and therapeutic psychosocial services have been offered with accommodations for coordination of these services. - 5/11/23 beer cans found in room - 6/6/23 Referred to [psychologist] - 8/3/23 Narcan administered, 911 called, resident refused to go to ER - 8/22/23 When [R11] goes on pass with (Person D) nurse to evaluate upon his return to the facility for change in condition/ or signs/symptoms of drug usage. - 8/22/23 Encourage visitation in high traffic areas with (Person D). Surveyor noted that R11 should have followed up with a counselor for SUD but the resident declined on 6/6/23. There was no further follow up or offer of psych services or counseling for SUD. There were no added psychosocial interventions or assessments to prevent mental health concerns and potential further drug use. Surveyor noted there is no indication if the facility pursued the care planned intervention as to whether R11 experienced traumas in the past and if there are triggers that may be influencing R11's substance abuse. There is no information indicating how the facility is assisting resident to attend support groups with others, whether they are assisting with transportation, companionship with attendance, online attendance etc. There is no indication if R11 is openly expressing his feelings and what fears and worries R11 may have as indicated in the care plan. There is no indication as to what activities R11 may find meaningful and how the facility may be promoting those activities and relationships. Surveyor reviewed R11's MD Orders. Documented with a start date of 5/5/23 and an end date of 9/3/23 was: Monitor resident every 4 hours for [signs and symptoms (s/sx)] of substance use/overdose: sudden changes in mood and behavior, drowsiness, lack of coordination, loss of consciousness etc. If resident has symptoms update MD. Y=symptoms N=no symptoms every 4 hours for substance abuse. Surveyor reviewed R11's Medication Administration Record (MAR) for 8/23/23 through 9/3/23. Documented on the following dates were: 8/23/23 at 4:00 PM: 4 8/24/23 at 12:00 AM: Y 8/24/23 at 12:00 PM: Y 8/27/23 at 4:00 PM: Y 8/30/23 at 12:00 PM: Y 8/30/23 at 4:00 PM: Y 8/30/23 at 8:00 PM: Y 9/2/23 at 4:00 PM: Y 9/3/23 at 4:00 AM: Y Surveyor noted that 4 documented on 8/23/23 indicated see nurses notes. There was no documentation in nurses notes related to drug use signs and symptoms. Surveyor noted R11 had an overdose on 8/23/23 requiring administration of Narcan. Review of the above documentation indicates R11 continued to be noted to be under the influence of possible drugs and alcohol with no assessment or details into the symptoms, type of substance used, if R11 was experiencing withdrawal symptoms and without consultation with the physician as the order indicates. (Cross-reference F580). On 9/3/23 the facility put a Behavior Contract in place for R11. Documented was: Police involvement has been required secondary to the possession of illicit drugs found in your room, unsecured, at the bedside. The police have taken the illicit drugs and have an open investigation. We have learned, recently, you may be involved with continued illicit drug use at this facility. This has been reported to law enforcement and an investigation will continue. You were made aware of your rights as a resident upon admission to our facility. You do not have a right, however, to place others at risk. While a resident at our facility we ask for you to commit to the following: - A room search (Which will include all of the following): To confirm illicit drugs are not inside your room that would place other residents in our facility at risk. The room search will include you voluntarily showing us your pockets, wheelchair, and anything on your person. - Once a room search is completed, the following will continue: - A room search will be completed after taking a leave of absence from the facility for an outing - After any visitations - Visitations with your identified [Person D] will take place in open supervised areas (Secondary to past police involvement and known drug activity which has already been reported to the police with an active and open police investigation) Should you refuse this agreement: - An assignment will be provided and scheduled to have 1:1 supervision on you at all times - Your privacy will be provided during self-cares and personal cares in rooms that are not in direct contact with any other resident You have intentionally involved yourself in illegal activity and have demonstrated a risk to those who live here. Our commitment is for the safety of you and every resident that resides inside this facility. The document was updated to include the following. Documented was: Revision 9.4.2023: In accordance with the Federal Rules of Participation under F563 [(right to receive/deny visitors] please see the attached regulations) Your identified (Person D) is restricted from any visitation with you at this facility. (Person D) has a history of bringing in illegal substances which places you and other residents health and safety at risk, should your (Person D) attempt visitation at our facility with you, law enforcement will be notified. A restraining order will be pursed. *We are eliminating the prior supervised visits as this has the potential to place our staff at risk. Safety for all is our only priority. R11 signed the document on 9/3/23 and the revised document on 9/4/23. R11's care plan was updated on 9/3/23. Documented was: Interventions: - 9/3/23 resident was placed on 30 min check while awake and 1 hour checks while in bed. Signed behavior contract allowing staff to search room, person and wheelchair - 9/3/23 Resident agreed to voluntary room search, therefore supervision will be set to hourly checks. - 9/9/23 resident placed on 1 to 1 observation due to suspected OD (overdose) Narcan given and 911 called, refused to go to ER, police served search warrant. Surveyor noted a Behavioral Contract intervention was identified as an intervention on R11's Care Plan on 5/3/23 but was not put in place until 9/3/23. Surveyor noted there was no assessment of R11's Mental Health prior to the Behavioral Contract and no assessment of the psychosocial effects the room searches and restriction of visitors would have on R11. Surveyor reviewed R11's Substance Abuse Risk Evaluation with an assessment date of 9/5/23. Documented was: A. Risk Questions A. Does the resident currently or have a history of illegal drug use? a. Yes B. Does the resident currently or have a history of substance abuse? a. Yes C. Does the resident currently or have a history of substance abuse with IV access? b. No D. Does the resident currently or have a history of homelessness? a. Yes E. Does the resident's family currently or have a history of substance use? a. Yes F. Does the resident currently or have a history of association with substance using peers? a. Yes G. Does the resident currently or have a history of misusing prescription drugs? a. Yes Resident will be considered High-Risk for substance use if yes is answered to any of the risk factors above. Surveyor noted this 9/5/23 Substance Abuse Risk Evaluation was the first assessment for SUD. Surveyor also noted this Substance Abuse Risk Evaluation did not address any interventions, counseling or mental health concerns related to SUD. This assessment identifies R11 as having a history of substance abuse however this assessment does not address how far back this history goes, it does not address if R11's substance use is associated with past traumas, stress and/or triggers. This assessment does not address past meaningful activities or relationships, and/or support systems/treatment R11 may have been involved with. The assessment also does not address what possible withdrawal may be for R11. A Care Plan was put in place 9/7/23 for R11's continued drug use. Focus: [R11] has a history having possession of illicit drugs on his person, and in room Goal: - Resident will behave in a safe manner consistent with resident conduct policies through the next review date. - Resident will comply with the rules and terms of his/her sentencing as required by state law through the next review date. - Police involved and opened a case and investigating - resident has signed a behavior contract which includes. A room search to be completed after taking a leave of absence from the facility. If not agreeing to a room search resident will be placed on 1 on 1 supervision. - [Person D] is restricted from entering the facility. Interventions: - Observe resident for behavioral changes. Update MD as indicated. - Refer resident to a mental health professional for evaluation. Surveyor noted this was the first time facility was assessing for behavioral changes, however the care plan does not identify resident specific behavioral changes to watch for. Another intervention was to include evaluation of mental health but the facility did not follow up on the past assessments of R11's mental health. Surveyor also noted increased monitoring for signs and symptoms of drug use and overdose. Surveyor noted there was no indication R11 was being monitored for possible withdrawal from either alcohol or drug use. Surveyor reviewed R11's Progress Notes. On 9/9/23 at 8:57 PM documented by Licensed Practical Nurse (LPN)-DD was The resident was diaphoretic, breathing, pinpoint pupils. The resident was sitting on the chair at 1530 hrs (3:30 pm). Prior to this he was seen on the resident smoking patio and was in a pleasant mood. The author when saw the resident tried to tap and try to wake him up but the response was very slow. Upon seeing the situation I called for assistance from other staff. 911 was called, Narcan was administered, and a Vital sign was taken. The resident is 1:1 monitoring. Surveyor noted that even with the Behavioral Contract and Care Plans including increased monitoring, R11 still overdosed and needed Narcan administered. Surveyor also noted no assessment of mental health after the overdose. On 9/13/23 at 12:34 PM Surveyor interviewed Social Worker Assistant (SWA)-H. Surveyor asked about R11's SUD and counseling or rehabilitation. SWA-H stated he has declined psych services in the past because R11 does not think he has a problem. Surveyor asked if R11 was asked after the overdoses to use psych or counseling services. SWA-H stated no because he had declined in the past.

Based on observation, interview, and record review, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure injuries for 2 (R7, R29) of 6 residents reviewed for pressure injuries. * R7 developed a facility acquired, Stage 4 pressure injury with an exposed tendon under a splint that had been applied to R7's hand. There was not a doctor order for R7's splint. The splint did not appear to have been removed for cares to check R7's skin impairment, the splint was not on the care plan or care delivery guide. Facility failure to obtain a doctor's order, care plan, and provide care for R7's splint caused R7 to develop a Stage 4 pressure injury with exposed tendon created a finding of immediate jeopardy that began on 1/6/2023. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 3/2/2023 at 3:28 PM. The immediate jeopardy was removed on 1/8/2023. However the deficient practice continues at a scope/severity of D as evidenced by the following example. * R29 was readmitted to the facility with a deep tissue injury (DTI). The facility did not comprehensively assess the area upon admission or establish a care plan until later. Findings include: The facility policy entitled Pressure Injury Prevention and Management' implemented on 1/6/2023 states: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk . e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/ evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. e. the goals and preferences of the resident and or/authorized representative will be included in the plan of care. 6. Modifications of Interventions b. Interventions on a resident's plan of care will be modified as needed. 1.) R7 was admitted to the facility on [DATE] and has diagnoses that include: encephalopathy, anxiety, major depressive disorder, dementia, muscle wasting and atrophy. R7's annual Minimum Data Set (MDS) dated [DATE] indicated R7 had severely impaired cognition with Brief Interview for Mental Status (BIMS) score of 00 and assessed R7 as needing extensive assist with bed mobility, dressing, eating, toileting, and hygiene, and total dependence with transferring and bathing. R7 was non ambulatory, used a Hoyer lift for transferring and had a Broda wheelchair. R7 was incontinent of bowel and bladder and wore a brief. R7's Braden score on 1/10/2023 was 13 indicating R7 was high risk for developing pressure injuries. R7's Potential for Impaired Skin Integrity was initiated on 2/19/2021 with the following interventions: - pressure redistribution mattress - apply cushion to wheelchair - Complete Braden scale upon admission, weekly X4, quarterly, with significant change of condition and as needed - lotion with skin cares - Weekly skin assessment - Monitor skin with all cares. Report any changes to Nurse - Update Physician as needed, refer to Registered Dietician and therapy as needed. - Tubi grips to bilateral upper arms, put on in AM and take of at bedtime. Offer long sleeve shirts to resident if available- initiated 8/5/2022 - Encourage to Free float heels in bed- initiated 11/15/2021 - Barrier cream after each incontinent episode and as needed- initiated 11/15/2021 - Encourage to reposition approximately every 2-3 hours and as needed-initiated 11/15/2021 On 8/18/2022 the Nurse Practitioner (NP) wrote an order for Occupational Therapy (OT) to evaluate and treat R7 due to R7 having stiff, swollen fingers and knuckles of the left hand. On 8/24/2022 OT started to see R7 per NP order. On 8/30/2022 OT implemented R7 to start wearing a palm guard with finger separators. OT noted deficits with positioning of R7's left upper extremity (LUE) impacting the risk of skin breakdown and functional use of LUE. OT applied a long skinny pillow under R7's elbow to support the elbow and the LUE to improve positioning while R7 was up in R7's Broda wheelchair. OT wrote up education for nursing to educate staff on R7's palmer guard schedule and how to position the LUE while R7 was in Broda wheelchair. On 10/21/2022 R7 was discharged from therapy with the following discharge recommendations: staff were educated on the use of the palm guard and Isotoner glove for the left hand. Surveyor noted that R7 did not have a care plan initiated regarding R7's Palmer guard with finger separators for R7's left hand or to have R7's left hand brace removed for cares or to check skin impairment. On 1/6/2023 at 12:39 PM in the progress notes, nursing charted R7 was noted to have a new open area to the base on R7's left thumb. R7 had been wearing a splint and the splint was removed. Nursing assessed the Skin. Nursing contacted R7's Power of Attorney (POA) and the NP. Nursing obtained a new order to have R7 seen in house by the wound doctor. The wound doctor was made aware and will see R7 on their next visit. Nursing obtained treatment orders and applied the treatment to R7. On 1/6/2023 on the Initial Wound Assessment, nursing documented the base of the left thumb had a Stage 4 pressure injury measuring 1.1 cm x 1.5 cm x 0.2 cm with 100% non-granulating tissue with exposed tendon. R7's Impaired Skin Integrity Care Plan was initiated on 1/6/2023 with the following interventions: - Complete Braden scale upon admission, weekly X4, quarterly, with significant change of condition and as needed - Consult in-house wound physician - Measure area weekly - Monitor of signs/ symptoms of infection - Monitor of signs/ symptoms of worsening skin tissue - Monitor pain and offer as needed analgesic as ordered - Monitor skin with all cares. Report any changes to Nurse/ physician. - Wound team to follow - Treatment as ordered - Update physician with changes in wound status and PRN (as needed). On 1/10/2023, the wound physician assessed R7's pressure injury to the base of the left thumb. The wound physician documented the Unstageable pressure injury measured 0.4 cm x 0.95 cm x 0.1 cm with early granulation tissue. The wound physician ordered the following treatment: cleanse the wound with normal saline, pat dry, apply skin prep to area around the wound, apply Xeroform dressing and bandage the wound daily and as needed. The wound physician documented the wound was crusted over with no tendon exposed at that time with no signs or symptoms of infection. On 1/17/2023 R7's measurements were: 1.39 cm X 0.59 cm X 0.1 cm, stage 4, 75-99% granulation tissue. The treatment was changed from Xerofoam dressing to bordered foam dressing. R7's Stage 4 pressure injury to the left thumb was assessed weekly and had the following measurements: -1/24/2023: 1.2 cm X 0.3 cm X 0.1 cm with early granulation tissue. -1/31/2023: 0.7 cm X 0.2 cm X 0.1 cm with early granulation tissue. -2/7/2023: 0.4 cm X 0.2 cm X 0.1 cm with early granulation tissue. -2/14/2023: 0.2 cm X 0.2 cm X 0.1 cm with early granulation tissue. -2/21/2023: 0.1 cm X 0.1 cm X 0.1 cm with early granulation tissue. On 2/28/2023, R7's measurements were: 0.93 cm X 0.68 cm X 0.1 cm, stage 4, 76% granulation with no other percentage type. (The wound base description should have 100% tissue type documented.) New treatment orders were received to cleanse R7's pressure injury with normal saline, protect around the wound with skin prep, cover with foam dressing every Tuesday, Thursday, Saturday, and as needed and to apply a washcloth under the left hand contractures to prevent further skin breakdown. An order was received to check skin integrity under washcloth every shift. On 3/2/2023 at 12:27 PM, Surveyor observed Licensed Practical Nurse (LPN)-O change R7's dressing to R7's left thumb per the wound physician's orders. Surveyor observed light brown drainage on the dressing. Surveyor observed R7's pressure injury at the base of R7's left thumb, measuring approximately 0.5 cm X 0.5 cm, with no depth noted, and pink tissue at wound base. Surveyor asked LPN-O how R7 developed the pressure injury. LPN-O stated R7 had a [NAME] soft brace for R7's contractures and the corner of R7's brace by the thumb area was doubled over and R7 would squeeze it tightly because of R7's contractures. Surveyor asked LPN-O if LPN-O ever took off R7's brace. LPN-O stated third shift staff would take R7's brace off and morning staff would put R7's brace on. LPN-O stated LPN-O never took off R7's brace. Surveyor asked LPN-O if LPN-O could show Surveyor R7's brace. LPN-O stated R7's brace was thrown out, but the brace was a palm guard, and the brace would go over the thumb and Velcro together. LPN-O stated that R7's brace had sheepskin under the fingers so R7 could not bend R7's fingers into R7's palm of the hand due to the contractures. On 3/2/2023 at 12:55 PM Surveyor asked the Director of Rehab (DoR)-P if therapy was consulted for R7 to be seen for a brace. DoR-P stated therapy had an order for R7 for OT to evaluate and treat R7 for stiff, swollen fingers and knuckles of the left hand. DoR-P stated R7 was seen from 8/24/2022 - 10/21/2022. On 3/2/2023 at 12:55 PM Surveyor asked OT-Q if OT-Q recommended a brace for R7. OT-Q stated OT-Q recommended a palm guard with finger separators for R7's left hand because of R7's contractures. OT-Q stated R7 could not tolerate the finger separators and recommended staff to take off or not wear the palm guard if R7 developed skin issues. Surveyor asked if OT-Q saw R7 to assess R7's brace. OT-Q stated OT-Q had not seen R7 since discharging from therapy in October 2022. On 3/2/2023 at 1:25 PM Surveyor asked the Regional Nurse Consultant (RNC)-G what orders R7 had for the palm guard with finger separator brace. RNC-G stated to Surveyor that the Nursing Home Administrator (NHA)-A had the past noncompliance binder and Surveyor would need to talk with NHA-A. Surveyor asked RNC-G to clarify about the binder for R7. RNC-G stated when R7's pressure injury was found RNC-G realized that R7 did not have orders for a brace and R7 was not supposed to have a brace. On 3/2/2023 at 1:30 PM Surveyor asked the NHA-A for information regarding R7's pressure injury that was found on 1/6/2023. NHA-A stated that when staff found R7's pressure injury on R7's left thumb, staff noted that there was not an order for R7 to have a brace and R7 did not have a care plan to do checks on R7's skin under the brace or to remove R7's brace. The facility's failure to obtain a doctor's order, care plan, and provide cares for R7's splint caused R7 to develop a Stage 4 pressure injury with exposed tendon created a finding of immediate jeopardy. The facility removed the jeopardy on 1/8/2023 when it had completed the following: - Audited all residents with splints/ medical devices. - Talked with staff regarding what residents were wearing splints. - Had therapy provide a list of all residents with splints. - Education was given to Nursing and CNAs regarding orders for splints, checking for skin impairment, and who to inform if a resident has a device and is not on the resident's care card. - facility to perform random audits of residents with/ without splints X4 weeks. - Audit of communication between therapy and nursing for use of devices. The deficient practice continues as a scope/severity of D based on the following examples: 46517 2.) R29 is a long-term resident at the facility with diagnosis including, unspecified severe protein calorie malnutrition, Chronic Kidney Disease stage 4, and Chronic Obstructive Pulmonary Disease. R29's quarterly MDS (Minimum Data Set) Assessment documents R29 has a BIMS (Brief Interview for Mental Status) of 14, indicating R29 is cognitively intact; R29 is at risk for pressure injuries and has one stage three pressure injury. R29's skin integrity care plan, initiated on 07/18/2019, documents: Resident has Potential for impaired skin integrity r/t (related to): decreased mobility, unspecified severe protein calorie malnutrition, dermatitis, left hip brace and has interventions that include: 10/11/22 skin prep to left heel . 10/28/22- soft boots on at all times in-house wound MD to follow . 11/22/22-Tx as ordered . 2/14/23-new treatment to left lateral heel . 2/21/23-new treatment to left lateral heel . pressure redistribution mattress; initiated on 09/16/2019 Assist with reposition PRN (As needed) Surveyor reviewed R29's medical record and noted the following nurses progress note dated 10/11/2022 at 3:53 PM: Resident returned from the hospital, writer looked at residents' heels, noted faint discoloration to L heel measuring 2cm x 2cm. Denies pain to area. [Name of Nurse Practitioner] NP (Nurse Practitioner) from [name of group] notified. New orders received to apply Skin Prep to area . Surveyor noted R29 had been hospitalized from 10/4/22 to 10/11/22. R29's medical record contained no documentation of a DTI prior to 10/4/22. Surveyor noted R29 had the following physician's order dated 10/11/22 and discontinued on 10/28/23: L (Left) HEEL: Cleanse area with saline, apply skin prep daily and PRN (As needed). On 03/01/23 at 10:12 AM, Surveyor interviewed Unit Manager LPN (Licensed Practical Nurse) J. LPN J informed Surveyor she noticed the DTI to R29's left heel upon admission and received an order for skin prep and soft boots. Surveyor reviewed R29's medical record and noted R29's care plan was not updated until 10/28/22 to include the intervention of soft boots on at all times. Surveyor could not locate pressure off-loading interventions added on 10/11/22 when the DTI was first discovered. On 03/02/23 at 9:39 AM, Surveyor interviewed DON (Director of Nursing) B and Corporate Nurse Consultant G. Surveyor asked if there were off-loading interventions added to R29's care plan after the discovery of the DTI on 10/11/22. DON B stated she would check R29's medical record and get back to Surveyor. On 03/02/23 at 1:50 PM, DON B informed Surveyor there were no pressure off-loading interventions added at the time of the DTI discovery on 10/11/22. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure it provided an environment that was free of accident hazards and safe for 43 residents of 45 residents reviewed for safety concerns. The facility identified at the time of the survey, 40 residents smoked and utilized the smoking patio at the facility. Additional concerns exist regarding R7 and R4. On 12/6/22 Surveyor observed R20 being taken out to the smoking patio by Certified Nursing Assistant (CNA)-P and observed R20 actively had oxygen on. The CNA was heard speaking to R20 about not wearing oxygen and smoking prior to the CNA leaving R20 unsupervised. R20 was then observed interacting with other residents on the patio including R21 who told R20 to take off her oxygen as they walked to R20. R20 was next observed with her oxygen tank and her nasal cannula in her lap as it was actively emitting oxygen. R20 was observed to have a lit cigarette in her mouth at that time while the oxygen was running in her lap. R20's Smoking assessment dated [DATE] indicated the resident liked to smoke, could light cigarettes without difficulty, did not need to have her lighter and cigarettes stored by staff for safety, and had been educated on smoking procedures. The smoking assessment did not indicate the resident used oxygen or delineate safety precautions related to smoking and oxygen use. It was later determined that facility staff stored the resident's smoking paraphernalia, and the smoking assessment was inaccurate. The facility identified that any given time there are currently 40 residents in the facility that actively smoke and could be present on the patio when a resident has oxygen in use. During interview with the Director of Nursing (DON-B) on 12/07/22 at 9:00 a.m., DON-B said, [R20] is the only resident who smokes that wears oxygen. One resident [R24] who smokes needs a smoking apron. Three residents who smoke including [R1] and [R16] go out on the 500-hall patio [Wing-5 patio (non-designated smoking area)]. DON-B indicated the three residents were allowed to smoke on the Wing-5 patio to accommodate social distancing during the coronavirus disease 2019 (COVID-19) pandemic. On 12/07/22 at 9:27 a.m., DON-B provided a list of three residents that included R3 and R20 indicating that the facility keeps their smoking paraphernalia. DON-B said, The nurse keeps their smoking material locked in the cart and the resident must ask for it. The facility identified multiple residents with varying levels of supervision or safety concerns related to smoking and did not have a system in place to ensure safety while smoking. The facility's failure to ensure the safety of residents who smoke and those that are smokers that use oxygen created a situation of immediate jeopardy that started on 12/6/22. Administrator (NHA)-A and Regional Director of Operations (RDO)-E were notified of the immediate jeopardy on 12/7/22 at 10:34 am. The immediate jeopardy was removed 12/7/22 when the facility implemented an action plan. The deficient practice continues at a scope and severity (s/s) of a G (actual harm/isolated) based upon the example regarding R7. R7 was left unsupervised while on the toilet resulting in a fall with three subsequent fractures. R4 was identified as at risk for elopement and was not provided with appropriate interventions to minimize the resident's risk for elopement and was later located walking on a local highway. Observations of the smoking area of the facility identify safety concerns related to debris that could possibly be ignited while resident's smoke. Findings include: 1.) Supervision to Prevent Accidents and Accident Hazards - Smoking The Facility Smoking Policy - Residents, 2001 Med-Pass, Inc (Revised July 2017) was provided by DON-B on 12/07/22 at 8:45 a.m. The policy stated, This facility shall establish and maintain safe resident smoking practices 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 3. Oxygen use is prohibited in smoking areas. 4. Metal containers, with self-closing cover devices, are available in smoking area .13. Residents are not permitted to give smoking materials to other residents. A facility policy titled, Smoking Guideline, that was dated 10/24/22, specified: The facility may designate certain areas for resident smoking. The facility must ensure precautions are taken for the resident individual safety, as well as the safety of others in the facility. Such precautions may include smoking only in designated areas, supervising residents whose assessment and care plans indicate a need for assisted and supervised smoking, limiting the accessibility of matches and lighters by residents who need supervision when smoking for safety reasons. Smoking by residents when oxygen is in use is prohibited, and any smoking by others near flammable substances is problematic and prohibited. Additional measures may include informing all visitors of smoking policies and hazards. The facility provided a list of residents who smoked. Out of the 40 residents on the list who smoked, R20 was identified as the only resident who was receiving oxygen. During an interview with Director of Nursing (DON)-B on 12/07/22 at 9:00 a.m., DON-B said, [R20] is the only resident who smokes that wears oxygen. One resident [R24] who smokes needs a smoking apron. Three residents who smoke including [R1] and [R16] go out on the 500-hall patio [Wing-5 patio (non-designated smoking area)]. DON-B indicated the three residents were allowed to smoke on the Wing-5 patio to accommodate social distancing during the coronavirus disease 2019 (COVID-19) pandemic. On 12/07/22 at 9:27 a.m., DON-B provided a list of three residents that included R3 and R20 indicating that the facility keeps their smoking paraphernalia. DON-B said, The nurse keeps their smoking material locked in the cart and the resident must ask for it. According to records reviewed by Surveyor, R20 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, and hemiplegia and hemiparesis to the left side. The resident had a left below the knee amputation and was receiving hemodialysis. On the Minimum Data Set (MDS) R20 scored a 12 on the Brief Interview for Mental Status (BIMS) dated 12/01/22 suggesting the resident had moderately impaired cognition. According to a physician's order and observations made during the survey, R20 was receiving oxygen by way of nasal cannula from a portable oxygen tank. R20's Admission Agreement dated 11/29/22 stated, 12. Smoking, Alcohol, and Drugs - If designated smoking areas are provided, smoking is permitted in designated areas of the Center only and only to the extent permitted by the Residents medical records. If a Resident requires assistance to smoke, you agree to do so only with appropriate assistance. All lighters and matches shall be kept at the nursing station. Residents may not keep lighters and matches in their rooms or on their person. R20's baseline care plan dated 11/29/22 indicated the resident had a self-care deficit related to the left below knee amputation; required one-to-two-person assistance for personal hygiene, toilet use, and transfers using a Hoyer(R) mechanical lift; had a potential for falls; and had cognitive impairment manifested by impaired compromised decision making and inability to understand course of treatment, care, and prognosis/likely outcome. [R20] has a need for a responsible adult to make health care and/or financial decisions on her behalf, has anemia due to dialysis and is on humidified oxygen. R20's baseline care plan dated 11/29/22 did not address smoking. R20 had a physician's order dated 11/30/22 that read, O2 (oxygen) at two to six (2-6) liters per minute via nasal cannula continuously while in room for chronic obstructive pulmonary disease to keep sats (oxygen saturation levels) above 90 percent. R20's Smoking assessment dated [DATE] indicated the resident liked to smoke, could light cigarettes without difficulty, did not need to have her lighter and cigarettes stored by staff for safety, and had been educated on smoking procedures. The smoking assessment did not indicate the resident used oxygen or delineate safety precautions related to smoking and oxygen use. It was later determined that facility staff stored the resident's smoking paraphernalia, and the smoking assessment was inaccurate. The following was observed by the Surveyor on 12/06/22 beginning at 4:00 p.m. Certified Nursing Assistant (CNA-P) transported R20 in her wheelchair to the smoking patio near the dining room. R20 had a portable oxygen cannister and was receiving oxygen through a nasal cannula. CNA-P moved the resident to a non-smoking area of the patio under the easement of the facility with the resident's back against a brick wall, locked the wheelchair brakes, and told R20 to take off her oxygen to smoke. CNA-P then returned to the facility. There were no other staff members on the smoking patio. There were nine other residents on the smoking patio; seven of the residents were smoking. R16 and R21, who were seated at a table about six to eight feet away from R20, yelled across the patio telling R20 to turn off her oxygen to smoke. R21 walked over to R20 and assisted R20 to take the oxygen tank off the back of the wheelchair and placed the oxygen tank on R20's lap; the nasal cannula was also on the resident's lap at this time. R20 had a lit cigarette in her mouth following the interaction with R21. When the Surveyor asked R20's name, the Surveyor could hear the oxygen tank running. The Surveyor immediately went into the building to find the Director of Nursing or a nurse in charge and first located the Regional Registered Nurse (RRN-Q). RRN-Q accompanied the Surveyor to the patio, extinguished R20's cigarette, and brought the resident inside. According to the facility map provided by DON-B on 12/05/22 at 3:30 p.m., R20 was not smoking in the designated smoking area. The designated smoking area is marked by yellow paint on the ground on the concrete patio itself. One side of the line is a designated smoking area, and the other side is non-smoking. R20's wheelchair was positioned in the non-smoking area against the brick building under the overhang. During an interview on 12/06/22 at approximately 4:15 p.m., R16 said, They bring people like her [pointing to R20] out [on the patio] and leave them [without supervision]. R16 expressed concerns that a resident could catch fire and I [R16] would feel responsible. During an interview on 12/06/22 at 4:55 p.m., R21 said she helped R20 place the oxygen tank on her lap as described above. R21 stated that R20 demanded a cigarette and R21 provided a cigarette and lit it for her. R21 said this was the first time she had ever seen R20 and the first time she had ever seen CNA-P, but, according to R21, CNA-P did tell the residents on the patio that it was ok for R20 to smoke without her oxygen tank on. R21 said all the residents know people with oxygen can't smoke. R21's most recent MDS dated [DATE] was coded to indicate the resident scored 15 on the BIMS suggesting R21 was cognitively intact. On 12/06/22 at 5:14 p.m., RRN-Q said, We educated everyone about smoking that is in the building now. Her smoking assessment said she wasn't going to smoke [the resident preferred not to smoke while at the facility]. R20 is her own person and can make her own decisions. We will try to educate her. I don't know why she needs oxygen, but maybe we can dc [discontinue] it. In an observation on 12/07/22 at 9:42 a.m., the Surveyor saw a resident smoking in the same non-designated smoking area under the easement near the designated smoking area by the dining room in his wheelchair. During interview on 12/07/22 at 9:42 a.m., the Administer (NHA-A) said the admissions packet was the only document that residents signed acknowledging the smoking policy. NHA-A stated, The residents are informed, upon admission, that smoking is not permitted in common areas of the center. The designated areas provided for residents are evaluated. On 12/08/22 at 4:10 p.m., a Licensed Practical Nurse Manager (LPNM-G) said, No one is supposed to smoke within 15 feet of the building and the area under the overhang is not a designated smoking area. The facility's failure to ensure Resident's are supervised and safe while smoking created a situation of immediate jeopardy that was removed on 12/7/22 when the facility implemented the following action plan: * Ad Hoc QA meeting was held to educate the entire leadership team on our plan and follow up. * All licensed and unlicensed personnel were educated on the policy regarding smoking, residents that choose to smoke and have oxygen, not giving residents smoking materials, where the designated smoking area is located and the safety equipment that is in the designated smoking area. * All education will be completed with staff in the building currently and all other staff will be educated prior to his/her next scheduled shift. * All residents that currently smoke were assessed for the smoking abilities, all care plans were reviewed and updated as necessary for their individual needs. The care delivery guides were reviewed and updated if a resident is an independent smoker or what level of assistance they need to smoke and where there smoking material are located if applicable. The facility smoking policy and procedures were reviewed to ensure that they are based on the current standards of practice. The facility will ensure that all residents currently residing in the facility are educated on the reviewed smoking policy, that they should not be sharing smoking materials with other residents and where the only designated smoking area is located. All new admissions will be educated on the smoking policy on admission to the facility. All resident education will be completed with residents that currently smoke in the facility. * The facility will ensure that smoking assessments are completed timely on new admissions that choose to smoke or any resident that chooses to start smoking. The social service department was educated on completing smoking assessments timely on 12/7/22. The facility will educate all staff to notify the DON/NHA if any resident chooses to start smoking. All education will be completed with staff that are currently in the building and all other staff will be educated prior to his/her next scheduled shift. * All residents that smoke have the potential to be affected by the alleged deficient practice. One resident was identified that currently is choosing to smoke and wears oxygen. The identified resident wasre-evaluated for their ability to smoke, she remains a supervised smoker and her smoking materials will be kept in the nurse's station. The identified residents plan of care was reviewed and updated. Her care delivery guide was updated to reflect her level of supervision needed, where her smoking materials are kept and to remove her oxygen prior to exiting into the smoking area. The resident was educated on the smoking policy, removing her oxygen prior to entering the smoking area and where her smoking materials will be kept if she chooses to smoke. * The social service department was educated on completing smoking assessments timely on 12/7/22. The facility will educate all staff to notify the DON/NHA if any resident chooses to start smoking so that a smoking assessment can be completed, and their care plan and care delivery guide can be updated. All education will be completed with staff that are currently in the building and all other staff will be educated prior to his/her next scheduled shift. * As per above the facility will ensure that all residents currently residing in the facility are educated on the reviewed smoking policy, sharing smoking materials and where the only designated smoking area is located. * All new admissions will be educated on the smoking policy, where the designated smoking area is located and sharing smoking materials on admission to the facility. All resident education will be completed with residents that currently smoke in the facility. * The facility will ensure that smoking assessments are completed timely on new admissions that smoke or any resident that chooses to start smoking. The social service department was educated on completing smoking assessments timely on 12/7/22. The facility will educate all staff to notify the DON/NHA if any resident chooses to start smoking to ensure a smoking assessment is completed and their care plan/care delivery guide is updated. All education will be completed with staff that are currently in the building and all other staff will be educated prior to his/her next scheduled shift. * NHA/Designee will audit the designated smoking area for residents with oxygen equipment, randomly 7 times per day Monday through Sunday x 2 weeks, then 5 times per day Monday through Sunday x 2 weeks, then 3 times per week Monday through Sunday x 2 weeks, then randomly through the week x 2 weeks. All audits will be brought to QAPI for review until the IDT determines there is no longer a risk identified. The deficient practice continues at a scope and severity of a G (actual harm/isolated) based upon the example regarding R7. 2.) A policy titled Falls and Fall Risk, Managing Policy Statement, revised March 2018, stated the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions 7. ln conjunction with the attending physician, staff will identify and implement relevant interventions . to try to minimize serious consequences of falling . According to records reviewed by Surveyor, R7 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident. R7's admission Minimum Data Set (MDS) documented the resident was usually able to understand others and was sometimes understood by others; the resident's vision was adequate, and resident did not wear a hearing aid. The resident scored a 2 on the Brief Interview for Mental Status (BIMS) suggesting severely impaired cognition. The MDS indicated the resident required limited assistance with bed mobility and transfers and walking in the resident's room; R7 required total assistance for bathing and toileting. According to the MDS, R7's balance was not steady, and the resident was only able to stabilize with staff assistance. R7's care plan, dated 09/15/22, was in place prior to the 10/20/22 fall described below and included the following information: The resident is at risk/has potential for falls, accidents R/T [related to] current diagnosis- hx [history] of falls, gait imbalance, generalized weakness, hx of CVA [cerebrovascular accident] with weakness R [right] side. The related care plan problem stated, Injuries will be minimized through the review date. Interventions/approaches were as follows: 9/15/22 - Fall assessment to be completed upon admission after falls, quarterly. Follow therapy - recommendations for transfers and mobility. Review information on past falls and attempt to determine the cause of falls. 10/20/22- Send to ER [emergency room ] and do not leave on toilet unattended. This approach was added following the 10/20/22 fall. R7's care card (not dated) included the following: Fall Risk - No, Continent of bowel and bladder and a check and change and utilizes a brief, Transfers with Hoyer. The care card did not include that R7 was at high risk for falling. R7's Bedside/ Kardex report dated 09/15/22 included the following information: Provide and encourage use of adaptive equipment bedpan . A fall risk assessment dated [DATE] indicated R7 was at high risk for falls with a score of 21.0 The physical therapy evaluation dated 09/16/22 also indicated the resident was at high risk for falls and had a fear of falling with unsteadiness to the resident's gait, requiring total support to the right upper extremity. Toilet transfers were not attempted due to medical condition or safety concerns. On 10/20/22 at approximately 6:45 p.m., according to Licensed Practical Nurse Manager (LPNM)-G who was interviewed by the Surveyor on 12/10/22, a Certified Nursing Assistant alerted LPNM-G that R7 was on the floor. LPNM-G entered R7's room and found the resident on her right side on the floor complaining of pain in her right shoulder. LPNM-G notified the medical provider and x-rays were ordered; ultimately the resident was transferred to acute care for further evaluation. According to LPNM-G, R7 sustained three fractures, including a right shoulder fracture, a right hip fracture and a right wrist fracture. During an interview with R7 after the fall she told the staff she was leaning forward and was unable to hold herself and fell . According to LPNM-G, after transferring the resident to acute care she started an investigation; LPNM-G obtained statements from staff working on the wing where R7 resided and determined the resident was assisted to the toilet by Certified Nursing Assistant (CAN)-Z who was provided by a staffing agency. A written statement from CNA-AA (a second agency CNA) further explained that R7 had been on a bedpan for 45 minutes prior to the fall and was taken off the bedpan and taken to the toilet by CNA-Z where the resident was left while CNA-Z went to lunch. R7's roommate (R27) was interviewed on 12/13/22 at 2:00 p.m. R27 stated that CNA-Z came into the room when R7 put on her call light to go to the bathroom. CNA-Z assisted R7 to the toilet and told R7 to call when she was done using the bathroom. R27 heard R7 fall about five minutes after she was assisted to the toilet. In summary, R7 was admitted to the facility on [DATE] following a cerebrovascular accident with right sided weakness. She was assessed at high risk for falling with a score of 21.0. Therapy had not attempted toilet transfers due to medical concerns or safety concerns. The resident was placed on the toilet by CNA-Z and left unattended while she went to lunch. R7 fell off the toilet fracturing her right wrist, right hip, and right shoulder. The Bedside care card/ Kardex indicated to use a bedpan. According to interview with LPNM-G, the grab bar by the toilet and call light in the bathroom are on the right side of the toilet and, due to R7's right sided weakness, the resident could not reach these. R7 was unable to hold herself upright due to the resident's physical limitations and therefore could not avoid falling. The resident was transferred to acute care for treatment and had not returned to the facility as of the dates of the survey. 3.) During observations made by Surveyor on 12/07/22, the facility failed to provide appropriate and safe cigarette butt receptacles and failed to adhere to designated smoking areas. Used coffee containers with cardboard sides, were being used by residents and possibly staff on two facility patios for cigarette ash and butt disposal. On the Wing-5 patio, that was not a designated smoking area, a red garbage can was observed with overflowing paper refuse such as fast-food containers, that prevented closure of the lid. This garbage can also contained multiple cigarette butts. Cigarette butts were observed throughout the Wing-5 patio space near piles of unraked leaves and two cardboard storage boxes that contained wheelchair cushions. A combustible coffee can that was half-filled with cigarette butts was observed on the metal patio table in Wing-5. No approved safety ash receptacles were observed on the Wing-5 patio and facility administration was unaware that people had been smoking in this area. On 12/07/22 from 9:02 a.m. to 9:13 a.m., the Wing-5 patio was observed with Licensed Practical Nurse Manager (LPNM)-G and Director of Nursing (DON)-B. LPNM-G told the Surveyor that during a recent facility quarantine for a respiratory virus, the smokers were smoking on the Wing-5 patio to limit resident movement in the building. LPNM-G stated that she was unaware when the last time anyone smoked on this patio and that the door codes had been changed recently to limit resident access this area. Upon entering the Wing-5 patio area on 12/07/22 with LPNM-G and DON-B, a round metal patio table and metal chairs were observed. Multiple cigarette butts, too numerous to count, and crushed beer cans were observed on the cement under the patio table. In the center of the metal table, a combustible, cardboard sided, used coffee container was observed half filled with cigarette butts. A red garbage can was observed to be overfilled with paper waste including fast food packages and liquor bottles that prevented the safety lid from closing. No approved ash receptacle was observed in this area. Approximately four feet away from the metal table, were two sealed cardboard boxes that contained wheelchair cushions. Next to these cardboard boxes were small piles of unraked leaves. When the clear, over-filled garbage bag was lifted out of the red waste can, numerous cigarette butts and used alcohol bottles could be seen amongst the garbage. On 12/07/22 at 9:32 a.m., Maintenance Supervisor (MS-J), the Regional Director of Operations (RDO-E), and the Assistant Administrator (AA-D) were observed on the patio removing smoking materials. RDO-E indicated not being aware people were using this area for smoking and this was not a designated smoking area. DON-B indicated not knowing how long it had been since anyone smoked in this area and did not know if staff were using this area to smoke. None of the staff knew who was drinking alcohol on the Wing-5 patio. On 12/07/22 at 9:42 a.m., the designated smoking area near the facility dining room was observed to have eight used coffee containers placed on the ground and on the tables. Five of these containers were combustible with cardboard siding and three were solid metal and non-combustible. All of the containers had cigarette butts in them. Two tall tower approved ash receptacles were also observed on this patio. 4.) According to records reviewed by Surveyor, R4 was admitted to the facility on [DATE] and discharged to home on 08/23/22. The resident's diagnoses included cerebral infarction, respiratory failure, hypoxic ischemia, and rhabdomyolysis. According to the admission Minimum Data Set (MDS) dated [DATE], R4 had adequate hearing, was understood, and was able to understand others. The MDS was coded to indicate R4 scored 11 on the Brief Interview for Mental Status (BIMS) which suggested moderately impaired cognition. According to the MDS, R4 required limited assistance for bed mobility, transfers, dressing, and bathing, and supervision for locomotion off the unit. An Elopement Risk Review dated 07/18/22 indicated R4 was not at risk for elopement. In contrast, the 08/01/22 Elopement Risk Review identified the resident as at risk for elopement; Director of Nursing (DON)-B and facility staff were unable to provide an explanation as to why R4 became at risk for elopement. Risk factors identified in the assessment included the resident being ambulatory, having predisposing conditions and a cognitive impairment, and taking antidepressants. Review of R4's care plan indicated there was no plan to prevent R4 from eloping from the facility despite the resident being identified as at risk for elopement. A smoking assessment, which was completed on 07/18/22 identified R4 as someone who did not currently smoke, although the resident had previously smoked. An investigation completed by the facility on 08/10/22 indicated that on 08/07/22 at approximately 4:00 p.m., R4 was observed leaving the facility through the gate in the smoking patio by an unidentified resident. The unidentified resident did not report this to anyone at the time of the observation, according to DON-B, however the unidentified resident was interviewed at a later time. Around 4:20 p.m., R4 was brought back to the facility by a community man that saw her walking up the highway [on the highway] and stopped to help her. R4 stated to the male, who found the resident, that she was going home. According to facility staff, R4's home was over an hour away from where the facility was located. During interview with DON-B on 12/06/22 at 1:00 p.m., DON-B stated that the resident refused to wear a Wanderguard (R) device and confirmed that there were no additional interventions to prevent the resident from eloping. The resident continued to smoke and spent time on the smoking patio, which was surrounded by a chain link fence that could be opened at the entrance.

Based on observation, record review, and interview, the facility did not comprehensively assess a resident on admission to ensure interventions were implemented to prevent the development of pressure injuries for 1 (R2) of 3 residents reviewed for pressure injuries. R2 was admitted to the facility on [DATE] and a Licensed Practical Nurse (LPN) completed the admission assessment form where redness was noted to R2's right and left buttocks and sacral area. A comprehensive skin assessment was not completed by a Registered Nurse (RN) at that time and there were no interventions. An LPN noted R2 had a red area to the right and left buttocks and sacral area on 2/14/2022 and an RN was not notified to comprehensively assess the area. On 2/15/2022, R2 was found to have an Unstageable pressure injury to the right buttock, a Deep Tissue Injury (DTI) to the left buttock, and a DTI to the left heel. According to N6 Wisconsin Nurse Practice Act, an LPN can collect data, but an RN is responsible for assessing, planning, intervening and evaluating. The Facility failure to ensure an RN comprehensively assessed a newly admitted resident for skin integrity, despite a reddened area noted on the buttock on 2/9/22 and again on 2/14/22, and the resulting failure to put more stringent measures in place to prevent the reddened areas from worsening led to an unstageable pressure injury, which became infected and required debridement and antibiotics. When the facility did implement two-hour repositioning on 2/15/22, the facility did not change the certified nursing assistant (CNA) care card. The failure to comprehensively assess and revise the resident's care plan to prevent the worsening of R2's skin condition and pressure injury created a finding of immediate jeopardy that began on 2/9/2022. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 3/22/2022 at 8:45 AM. The immediate jeopardy was removed on 3/24/22 and continues at a scope and severity level of E (potential for harm/pattern) as the facility continues to implement and monitor the effectiveness of their removal plan for the 44 residents identified to be at risk for the development of pressure injuries. Findings include: The facility policy and procedure entitled Admission Assessment and Follow Up: Role of the Nurse dated 9/2012 states: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. 8. Conduct a physical assessment, including the following systems: . j. Skin. 9. Conduct supplemental assessments (following facility forms and protocol) including: . e. Skin assessment: . Reporting: 1. Notify the supervisor and the Attending Physician of immediate needs that the resident may have. 3. Report other information in accordance with facility policy and professional standards of practice. The facility policy and procedure entitled Prevention of Pressure Ulcers/Injuries dated 7/2012 states: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., nonblanchable [CONDITION(S)]). b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Mobility/Repositioning: 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. The facility policy and procedure entitled Skin Management Guidelines Practice Guidelines dated 10/2021 states: . Newly admitted Residents: Upon admission, all residents are assessed for skin integrity within 8 hours of admission by completing a head to toe physical assessment and documenting on the admission assessment and completing the Braden Scale - For Predicting Pressure Sore Risk . Following admission; the Braden Scale - For Predicting Pressure Sore Risk in (the computer charting system) will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with a change of condition, for their risk for development of pressure injury. A resident risk may increase due to an acute illness or condition changes (URI, Pneumonia, or exacerbation of underlying CHF, etc) and may require additional evaluation. Therefore it is recommended a repeat Braden assessment be completed if a resident has a significant change of condition. Nurse aides will complete body audits at least weekly, but preferably with every bathing opportunity. The body audits post shower will be turned into the licensed nurse to review for changes in skin condition. Appropriate preventive measures will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale - For Predicting Pressure Sore Risk), and the interventions documented on the Care Plan . A Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment (there should be separate care plans for Risk of and actual), and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to: Hydration, Nutrition, Preventive devices, Physical Activity, Pain, Positioning requirements, Proper Body Alignment . On 2/3/2022, R2 was sitting in a wheelchair at home when R2 fell asleep and fell forward landing face first on the ground sustaining a bruise to the forehead. R2 was transported to the hospital and admitted with acute kidney injury and [CONDITION(S)] of the right leg with an ulcer requiring intravenous (IV) antibiotics. The hospital records on 2/9/2022 included documentation of wounds to the left great toe due to trauma, the left second toe due to trauma, and a venous ulcer to the right lower leg that measured 1.5 cm x 1.4 cm x 0.1 cm. There was no documentation of a wound or area of concern to the right or left buttock or sacrum. Patient Discharge Instructions from the hospital on 2/9/2022 stated activity as tolerated, resume prior diet, and see provided instructions for wound care. No hospital instructions for wound care were found in R2's facility record. R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/9/2022, LPN-C did the admission assessment of R2. The Skin section of the assessment documented an abrasion to the top of the scalp on the left side, bruising to the back of the right hand, redness to the front of the right lower leg, a vascular ulcer to the front of the right lower leg measuring 1.5 cm x 0.7 cm x 0 cm, and the left toe was missing the great toenail. No other areas were documented on this form. LPN-C had a hand-written worksheet dated 2/9/2022 with vital signs and a body diagram that had the same areas circled as documented above as well as a large circle around the sacral/buttocks area that said redness. No measurements or other descriptors of the area were documented. No documentation was found by Surveyor that an RN assessed R2's skin. On 2/9/2022, a Braden scale was completed that had a score of 13 indicating moderate risk of skin breakdown. A baseline care plan was done on 2/9/2022 by Director of Nursing (DON)-B that indicated R2 had -a special mattress, -heel protectors/elevate heels, -reposition every 2-3 hours, -wound to the buttocks/sacrum that was present prior to admission. -was incontinent of bowel -had a foley catheter -aids used for transfers (example: Hoyer) but did not specify what type of lift was to be used No bathing or toileting plan was completed on the baseline care plan. In an interview on 3/21/2022 at 10:00 AM, Director of Nursing (DON)-B stated the wound to the buttocks and sacrum written on the baseline care plan was in reference to the reddened area that LPN-C noted on admission. Surveyor asked DON-B if DON-B had assessed R2's skin on 2/9/2022. DON-B stated DON-B never looked at R2's skin but was told by LPN-C that the sacral area had blanchable redness and so DON-B put it on the care plan for staff to monitor the area. Surveyor asked DON-B and Corporate RN-F what kind of specialty mattress did R2 have in place on 2/9/2022. Corporate RN-F stated the mattress was a pressure-reducing mattress that is on all resident beds. Surveyor clarified R2 did not have an alternating pressure mattress. Corporate RN-F confirmed R2 did not have an alternating pressure mattress on 2/9/2022. On 2/10/2022 at 3:23 AM in the progress notes, nursing charted R2 was on oral antibiotics for [CONDITION(S)] and the right lower leg dressing was intact. Surveyor reviewed R2's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/10/2022 on the Physical Therapy (PT) evaluation, PT charted R2 demonstrated excellent rehab potential with the ability to participate in tasks of increased complexity, ability to safely adapt to change, ability to self-correct, able to make needs known, active participation in skilled treatment, high prior level of function, motivated to participate, motivated to return to prior level of living, strong family support, high cognitive functioning, ability to follow 2-step directions, ability to imitate targets, able to scan environment, active participation with plan of treatment and attentive to tasks. On 2/10/2022 on the PT Treatment Encounter note, PT charted R2 exhibited limited motion of lower extremities due to increased pain with movement and reported feeling apprehensive to sit at the edge of the bed. Per R2, the sheet does not slide like the sheets at home. PT recommended R2 to be a Hoyer lift for transfers and a maximum assist for bed mobility. On 2/10/2022 on the Occupational Therapy (OT) evaluation, OT charted that due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, R2 is at risk for decreased ability to return to prior level of assistance, decrease in level of mobility, decreased participation with functional tasks, and falls. On 2/14/2022 on the OT Treatment Encounter note, OT charted R2 was lying on the bed and needed maximum assist of two for rolling in either direction with R2 stating R2 was stiff all over. R2 was very challenged with rolling, needing maximum assist of one to bring legs to the edge of the bed and moderate assist of two to bring R2 to an upright position on the edge of the bed. R2 needed maximum assist of two to lie back down with cuing to lean into the right elbow and maximum assist to bring legs up onto the bed. R2 sat on the edge of the bed for approximately 14 minutes. R2 attempted with the use of a sit-to-stand lift to get buttock partially off the bed before needing to sit down with assistance of two. In an interview on 3/21/2022 at 10:45 AM, Certified Nursing Assistant (CNA)-E stated bath sheets are filled out by the CNA when a bath or shower is done. CNA-E stated the front of the sheet shows what is provided to the resident with the shower or bath and then the comment section on the bottom of the front is where any skin concerns are written or if the resident wanted a bed bath instead of a shower. CNA-E stated the form is then signed by the CNA and given to the nurse on the floor who signs the form and does the skin check on the back of the sheet. The back of the sheet has a diagram of the front and back of a body and a place for the signature of who completed the form and a place for the nurse's signature. CNA-E stated the form is then put in a plastic filing unit mounted on the wall of the nurses' station where the DON or unit manager collects them. On 2/14/2022 at 7:00 PM on the shower sheet/skin check sheet, a circle was hand-written around the buttocks/sacrum area and RED was written in capital letters on the body diagram on the back of the form. The front of the form had a signature by a CNA and an LPN. No signatures were on the back of the form to indicate who circled the area of concern. No measurements were documented of the area of concern. No documentation was found by Surveyor that an RN assessed R2's skin. The CNA and LPN were not available for interview. On 2/15/2022 on the PT Treatment Encounter note, PT charted R2's incontinence brief was inspected, and dry blood was noted around the penile/catheter site. PT addressed care to the area and noted stool in the brief. R2 was dependent for rolling and during the care, a large sacral wound with eschar was found. The therapist informed the nurse who then retrieved the Regional Director of Nursing to observe the wound. R2 was dependent on assist of two to maintain lying on the side. Once nursing addressed and noted the wound, R2 was returned to lying on the back and was dependent on two to three to assist scooting up in bed. R2 had heels floated with a pillow. On 2/15/2022 on the OT Treatment Encounter note, Certified Occupational Therapy Assistant (COTA)-H charted R2 was lying in bed upon entering the room and stated R2 was on the bed pan. After COTA-H returned to the room, R2 stated R2 was not sure if R2 was on a bed pan or not. COTA-H confirmed R2 was not on a bed pan and had a bowel movement in the incontinence brief. COTA-H charted PT was with COTA-H at the encounter and together, due to maximum assistance of two to roll R2 to roll in either direction, attempted to clean R2 up. R2 complained of moderate back pain when bed was partially lowered and when rolled. R2 was rolled onto the right side and COTA-H charted COTA-H noticed a pink bandage on the left buttock cheek as well as blackened skin on the right buttock cheek that was difficult to see as R2 was lying on the right side. R2 needed slow careful rolling to return to the back and resting before rolling to the left side for cleaning and putting a clean incontinence brief on. COTA-H charted after rolling R2 to the left, the right buttock cheek was noted to have a large, blackened area and nursing was notified. COTA-H and PT assisted in holding R2 on the side while Corporate RN-F measured the wounds and R2 was then cleaned. COTA-H documented R2 was unaware of a sore on the bottom and could not remember if one had been present before. R2 was returned to the back position, scooted up in bed, and sat up for breakfast with the recommendation to be placed on the side every two hours. In an interview on 3/21/2022 at 11:22 AM, COTA-H stated COTA-H and a PT assistant had gone into R2's room on 2/15/2022 to do therapy with R2, but R2 thought R2 was on the bedpan. COTA-H stated R2 was not on the bedpan but had been incontinent of bowel in a brief so COTA-H and the PT assistant decided to assist nursing staff and clean R2 up. COTA-H stated R2 had a pink patch or bandage on the left cheek and when they rolled R2 over the other way, they could see the right cheek looked black. COTA-H stated the area was quite large and black and could not understand how no one up until that time had not noticed the area. Surveyor did not find any documentation in R2's record of a dressing being ordered or applied to R2's left buttock prior to 2/15/2022. In an interview on 3/21/2022 at 10:55 AM, CNA/Med Tech (MT)-G stated on 2/15/2022 CNA/MT-G was passing medications on the unit and therapy reported to CNA/MT-G that R2 had something on R2's bottom. CNA/MT-G stated CNA/MT-G went to look at R2 and that was the first time CNA/MT-G had seen R2's skin. CNA/MT-G stated CNA/MT-G immediately got Corporate RN-F to look at the wounds. On 2/15/2022 on the Initial Wound Assessment form, Corporate RN-F documented R2 had an Unstageable Pressure Injury to the right buttock that measured 13.3 cm x 6.8 cm x 3.2 cm with 70% granulation, 7% slough, 7% eschar, 16% epithelialization with a small amount of serosanguineous drainage. On 2/15/2022 on the Initial Wound Assessment form, Corporate RN-F documented R2 had a Suspected Deep Tissue Injury to the left buttock that measured 7.6 cm x 4.7 cm x 0.1 cm with 97% granulation and 3% eschar with moderate amount of serous drainage. On 2/15/2022 on the Initial Wound Assessment form, Corporate RN-F documented R2 had a Suspected Deep Tissue Injury to the left heel that measured 1.7 cm x 1.8 cm with no description of the color of the area. The left heel Deep Tissue Injury was comprehensively assessed weekly. Wound Physician-I was in the facility on 2/15/2022 and assessed R2 at that time with Corporate RN-F. A treatment was ordered for the three pressure injury wounds, ProStat 30 ml twice daily was ordered, and R2 was placed on bedrest. In an interview on 3/21/2022 at 12:49 PM, Wound Physician-I stated on 2/15/2022 when the pressure injuries were initially looked at, the right buttock was an unstageable pressure injury and the left buttock was a deep tissue injury. Surveyor asked Wound Physician-I if there was any granulation tissue to the left buttock. Wound Physician-I stated the left buttock was not open and had the characteristics of a deep tissue injury with partial thickness damage but was not really open that turned into black eschar. Wound Physician-I stated the right buttock wound was debrided on 2/15/2022. Surveyor asked Wound Physician-I if any interventions were ordered to prevent further breakdown. Wound Physician-I stated staff were verbally told to turn R2 side to side as much as possible but there were no written orders. R2's Potential/Actual Impaired Skin Integrity Care Plan was created on 2/15/2022 with the following interventions: -Wound Physician consult -Treatment as ordered -Bed rest at this time -Protein meal supplement -Labs -Float heels in bed/heel boots in bed -Turn and reposition every two hours -Apply cushion to wheelchair -Barrier cream after each incontinent episode and as needed -Complete Braden scale on admission, weekly times 4, quarterly, with significant change, and as needed -Free float heels in bed -Weekly skin assessment -Monitor skin with all cares; report any changes to nurse -Update physician as needed -Refer to Registered Dietician as needed -Assist to reposition every 2-3 hours and as needed was put in the care plan and removed from the care plan on 2/15/2022 -Pressure redistribution mattress was put in the care plan and removed from the care plan on 2/15/2022 -Alternating pressure mattress On 2/19/2022 at 3:21 PM in the progress notes, nursing charted the Nurse Practitioner was aware of the lab results for R2 and [MEDICATION(S)] was placed on hold until 2/20/2022 due to elevated PT/INR (Prothrombin Time/International Normalized Ratio) indicating an increased potential for bleeding. R2's Potential/Actual Impaired Skin Integrity Care Plan was revised on 2/20/2022 with the following interventions: -Float heels in bed -Heel boots in bed -Turn and reposition every 2 hours On 2/22/2022 on the Weekly Wound Assessment form, Corporate RN-F documented the left and right buttock pressure injuries merged to become one Unstageable pressure injury to the sacrum/bilateral buttocks measuring 13.9 cm x 15.8 cm x 5.5 cm with 25% eschar, 25% necrotic, and 50% adipose tissue with a small amount of serosanguineous drainage. In the comment section of the form, Corporate RN-F documented the area was debrided by Wound Physician-I and there was a moderate amount of bleeding. Dakins wet to dry ABD pad and calcium alginate were placed on the wound. R2 was instructed to lay on the back for two hours and then have the wound rechecked for bleeding. If bleeding was noted at that time, Wound Physician-I was to be notified. On 2/22/2022 at 11:12 AM in the progress notes, Corporate RN-F charted R2 was seen by the wound team and Wound Physician-I. The left and right buttock wounds were debrided and are now listed as one wound to the sacrum/bilateral buttocks as unstageable. There was a moderate amount of bleeding during the procedure with one area covered with calcium alginate to help stop the bleeding. The wound was packed with Dakins wet kerlix and covered with two ABD pads. R2 was positioned on the back to help aid in stopping any active bleeding. R2 was to stay on the back for two hours and then have staff check for bleeding. If there is still bleeding, Wound Physician-I was to be notified. On 2/22/2022 at 1:18 PM in the progress notes, Corporate RN-F charted debridement had been done at 1:15 PM and staff are aware to check on the wound for bleeding in two hours. On 2/22/2022 at 3:29 PM in the progress notes, DON-B charted the dressing was pulled down and had a moderate amount of dark red blood drying on the dressing. Calcium alginate was still in place and no active bleeding was noted at that time. R2 did not have any complaints of pain and was positioned on the back to continue to have pressure applied to the area. On 2/22/2022 at 5:45 PM in the progress notes, nursing charted the dressing was checked and R2 was still having active bleeding from the wound. Wound Physician-I was notified, and orders were received to send R2 to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/22/2022 at 9:04 PM in the progress notes, nursing charted 911 was called and the paramedics arrived at approximately 5:30 PM. On 2/22/2022 on the emergency room report, R2 received the following care and treatment: R2 presents to the emergency department for evaluation of bleeding sacral wound. The patient had 3 distinct areas of bleeding on his sacral wound. Two of them were able to be stopped with silver [MEDICATION(S)] sticks. However 1 of them was unable to be controlled by silver [MEDICATION(S)] as it had continuous oozing. I tried TXA ([MEDICATION(S)]) soaked gauze as well. However this did not stop the bleeding. I discussed the case with (another physician). He recommended [MEDICATION(S)] sutures to the area of oozing. For [sic] (4) [MEDICATION(S)] sutures were placed in that area in a figure-of-eight pattern which did allow for hemostasis of the bleeding areas. Patient was otherwise well appearing and plan for discharge back to his nursing facility given that he has hemostasis at this time. Patient to follow-up with his wound care physician there for further management. Patient is to follow up with (physician named) . Schedule an appointment as soon as possible for a visit in 1 week. On 2/22/2022 at 11:06 PM in the progress notes, nursing charted R2 returned with three sutures in place and bleeding controlled. R2's Potential/Actual Impaired Skin Integrity Care Plan was revised on 2/22/2022 with the following intervention: turn and reposition side to side every 2 hours. On 2/23/2022 at 11:38 AM in the progress notes, nursing charted the Nurse Practitioner approved the Registered Dietician's recommendation for multivitamins with minerals and Med Pass 2.0 supplement 90 ml twice daily. On 2/23/2022 at 2:56 PM in the PT Treatment Encounter Note, PT charted due to recent change of status- sacral pressure sore- pt (patient) has been placed on bed rest**-- [sic] this pressure sore was present before entry to facility and eval, but not documented or known of-until therapy discovered during a session. approached pt for session, no bed mobility can be performed, pt kept EC during interation [sic] (R2 kept ending conversation during interaction), eventually pt stopped responding to writers inquiries. Writer then left room. On return, pt demo'd (demonstrated) minimal response to writer, will assess pt next session. On 2/23/2022 in the OT Treatment Encounter Note, OT charted Writer returned later, with pt (patient) up in WC (wheelchair), awaiting new mattress to be aired up, expressing discomfort after ~10 min (approximately ten minutes). Writer then assisted CNA in returning pt to bed and adjusting air and positioning, following hoyer transfer. Pt stated being more comfortable following bed change. In an interview on 3/21/2022 at 1:15 PM, DON-B stated the facility had to get a rental alternating pressure mattress because there was a problem with the motor one night with the mattress they were using, and the mattress was replaced the next day. DON-B stated the mattress had to be kept on static instead of alternating pressure for it to work. Surveyor reviewed the delivery invoice of the low air loss mattress and pump. The invoice was dated 2/24/2022 with delivery time of 12:00 Noon. Per the OT note on 2/23/2022, a mattress was obtained on 2/23/2022 to replace a malfunctioning mattress and with the delivery date of 2/24/2022 for another mattress, R2 had a malfunctioning mattress for at least 24 hours. On 2/26/2022 at 2:15 PM in the progress notes, nursing charted wound care to the coccyx was completed with a large amount of serous drainage on the old dressing. R2 was instructed on the importance of changing position every two hours and keeping off the wound as much as possible. R2 verbalized understanding. On 2/27/2022 at 3:39 AM in the progress notes, nursing charted R2 does not like to reposition/turn side to side with rounds. The air mattress was functioning. On 3/1/2022 on the Weekly Wound Assessment form, Corporate RN-F documented the Unstageable pressure injury to the sacrum/bilateral buttocks measured 15.7 cm x 18.2 cm x 4.7 cm with 25% granulation and 75% eschar with a small amount of serosanguineous drainage. In the comments section of the form, Corporate RN-F documented R2 was seen by the wound team and Wound Physician-I. The wound was debrided with a moderate amount of eschar and necrotic tissue. R2 tolerated the debridement without complaints and with minimal bleeding. A culture was taken of the wound. Wound Physician-I informed Corporate RN-F there were no signs or symptoms of infection and would get a complete blood count (CBC) ordered for 3/2/2022. On 3/1/2022 at 8:01 AM in the PT Discharge Summary, PT charted R2 is unable to progress towards goals and level of indep (independence) d/t (due to) significant sacral wound status placing pt (patient) at bed rest per nursing. Plan is for pt to stay LTC (Long Term Care) at this time. May benefit with reassessment of functional status upon clearance of bed rest/wound status. On 3/2/2022 at 11:03 AM in the progress notes, nursing charted a new order was received from Wound Physician-I to start [MEDICATION(S)] 1 Gm intramuscularly (IM) daily for two weeks and [MEDICATION(S)] 100 mg twice daily for two weeks for possible wound infection. The CBC on 3/2/2022 had an elevated white blood count of 13.8 indicating an infectious process and the culture of the wound had grown out pseudomonas aeruginosa and bacteroides thetaiotaomicron. On 3/2/2022 at 12:47 PM in the progress notes, nursing charted the CBC and culture and sensitivity from the wound culture were reviewed and the [MEDICATION(S)] was discontinued, and the IM [MEDICATION(S)] was changed to IV [MEDICATION(S)]. A new order for [MEDICATION(S)] 1 Gm IV daily for two weeks was given. A PICC line was to be inserted. Surveyor reviewed R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -3/2/2022: [MEDICATION(S)] ([MEDICATION(S)]) 1 GM IM daily -3/4/2022-3/5/2022: [MEDICATION(S)] ([MEDICATION(S)]) 1 GM IV daily and [MEDICATION(S)] 1 GM IV daily -3/6/2022-current: [MEDICATION(S)] 500 mg IV twice daily (only received one dose on 3/6/2022 and 3/7/2022) and [MEDICATION(S)] 500 mg IV twice daily (only received one dose on 3/6/2022, 3/7/2022, and 3/8/2022) On 3/8/2022 on the Weekly Wound Assessment form, Corporate RN-F documented R2's sacrum/bilateral buttocks Unstageable pressure injury measured 15.3 cm x 20.1 cm x 4.4 cm with 25% granulation and 75% eschar with a small amount of serosanguineous drainage. In the comments section of the form, Corporate RN-F charted the wound was debrided by Wound Physician-I with minimal bleeding and R2 continued IV antibiotics. On 3/15/2022 on the Weekly Wound Assessment form, Corporate RN-F documented R2's sacrum/bilateral buttocks Unstageable pressure injury measured 14.0 cm x 17.3 cm x 4.7 cm with 50% granulation and 50% eschar with undermining from 11 o'clock to 4 o'clock measuring 4.7 cm with a scant amount of serous drainage. In the comments section of the form, Corporate RN-F charted the wound was debrided by Wound Physician-I with minimal bleeding. Undermining was now present and R2 continued IV antibiotics. R2's Potential/Actual Impaired Skin Integrity Care Plan was revised on 3/15/2022 with the following interventions: -3/2/22 Intramuscular (IM) antibiotic, labs, and wound culture -3/5/22 Peripherally inserted central catheter (PICC) care and flushes, intravenous (IV) antibiotic as ordered, monitor for adverse reaction to antibiotic R2's Actual Infection to Sacral/Buttocks Wound Care Plan was created on 3/15/2022 with the following interventions: -Administer antibiotics per physician order -Cares and flushes of IV/PICC line per policy -Encourage fluids -Monitor IV site every shift; report any redness, swelling, or signs/symptoms of infiltrate -Monitor labs as ordered -Notify physician or nurse of signs/symptoms of adverse response to antibiotic/treatment R2's Potential/Actual Impaired Skin Integrity Care Plan was revised on 3/21/2022 with the following intervention: may remove soft boots for 15 minutes per R2's request. R2's CNA Care Card obtained on 3/21/2022 informing the CNA staff caring for R2 of R2's needs had the following information: -Bath Day: Monday PM shift -Transfer Status: assist of two with a mechanical lift (the type of mechanical lift is not designated) -ADL (activities of daily living): assist of 1 -Safety Devices and Appliance [TRUNCATED]

Based on interview and record review, the facility did not ensure that 4 (R59, R97, R93 and R18) of 22 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, that will meet each resident's physical, mental, and psychosocial needs. 1. R59 had orders for 2 Comprehensive Metabolic Panel (CMP) lab draws to be completed on 11/8/21 and 11/15/21. The labs were not ordered and never completed. There was no follow up from the facility to ensure the labs were completed as ordered. On 11/15/21 R59 was hospitalized for acute [CONDITION(S)] Stage 3, [CONDITION(S)] with recent treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These changes and abnormal lab values could have been identified had the 11/8/21 and the 11/15/21 labs been drawn. 2. R97 had a surgical wound. The facility did not follow MD orders for care and treatment. 3. R93 sustained a toe injury and was not having diabetic foot checks or care to that area. 4. R18 had missing assessments of blisters to the right lower leg and R18 was not comprehensively assessed for six days when readmitted to the facility. The example involving R59 is being cited at a scope/severity of a G (actual harm/isolated). Findings include: 1. Surveyor reviewed facility's Lab Diagnostic Test Results - Clinical Protocol policy with a revision date of November 2018. Documented was: Assessments and Recognition 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility . R59 was admitted to the facility 9/2/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed Progress Notes documented by Former Nurse Practitioner (NP)-D. Documented on 10/6/21 was: [History of Present Illness (HPI)]: The patient was admitted to the [facility] on 9/2/21 after a 2-week long hospital stay. The patient presented to the hospital with abdominal pain, nausea and vomiting. After further review, the patient recently underwent a pancreatic necrosectomy and a diverting [CONDITION(S)] with a GJ tube that was converted to a G-tube due to necrotizing infected pancreatitis with colonic pancreatic fistula. After further workup, the patient was found to have [acute kidney injury (AKI)]. She was started on IV fluids and given pain medications and antiemetics. Due to the patient's dementia, she is unable to contribute to historical health information. After further review, the patient's health history includes hypertensive heart failure, [CONDITION(S)], coronary artery disease, [CONDITION(S)], and on a long-term anticoagulant. She has seasonal/environmental allergies, chronic obstructive pulmonary disease and obstructive sleep apnea. She has anxiety and depression and is followed by psych. The patient is malnourished, has dysphagia, gastro-[CONDITION(S)] reflux disease, and the presence of [CONDITION(S)]. She has [CONDITION(S)], diabetes mellitus type II, and [CONDITION(S)] stage 3 without the use of insulin. She has [CONDITION(S)], [CONDITION(S)] and an unsteady gait with a history of falls . CARE PLAN / ASSESSMENT ICD 10 or [diagnosis (DX)]: [CONDITION(S)], unspecified -New order for repeat [Basic Metabolic Panel (BMP)] -Monitor intake and output -Monitor weight -Monitor BMP -Monitor vitals -Avoid nephrotoxic medications . Surveyor reviewed BMP labs ordered and drawn on 9/16/21. Results were reviewed by NP-D and no new orders were given. Lab results were: Potassium: 4.3 (normal reference range 3.4 - 5.1) Blood Urea [MEDICATION(S)] (BUN): 35 High (normal reference range 6 - 23) Creatinine: 2.35 High (normal reference range 0.70 - 1.30) Calcium: 12.4 High (normal reference range 8.4 - 10.2) Surveyor reviewed BMP labs ordered and drawn on 9/24/21. Results were reviewed by NP-D and no new orders were given. Lab results were: Potassium: 3.8 (normal reference range 3.4 - 5.1) BUN: 29 High (normal reference range 6 - 23) Creatinine: 2.11 High (normal reference range 0.70 - 1.30) Calcium: 12.2 High (normal reference range 8.4 - 10.2) Surveyor reviewed BMP labs ordered and drawn on 10/1/21. Results were reviewed by NP-D and no new orders were given. Lab results were: Potassium: 3.8 (normal reference range 3.4 - 5.1) BUN: 36 High (normal reference range 6 - 23) Creatinine: 1.88 High (normal reference range 0.70 - 1.30) Calcium: 11.9 High (normal reference range 8.4 - 10.2) Surveyor reviewed BMP labs ordered and drawn on 10/6/21. Results were reviewed by NP-D and no new orders were given. Lab results were: Potassium: 4.1 (normal reference range 3.4 - 5.1) BUN: 32 High (normal reference range 6 - 23) Creatinine: 1.88 High (normal reference range 0.70 - 1.30) Calcium: 12.1 High (normal reference range 8.4 - 10.2) Surveyor reviewed R59's MD orders with a date of 10/12/21. Documented was discontinue Sodium [MEDICATION(S)]. There was no further BMP, CMP or other labs to monitor Potassium, BUN, Creatinine, Calcium or Sodium [MEDICATION(S)] from 10/12/21 through 11/5/21. NP-D was not employed at the facility after 10/18/21 and MD-L continued to follow R59 and write orders. Surveyor reviewed R59's MD-L's orders with an order date of 11/5/21. Documented with a start date of 11/8/21 was CMP, one time only for 1 Day. This order was documented Completed on 11/9/21. Documented with a start date of 11/15/21 was CMP and [Vitamin D], one time only for 1 Day. This order was documented Completed on 11/16/21. Surveyor reviewed R59's hard chart, Electronic Medical Record and lab results provided by the facility. There were no lab results from 11/8/21. The lab results from 11/15/21 included a stool sample lab and a blood test but did not include a CMP or Vitamin D lab test as ordered. Surveyor reviewed R59's Progress Notes with a date of 11/15/21. Documented at 3:35 PM was Patient transported to a local ED after discussing her condition with [NP]. Patient had been complaining of headache past several days . Surveyor reviewed Hospital Paperwork with an admitted [DATE] and discharge date of [DATE]. Documented was: Hospital Course . Acute [CONDITION(S)] on stage 4 [CONDITION(S)] Electrolyte derangements including [CONDITION(S)] with recent treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . -IV fluids per Nephrology. Creatinine on admission 3 (with baseline creatinine on 09/23/2021 2.1) -> improved 1.9 with fluids, at baseline. -calcium [MEDICATION(S)] per nephrology -ionized calcium ordered -phosphorus normal -Vitamin-D ordered Mild [CONDITION(S)] -no acute changes on [electrocardiogram (EKG)] -use IV fluids -nephrology on consult, started on Veltessa. Placed on 70 mEq per day oral potassium restriction. Continue oral sodium [MEDICATION(S)]. Attached 5.9 -> 5.6. -cleared for discharge and follow with Nephrology outpatient Severe [CONDITION(S)] - replaced and corrected, replaced Decreased [MEDICATION(S)] -likely secondary to her renal disease -has been on sodium [MEDICATION(S)] . Laboratory values: 11/15/21 [4:05 PM] BUN: 56 High (normal reference range 6 - 23) Creatinine: 3.03 High (normal reference range 0.70 - 1.30) Calcium: 5.3 Low (normal reference range 8.4 - 10.2) . On 12/02/21 at 10:43 AM Surveyor interviewed Registered Nurse (RN)-G. Surveyor asked who puts lab orders in and the process followed. RN-G stated the nurse who takes the order is in charge of putting in the labs. RN-G stated they go in 2 places; first the order is entered into the patients Electronic Medical Record and second they are entered into the lab online system so lab comes out to draw it. RN-G stated this is done on the computer with a login and password. Surveyor asked if someone was in charge of checking to make sure the labs were completed and drawn. RN-G stated she was not sure and that would be above me noting someone in management. On 12/2/21 at 12:02 PM Surveyor interviewed anonymous Medical Professional (MP)-U. Surveyor asked MP-U why a medical professional would order labs. MP-U stated they would order labs on admission to get a baseline and then routinely as needed depending on the patient. Surveyor asked what labs would be monitored for R59. MP-U said BMP to include BUN and Creatinine and electrolytes. Surveyor asked if the labs on 11/8/21 and 11/15/21 were drawn, would it be possible to correct or possibly avoid the acute [CONDITION(S)] and electrolyte derangements that R59 needed to be hospitalized for . MP-U stated yes, by monitoring these labs you could have monitored and see if they were trending up. MP-U stated it certainly would have given an indication that something was going on with the resident that could have allowed a change in treatment and avoid hospitalization . On 12/02/21 at 2:04 PM Surveyor interviewed Regional Nurse Consultant (RNC)-C. Surveyor asked who puts lab orders in and the process followed. RNC-C stated the nurse who takes the order is in charge of putting in the labs. Surveyor asked how the lab receives the order. RNC-C stated the orders are entered into the labs online portal called Test Direct. Surveyor asked if the facility has any system to know what labs were completed. RNC-C stated the facility has a lab binder. Surveyor asked if that confirms labs were drawn per order. RNC-C stated no. Surveyor noted the CMP labs on 11/8/21 and 11/15/21 that were not drawn. RNC-C stated she is not sure why they were not drawn. RNC-C checked the online portal system and those 2 labs were never put into the system to be drawn. RNC-C stated the nurse who took that order should have entered them into the online portal. Surveyor asked if there was any other documentation noting why these labs were not completed. No additional information was provided. 2.) R93 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R93's Admission MDS (Minimum Data Set) dated 11/5/21 documents a BIMS (Brief Interview for Mental Status) score of 11, indicating that R93 has moderate cognitive impairment. R93's Diabetes Mellitus management care plan dated as initiated on 11/1/21 documents under the Interventions section, Inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness. On 11/29/21 at 10:24 a.m., Surveyor interviewed R93 regarding the quality of care at the facility. R93 informed Surveyor that he had recently stubbed his right big toe on the dresser and that a nurse came and just put a Band-Aid on it. R93 informed Surveyor that he was concerned that since then, nursing staff had not come to evaluate the area and or change the Band-Aid. Surveyor reviewed R93's medical record, including R93's MAR (Medication Administration Record) and TAR (Treatment Administration Record) and was unable to locate any documentation that facility staff had assessed or treated R93's right toe and or that facility staff was inspecting R93's feet daily as documented in R93's diabetes management care plan. On 11/30/21 at 2:51 p.m., Surveyor observed CNA (Certified Nursing Assistant)-N remove R93's socks. Surveyor observed some dried blood on R93's left toe nail and a scab on his right toe. On 11/30/21 at 2:59 p.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. NHA-A informed Surveyor that she would get nursing staff to assess R93's feet and would follow up with Surveyor. R93's nursing note dated 11/30/21 at 4:06 PM documents, Nurses Note Text: This writer was informed that resident complained that he bumped his toe on his dresser a few days ago and a nurse put on band aid on it. Writer went and talked to resident he states that maybe 5-6 days ago he bumped his right big toe un the dresser and he got a small cut he stated he told a nurse and she put a band aid on it. No band aid noted. Right great toe has a 1.5 x 1.5 (centimeter) scab on it no s/sx (signs or symptoms) of infection. Resident denies any pain. No treatment needed at this time. NP (nurse practitioner) aware NNO (no new orders). On 12/1/21 at 10:32 a.m., Surveyor informed DON (Director of Nursing)-B and RN (Registered Nurse) Consultant-C of the above findings. Surveyor asked RN Consultant-C if R93 should be getting daily foot checks as documented in R93's diabetes management plan of care. RN Consultant-C reviewed R93's medical record and informed Surveyor that R93 should be getting daily foot checks as documented in R93's plan of care. RN Consultant-C informed Surveyor that she had added daily foot checks to R93's TAR (Treatment Administration Record) so that it could be completed daily. No additional information was provided. 3.) R97 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R97's Admission MDS (Minimum Data Set) dated 8/29/21 documents a BIMS (Brief Interview for Mental Status) score of 10, indicating that R97 is moderately cognitively impaired. Section G (Functional Status) documents that R97 requires extensive assistance and a two person physical assist for his bed mobility needs. Section G0400 (Functional Limitation in Range of Motion) documents that R97 has impairment to one side of his upper extremities and no impairment to either side of his lower extremities. Section M (Skin Conditions) documents that R97 was admitted to the facility with 1 surgical wound present upon admission to the facility. R97's Skin Integrity care plan dated as initiated on 8/23/21 documents under the Focus section, Resident has impaired skin integrity .surgical wound to RLE (right lower extremity)- resolved 11/23/21. Under the Interventions section it documents, Treatment as ordered. R97's wound assessment dated [DATE] documents, right lower extremity- surgical incision; measurements: 12.5 (centimeters) x 4.3 cm x 0; Description: scab; Treatment: [MEDICATION(S)]. Surveyor noted that R97 received weekly wound assessments and daily treatments for his Right lower extremity surgical wound from 8/24/21 to 9/14/21. R97's Tissue Analytics assessment as completed by Wound MD (Medical Doctor)-P and dated 9/14/21 documents, Location: Right shin; Length: 10.23 cm, Width: 2.67 cm, Depth 0.10 cm, Etiology: Trauma, Woundbed Assessment: Eschar: 76-100%, Plan of Care: Discussed with facility staff. Surveyor noted that per Wound MD-P's documentation, R97's right shin surgical wound was debrided by Wound MD-P on 9/14/21. R97's Tissue Analytics post debridement assessment as completed by Wound MD-P, dated 9/14/21 documents, Location: Right Shin; Length: 10.93 cm, Width: 3.20 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 1-25%, Slough 51-75%; Orders: Cleanse wound with saline; protect periwound with skin prep, apply silver gel to wound bed, cover wound with ABD (Army Battle Dressing), secure dressing with Kerlix, change daily, Change PRN (as needed) for soiling and/or saturation. R97's Orthopedic Clinic Visit Notes dated 9/21/21 documents, RLE (Right Lower Extremity): Right lower extremity incision is open. Please put on wound vac (vacuum) on this incision that is okay today when patient arrives back to facility. Dressing changes need to bed 3 x (times) a week. R97's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Please put wound vac on right leg today; please do dressing changes 3 times a week. Please call us with wound concerns. Surveyor was unable to locate any documentation in R97's medical record that R97's physician or Wound MD-P was notified of the above orders. Surveyor was unable to locate any documentation that any facility staff followed up on R97's orthopedic clinic orders dated 9/21/21. Surveyor was unable to locate any documentation in R97's medical record that the above orders for a wound vacuum to be applied to R97's right lower extremity wound were followed and implemented by facility staff on 9/21/21. R97's wound assessment dated [DATE] documents, right lower extremity- surgical incision; measurements: 13.2 (centimeters) x 2.16 cm x 0.2; Description: 75% granulation 25% slough, small drainage; Treatment: change to skin prep. R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 9/28/21 documents, Location: Right Shin; Length: 6.05 cm, Width: 2.16 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 51-75%, Slough 1-25%; Orders: Cleanse wound with saline; protect periwound with skin prep, apply santyl to wound bed, cover wound with bordered gauze, change daily, Change PRN (as needed) for soiling and/or saturation. Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97. R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 10/5/21 documents, Location: Right Shin; Length: 10.73 cm, Width: 3.28 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 51-75%, Slough 1-25%; Orders: Cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep, apply santyl to wound bed, apply alginate to wound bed, change daily, change PRN (as need) for soiling and/or saturation. Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97. R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 10/12/21 documents, Location: Right Shin; Length: 10.73 cm, Width: 3.28 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 51-75%, Slough 1-25%; Orders: Cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep, apply santyl to wound bed, apply alginate to wound bed, change daily, change PRN (as need) for soiling and/or saturation. Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97. R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 10/12/21 documents, Location: Right Shin; Length: 9.82 cm, Width: 3.31 cm; Depth 0.10 cm; Etiology: Trauma; Woundbed Assessment: Granulation 76-100%; Orders: Cleanse wound with saline, protect periwound with skin prep, apply Xeroform gauze (cut to size) to wound bed, cover wound with ABD (Army Battle Dressing), Secure dressing with Kerlix, change daily, change PRN (as needed) for soiling and/or saturation. Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97. R97's Orthopedic Clinic Visit Notes dated 10/15/21 documents, RLE (Right Lower Extremity): Right lower extremity incision is open (orthopedics is following this wound). Please put on wound vac (vacuum) on this incision that is okay today when patient arrives back to facility. Dressing changes need to bed 3 x (times) a week; Plan: Doctor is following this wound as this is their incision from surgery so we will be providing instructions for wound care. Please continue to use of wound vac until we see him back in clinic on 10/26/21. Patient needs to see infectious disease team- Infectious Disease Clinic at 414- . R97's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Put wound vac on asap (as soon as possible); Keep on until our next visit. Change vac dressing 3 times a week. Surveyor was unable to locate any documentation in R97's medical record that the above orders for a wound vacuum to be applied to R97's right lower extremity wound were followed and implemented by facility staff on 10/15/21. Surveyor was also unable to locate any documentation from facility staff that the infectious disease clinic was contacted by facility staff for R97 as documented in R97's Orthopedic Clinic Visit Notes dated 10/15/21. R97's nursing note dated 10/15/21 documents, Type: Nurses Note Text: MD CONTACT: Staff Member contacted B@B (name of facility) today. Stated that this resident was to have a Wound Vac and wanted to know why it had not been started. Author could not answer that question; informed her that author would have to review the orders. Dr (doctors)'s office would like a supervisor to contact them regarding this issue. R97's nursing noted completed by LPN (Licensed Practical Nurse)-S and dated 10/15/21 documents, Type : Nurses Note Text: Writer received phone call from ortho office. Resident was seen and orders to have wound vac placed. Writer explained resident has been seen by wound doctor here in facility and Wound MD-P has stated wound vac is not appropriate this RLE wound. Writer gave ortho office Wound MD-P, phone number and faxed over wound assessment to ortho office. At this time wound vac is not ordered by Wound MD-P and continue treatment as ordered and wound is healing evidenced by assessment. On 12/2/21 at 1:02 p.m., Surveyor interviewed Wound MD-P regarding R97's right shin surgical wound. Surveyor asked Wound MD-P if he was aware of R97's orthopedic recommendations dated 9/21/21 and 10/15/21 for a wound vacuum placement on R97's right lower extremity. Wound MD-P informed Surveyor that he was informed by LPN-S that the orthopedic clinic wanted a wound vacuum placed on R97's right lower extremity on 10/15/21 and not prior to that. Wound MD-E informed Surveyor that he was not aware that the wound vacuum recommendation was initially made on 9/21/21. Wound MD-P informed Surveyor that due to the granulation in R97's right lower extremity wound, he felt that a wound vacuum was inappropriate for R97. Surveyor asked Wound MD-P if he had been made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21. Wound MD-P informed Surveyor that he was not made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21. Surveyor asked Wound MD-P if he had spoken to the orthopedic clinic regarding the disagreement on the placement of a wound vacuum for R97, as Surveyor was unable to locate any documentation in R97's medical record that he (Wound MD-P) had documented a reason for disregarding the orthopedic surgeon's physician orders. Wound MD-P informed Surveyor that he never spoke to the orthopedic clinic regarding the disagreement on the placement of a wound vacuum for R97 as he assumed LPN-S had informed the clinic to contact him (Wound MD-P). Wound MD-P informed Surveyor that he felt the wound vacuum order was for another wound and not R97's right lower extremity, but informed Surveyor that he was not aware of R97's orthopedic clinic orders or recommendations. On 12/2/21 at 3:07 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. At the time, no additional information was provided. On 12/6/21 at 2:47 p.m., Surveyor informed LPN-S of the above findings. Surveyor asked LPN-S if she had been aware that R97's orthopedic clinic had provided physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-S informed Surveyor that she was not aware that R97's orthopedic clinic had provided physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked LPN-S if she had been made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21. LPN-S informed Surveyor that he was not made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21. Surveyor asked LPN-S if she had reached out to the orthopedic clinic to inform them that Wound MD-P did not want a wound vacuum placed on R97's right lower extremity on 10/15/21. LPN-S informed Surveyor that she only reached out to the orthopedic clinic to provide them with Wound MD-P's contact information and that she assumed Wound MD-P would clear up any confusion with the orthopedic clinic. No additional information was provided as to why the facility did not ensure that R97's right lower extremity wound received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 4.) R18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R18 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and coded R18 as being independent with bed mobility and transfers. R18's Impaired Skin Integrity Care Plan was initiated on 1/4/2020. On 9/17/2021 at 2:57 AM in the progress notes, a Registered Nurse (RN) charted R18 had fluid draining down the right lower leg and two open areas were noted on the right lower lateral shin draining serous drainage with no signs of infection. Nursing charted the area appears to be opened blisters related to [CONDITION(S)]. Nursing notified the Nurse Practitioner. R18's Impaired Skin Integrity Care Plan was revised with interventions to elevate the legs to reduce [CONDITION(S)] and have the wound team monitor the wounds. On 9/17/2021, an Initial Wound Assessment was completed on both open areas of the right lower leg measuring 2.0 cm x 2.2 cm x 0.1 cm and 0.5 cm x 2.0 cm x 0.1 cm with the wound base 75% granulation and 25% slough for both areas. On 9/17/2021, an SBAR Communication Form was completed indicating R18 had a skin wound or ulcer in an area where a wound had been before, with [CONDITION(S)] and a blister. On 9/18/2021, a treatment was started of oil [MEDICATION(S)] non-adhesive dressings to both areas followed by an ABD bandage and wrapped with rolled gauze and tubi grip daily. No documentation of weekly comprehensive assessments was found of the right lower leg wounds after the initial assessment on 9/17/2021. On 10/12/2021, R18 was transferred to the hospital. On 10/18/2021 at 11:03 PM in the progress notes, an RN charted R18 was readmitted to the facility at 5:30 PM and a skin assessment was completed. No skin assessment documentation was found on 10/18/2021. A treatment to the right lower leg was continued as prior to hospitalization . No Admit/Readmit Assessment was completed on 10/18/2021 when R18 returned to the facility. On 10/24/2021 an Admit/Readmit Assessment was completed and the Skin Integrity section of the form documented R18 had a vascular wound to the left lower leg measuring 4.0 cm x 3.2 cm with no depth and a description stating the wound was venous. The documentation of the location of the wound was incorrect: the wound was on the right lower leg. This assessment was six days after R18 had been readmitted to the facility. On 10/26/2021 on the Weekly Wound Assessment form, nursing documented the vascular wound to the right lower leg measured 4.0 cm x 3.2 cm x 0.1 cm with 100% granulation. The wound to the right lower leg was comprehensively assessed weekly from 10/26/2021 until the time of the survey. In an interview on 11/29/2021 at 3:06 PM, R18 stated there is a wound to the right lower leg that gets a treatment almost every day and R18 had no concerns with the wound treatment being completed. Surveyor verified that a treatment was ordered to be completed every three days. In an interview on 12/6/2021 at 12:27 PM, Surveyor shared with Director of Nursing (DON)-B and Regional Nurse Consultant-C the concerns R18 did not have weekly comprehensive assessments of the right lower leg wounds after the initial discovery on 9/17/2021 until R18 was admitted to the hospital on 10/12/2021, when R18 was readmitted to the facility on [DATE] a complete assessment was not done for six days until 10/24/2021, and the skin assessment was not completed until 10/26/2021. Regional Nurse Consultant-C stated the readmission assessment on 10/24/2021 should have been the right leg instead of the left leg. Surveyor asked when would the facility expect a readmission assessment to be completed. Regional Nurse Consultant-C stated it should have been done as soon as the resident got into the building. Regional Nurse Consultant-C agreed with Surveyor the wounds should have been assessed weekly and documented in R18's medical record. No further information was provided at that time.

Based on interview and record review the facility did not ensure that 1 (R1) of 3 residents reviewed and at risk for developing pressure injuries received consistent measures to prevent the development of pressure injuries. * R1 developed an unstageable pressure injury at the facility as a result of not having offloading interventions for his left heel upon admission to the facility. Findings include: 1.) R1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set) dated 7/20/21 documents a BIMS (Brief Interview for Mental Status) score of 14, indicating that R1 is cognitively intact. Section G (Functional Status) documents that R1 requires extensive two person physical assist for bed mobility needs. Section G also documents that R1 has total dependence on staff and requires a two person physical assist for transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R1 has impairment to one side of his upper extremities. Section M (Skin Conditions) documents that upon admission to the facility, R1 did not have any unhealed/open pressure injuries. Section M also documents that R1 was at risk for the development of pressure injuries. R1's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 7/27/21 documents under the Analysis of Findings section, R1 is at risk for pressure ulcers. Under the Care Plan Considerations section it documents, R1 is at risk for pressure ulcers d/t (due to) limited bed mobility, incontinence, and being chairfast. He requires extensive assist of two staff at times for bed mobility and changing his brief. Plan of care to be developed. R1's Pressure Injury care plan dated as initiated on 7/20/21 documents under the Focus section, Resident has potential/actual for impaired skin integrity r/t (related to): Bladder Incontinence, decreased mobility, diabetes, dry skin, left groin open area, scratches to LLE (Left Lower Extremity). R1's Pressure Injury care plan dated as initiated on 7/20/21/21 documents the Interventions section the following offloading interventions in place as of 7/20/21 for R1: Pressure redistribution mattress; Assist to reposition approximately every 2-3 hours and as needed; apply cushion to w/c (wheelchair); apply barrier cream after each incontinence episode; Avoid friction/shearing while repositioning; If Resident is unable to assist use at least two staff members, use lift sheet, bed should be as flat as possible while lifting. Surveyor was unable to locate any pressure reliving interventions for the offloading of R1's left heel or diabetic checks for R1's left foot upon admission to the facility or prior to 8/6/21. R1's Initial Wound assessment dated [DATE] documents, Date wound was identified: 8/6/21; Where was the wound acquired: acquired after admission to the facility; Type of Wound: Pressure; Site: Left Heel, Type: Pressure, Length 4.3 cm (centimeters), Width 3.9 cm, Depth 0.1 cm, Stage: Unstageable. Surveyor noted that R1's Initial Wound assessment dated [DATE] for his left heel was incomplete as it did not describe the wound bed, percentage of granulation, slough, eschar or epithelization or wound edges. The assessment did not include any documentation that any new interventions were put in place to offload R1's left heel. Surveyor also noted that R1's Initial Wound assessment dated [DATE] for his left heel was completed by LPN (Licensed Practical Nurse) Unit Manager-B and no RN (Registered Nurse) assessment was documented. R1's August 2021 TAR (Treatment Administration Record) documents the following treatment as in place on 8/7/21, Left heel [MEDICATION(S)] to necrotic area and foam border two times a day. Surveyor was unable to locate any monitoring of R1's left foot prior to 8/6/21, despite R1 being a diabetic and had a prior right below the knee amputation. Surveyor also could not locate an initial assessment by an RN when R1's left heel pressure injury was discovered on 8/6/21. Surveyor was unable to locate any pressure reliving interventions for the offloading of R1's left heel or diabetic checks for R1's left foot upon admission to the facility or prior to 8/6/21. R1's Weekly Wound assessment dated [DATE] documents, Wound Measure Date: 8/10/21; Type of Wound: Pressure; Site: Left Heel, Type: Pressure, Length 4.8 cm (centimeters), Width 4.9 cm, Depth 0.1 cm, Stage: Unstageable; Percentage of Granulation: 10, Percentage of eschar 90; Is wound odorous: No; Onset; Other: Dr (doctor) saw resident this shift. New orders to soak resident foot in iodine soak for 2 minutes, cover with ABD (Army Battle Dressing), wrap with Kerlix, change BID (twice a day)/PRN (as needed), CBC (Complete Blood Count) ordered. R1's Tissue Analytics Wound Evaluation, completed by the wound physician and dated 8/10/21, documents, Location: Left Heel; Length: 4.87 cm (centimeters); Width 4.95 cm; Depth: 0.10 cm; Observations: Depth 0.10 cm; Etiology: Pressure Ulcer- Unstageable; Margin Detail: Attached edges; Wound bed Assessment: Eschar; Drain Amount: Scant; Periwound: Clean, dry, intact; Plan of Care: Rx (order): Pour [MEDICATION(S)] in basin, soak wound for 2 minutes in [MEDICATION(S)] BID (twice a day), secure with ABD and Kerlix. R1's August 2021 TAR documents the following treatment as in place on 8/10/21, Soak Left heel in [MEDICATION(S)] soak for 2 minutes. Cover wound with ABD pad and wrap with Kerlix BID/PRN two times a day for Wound care Do not use gauze to cover wound. Only ABD against wound. Surveyor noted that despite R1 developing a pressure injury to his left heel on 8/6/21, the facility did not put any pressure relieving interventions until 8/11/21. R1's Pressure Injury care plan dated as initiated on 7/20/21/21 documents the Interventions section the following offloading interventions in place as of 8/11/21 for R1: Diabetic foot checks every shift; Float L (left) heel when in bed; Padded boot to left foot at all times. Surveyor was unable to locate any documentation in R1's nursing notes, assessments or therapy notes that R1 had any offloading interventions in place for his left heel prior to 8/11/21. Due to R1 no longer residing at the facility at the time of the survey, Surveyor was unable to obtain an interview from R1. On 10/22/21 at 12:01 p.m., Surveyor interviewed Rehabilitation Director-D regarding R1's pressure injury. Surveyor asked Rehabilitation Director-D if R1 had any offloading interventions for his left heel prior to 8/11/21. Rehabilitation Director-D informed Surveyor that to the best of her knowledge, R1 did not have any offloading interventions or boot wearing prior to 8/11/21, as R1 used his left foot/leg for mobility due to him (R1) having a BKA (below knee amputation) to his right foot prior to admission to the facility. Rehabilitation Director-D informed Surveyor that once R1 developed the pressure to his left heel, R1's mobility was diminished and that R1 went from a stand and pivot with assist of two non-weight bearing and a full Hoyer lift. R1's OT (Occupational Therapy) Discharge Summary dated 8/13/21 documents, Summary of Skilled Services: Since therapy was notified of left heel wound from nursing, pt (patient) has been downgraded to LLE (Left Lower Extremity)- trialed standing with two person assist, max assist of 2 and pt unable to stand while adhering to precautions and therefore, pt was downgraded to a Hoyer on the unit to maximize protection of left heel wound. R1's PT (Physical Therapy) Discharge Summary dated 8/13/21 documents, Pt (patient) struggled to make progress during rehabilitation stay d/t (due to) anxiety about transfers, new skin breakdown on left heel and continued NWB (non-weight bearing status) to RUE (Right Upper Extremity). Pt now unable to bear weight through LLE (left lower extremity) d/t (due to) wound therefore Hoyer required for transferred. On 10/22/21 at 2:08 p.m., Surveyor informed LPN Unit Manager-B of the above findings. Surveyor asked LPN Unit Manager-B if she had been the nurse whom initially assessed R1's left heel pressure injury on 8/6/21 and if she had completed the assessment dated [DATE] as it was incomplete in R1's medical record. LPN Unit Manager-B informed Surveyor that she was the nurse whom initially assessed R1's left heel pressure injury on 8/6/21. LPN Unit Manger-B reviewed R1's medical record with Surveyor and informed Surveyor that R1's Initial Wound assessment dated [DATE] for R1's left heel was incomplete and that she could not provide any documentation that an RN (Registered Nurse) assessed R1's left heel along with her (LPN Unit Manager-B).LPN Unit Manager-B informed Surveyor that an RN usually assesses wounds with her but that she was unsure as to why no RN documented an assessment of R1's left heel wound on 8/6/21. Surveyor asked LPN Unit Manager-B why R1 did not have any documented offloading interventions for his left heel prior to 8/11/21. LPN Unit Manager-B reviewed R1's medical record with Surveyor and informed Surveyor that R1 should have had offloading interventions for his left heel prior to 8/11/21 but that she could not provide any documentation as to why R1 did not have offloading interventions for his left heel prior to 8/11/21. Surveyor asked LPN Unit Manager-B if R1 had a decline in his mobility upon developing the left heel pressure injury. LPN Unit Manager-B informed Surveyor that R1 did have a decline in his mobility upon developing the left heel pressure injury, as R1 went from transferring with an assist of two to being non-weight bearing. On 10/22/21 at 2:43 p.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. No additional information was provided why R1 did not have pressure relieving interventions in place to prevent the development of his left heel pressure injury.

Based on observation, interview and record review, the facility did not ensure that 1 (R1) of 3 sampled residents was free of from accident hazards and provided supervision and assistive devices to prevent avoidable accidents. R1 was admitted to the facility after a hospital stay for falls. R1 had multiple falls during his stay at the facility. In June and July 2021 R1 had 14 falls including 6 on the patio, 4 in his room and 3 in his bathroom. The facility did not perform a root cause analysis for falls, did not put an immediate intervention in place for some falls and did not put a new intervention in place for some falls. On 6/16/21 R1 was sent to the hospital post fall and returned with a soft cast and on 712/21 R1 required transfer to the hospital for stitches to his head with lacerations. During the survey R1 was observed without safety care planned interventions in place including a body pillow in bed, gripper socks and lids on cups. Findings include: Surveyor reviewed facility's Falls and Fall Risk, Managing policy with a revision date of March 2018. Documented was: Policy Statement Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Policy Interpretation and Implementation Definition According to the [Minimum Data Set (MDS)], a fall is defined as: Unintentionally coming to rest on ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost her/his balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . Resident-Centered Approaches to Managing Falls and Fall Risks 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once) . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified . Surveyor reviewed facility's Assessing Falls and Their Causes policy with a revision date of March 2018. Documented was: Purpose The purpose of this procedure are to provide guidance for assessing a resident after a fall and to assist staff in identifying causes of the fall . Defining Details of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred . Identifying Causes of a Fall or Fall Risk: 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known functional impairments, etc. 2. Evaluate chains of events or circumstances preceding a recent fall, including: a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture or objects in the way); and/or h. Whether there is a pattern of falls for this resident . R1 was admitted to the facility 10/28/20 with diagnoses that included [CONDITION(S)] with Intoxication [CONDITION(S)], Constipation, Acute Kidney Failure, [CONDITION(S)] and Protein-Calorie Malnutrition. Surveyor reviewed R1's hospital Discharge Summary with a date of 10/28/21. Documented was On [7/14/20], 3 days prior to admission, he was brought to [hospital] after reportedly falling down several stairs at the motel he was living at. He had trauma workup which included head CT which revealed bilateral chronic subdural hematoma (SDH) which possible acute component to bleed. The rest of his trauma workup was negative. He was admitted to neurosurgery service for observation. Repeat head CT 4 hours later revealed stable SDH. He unfortunately left [against medical advice (AMA)] from that admission. Later in day of admission he was found down on the ground lying in the middle of the street so he was brought to the ED for further evaluation . [R1] had multiple minor falls while in the hospital. His last fall was unwitnessed on the afternoon of 10/27/20 and resulted in a small laceration above his right eye and an area of swelling on the right side of his forehead . Surveyor reviewed R1's Comprehensive Care Plan with an initiation date of 10/29/20. Documented was: Focus: Resident has the potential for falls, accidents and incidents [related to (r/t)] [history (hx)] of falls, unaware of safety needs. Goal: Injuries will be minimized through the next review. Interventions: - Encourage resident to ask for assistance. - Fall assessment to be completed upon admission, after falls, quarterly, with [significant change of condition (SCOC)] and PRN - Follow therapy recommendations for transfers and mobility. - Review information on past falls and attempt to determine cause of falls. Surveyor reviewed R1's Comprehensive Care Plan with revision dates of 11/7/20, 12/25/20, 12/27/20, 12/30/20, 1/2/21, 1/3/21, 1/4/21, 1/11/21, 1/18/21, 1/20/21, 2/17/21, 3/5/21, 5/12/21, 5/14/21 and 5/27/21. Documented was: .Interventions: - 1/11/21 - Send to ER, staples left side of head, (staples removed) Low bed - 1/12/21 - staff to check floor for spills and if resident needs water. - 2/17/21 - change to 30 minute checks d/c'ed - 3/5/21 - 60 minute checks - 1/18/21 - body pillow in bed . - 1/18/21 - lids on drinks - 1/2/21 - night light in room - 1/3/21 - sign in room - 1/4/21 - staff to remove tray when meal is over and assess floor for spills . - 1/6/21 - gripper strips on floor when available - 11/7/20 - all plastic patio chairs removed from outdoor seating area - 12/25/20 - prompt to toilet [every (Q)] 2-3 hours and [PRN (as needed)] - 12/27/20 - knife removed - 12/30/20 - slippers removed, encourage gripper socks at all times - 5/12/21 - night light - 5/14/21 - returned from ER with soft cast to right arm - 5/27/21 - continue current safety interventions. Surveyor reviewed Unwitnessed Fall Reports for R1 from June and July 2021. R1 had falls on 6/2/21, 6/3/21, 6/9/21, 6/13/21, 6/14/21, 6/16/21, 6/18/21, 6/26/21, 7/1/21, 7/8/21, 7/12/21 AM, 7/12/21 PM, 7/15/21 and 7/17/21. Surveyor reviewed Unwitnessed Fall Report for fall on 6/2/21. R1 had a fall on the patio with no injury. There was no documentation under Immediate Action Taken. The Comprehensive Care Plan was updated to include 6-2-21, Therapy eval and screen, pt re-education on self transferring with risk of injury to self. There was no Root Cause Analysis completed to investigate the fall on the patio. Surveyor reviewed Unwitnessed Fall Reports for R1 from 6/3/21. R1 had a fall on the patio with no injury. Documented under Immediate Action Taken was Resident was assessed and assisted off the ground. The Comprehensive Care Plan was not updated with any added interventions. There was no Root Cause Analysis completed to investigate 2 falls in 2 days on the patio. Surveyor reviewed Unwitnessed Fall Reports for R1 from 6/9/21. R1 had a fall in his bathroom and sustained a 7 cm scratch to right buttock. Documented under Immediate Action Taken was Resident was assessed and assisted. The Comprehensive Care Plan was updated with new intervention for [MEDICATION(S)] for [CONDITION(S)]. There was no Root Cause Analysis completed to investigate the fall in the bathroom. Surveyor reviewed Unwitnessed Fall Reports for R1 from 6/13/21. R1 had a fall on the patio with no injury. Documented under Immediate Action Taken was a head to toe assessment and R1 was brought back to his room. The Comprehensive Care Plan was updated with 6/14/21 - dining room chair placed out on courtyard for residents use. Resident provided verbal understanding. There was no Root Cause Analysis completed to investigate 3 falls in 10 days on the patio. Surveyor reviewed Unwitnessed Fall Reports for R1 from 6/14/21. R1 had a fall in his room with no injury and reported the floor was wet. Documented under Immediate Action Taken was [Patient (pt)] assisted to low bed. The Comprehensive Care Plan was not updated with any added interventions. There was no Root Cause Analysis completed to investigate the fall in his room. Surveyor reviewed Unwitnessed Fall Reports for R1 from 6/16/21. R1 had a fall on the patio and was sent to the hospital after his right elbow preexisting wound opened. Documented under Immediate Action Taken was a head to toe assessment and R1 was provided emotional support. The Comprehensive Care Plan was updated with [6/17/21] - Labs and [urinalysis (UA)] completed at hospital evaluation. UA negative. New soft cast applied to arm. Resident removed soft cast upon return. There was no Root Cause Analysis completed to investigate 4 falls in 13 days on the patio. Surveyor reviewed Unwitnessed Fall Reports for R1 from 6/18/21. R1 had a fall in his room with no injury. Documented under Immediate Action Taken was Resident assessed and started getting up off the floor himself not wanting assistance. The Comprehensive Care Plan was updated with new intervention for [MEDICATION(S)] for anxiety. There was no Root Cause Analysis completed to investigate 2 falls in 4 days in his room. Surveyor reviewed Unwitnessed Fall Reports for R1 from 6/26/21. R1 had a fall in the dining room with no injury. Documented under Immediate Action Taken was RN called to assess, [vital signs] taken, neuro checks initiated, [Nurse Practitioner] notified, spouse present and witnessed fall, witness statement taken from spouse. The Comprehensive Care Plan was updated with no new interventions and stated Fall interventions reviewed and continue to be appropriate. There was no Root Cause Analysis completed to investigate the fall in the dining room. Surveyor reviewed Unwitnessed Fall Reports for R1 from 7/1/21. R1 had a fall coming inside from the patio with no injury. Documented under Immediate Action Taken was resident assessed and hoyered off ground. The Comprehensive Care Plan was updated with no new interventions and stated 7/2/21 - Safety interventions reviewed, continue appropriate. There was no Root Cause Analysis completed to investigate the fall coming in from the patio. Surveyor reviewed Unwitnessed Fall Reports for R1 from 7/8/21. R1 had a fall attempting to go outside onto the patio with no injury. Documented under Immediate Action Taken was resident assessed and assisted up with hoyered and 2 assist. The Comprehensive Care Plan was updated with no new interventions and stated 7/8/21 - remove slip on slippers, gripper socks on at all times. This intervention was already in place as of 12/30/20. There was no Root Cause Analysis completed to investigate the fall going out to the patio. Surveyor reviewed Unwitnessed Fall Reports for R1 from 7/12/21 AM. R1 had a fall on the patio and was sent to the hospital. Per hospital documentation R1 suffered laceration to head, left elbow skin tear and nosebleed and required stitches to left forehead. Documented under Immediate Action Taken was Dressing applied to laceration above left eye, resident refused [vital signs] and neuro assessment, [hospital] notified and send for eval and treat. The Comprehensive Care Plan was updated with an increase to [MEDICATION(S)] for [CONDITION(S)]. There was no Root Cause Analysis completed to investigate 5 falls in June and July on the patio. Surveyor reviewed Unwitnessed Fall Reports for R1 from 7/12/21 PM. R1 had a fall in his room with no injury. Documented under Immediate Action Taken was Resident assessed and assisted off floor. The Comprehensive Care Plan was updated with no new interventions and stated 7/12/21 - continue current interventions. There was no Root Cause Analysis completed to investigate the 3 falls in June and July in resident's room. Surveyor reviewed Unwitnessed Fall Reports for R1 from 7/15/21 PM. R1 had a fall in his room with no injury. Documented under Immediate Action Taken was an assessment and assisted to bed. The Comprehensive Care Plan was updated with new intervention of Physical Therapy to treat R1. There was no Root Cause Analysis completed to investigate the 4 falls in June and July in resident's room. Surveyor reviewed Unwitnessed Fall Reports for R1 from 7/17/21. R1 had a fall in his bathroom and sustained a scratch to left buttock. Documented under Immediate Action Taken was Cleanse with [normal saline followed by] bordered gauze. The Comprehensive Care Plan was updated with no new interventions and stated 7/18/21 - safety interventions reviewed and remain appropriate at this time. There was no Root Cause Analysis completed to investigate the 3 falls in the bathroom in June and July. Surveyor reviewed Unwitnessed Fall Reports for R1 from 7/19/21. R1 had a fall on the patio with no injury. Documented under Immediate Action Taken was a head to toe assessment. The Comprehensive Care Plan was updated with 7/19/21 - Hospice eval and treat. There was no Root Cause Analysis completed to investigate 6 falls in June and July on the patio. On 8/12/21 at 8:52 am, 9:19 am, 9:32 am, 10:50 am, 12:04 pm, and 2:18 pm Surveyor observed R1 in his bed. The surveyor observed no body pillow was in the bed with the resident. R1's Comprehensive Care Plan noted an intervention for a body pillow while in bed. On 8/12/21 at 12:04 pm and 2:18 pm Surveyor observed a drink in a Styrofoam cup with a straw with no lid on it next to the resident on R1's bedside table. R1's Comprehensive Care Plan noted an intervention for lids on cups. On 8/12/21 at 2:18 pm Surveyor observed R1 in bed with white and gray plain socks and not gripper socks on as indicated per his plan of care. R1's Comprehensive Care Plan noted an intervention for gripper socks on at all times. On 8/12/21 at 2:22 pm Surveyor interviewed Certified Nursing Assistant (CNA)-C. Surveyor asked what interventions were in place for R1 to prevent falls. CNA-C stated low bed, no mat on floor, 15 minute checks and gripper socks. CNA-C did not mention the body pillow or covers on cups. On 8/12/21 at 3:00 pm Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what the facility's process was if a resident has a fall. DON-B stated the resident is assessed by a nurse, an immediate intervention is put in place, incident report is completed, pain assessment completed, neuro checks completed, family updated and MD updated. DON-B stated with 24 hours the interdisciplinary team reviews and comes up with a new intervention for the care plan. Surveyor asked DON-B what interventions are in place for R1 to prevent falls. DON-B reviewed Comprehensive Care Plan and reviewed interventions including body pillow, gripper socks and lids on cups. Surveyor noted observations made on survey of R1. DON-B stated those interventions should have been in place. Surveyor asked if a new intervention is put in place for each fall. DON-B stated yes. Surveyor noted to DON-B the interventions that only stated current interventions are appropriate. DON-B stated all interventions should be reviewed to make sure they are appropriate after a fall but also a new intervention should be added.

Based on record review and interviews, the facility did not ensure a resident who entered the facility with skin wounds received appropriate care, treatment, and preventative interventions to promote healing for 1 of 3 residents reviewed (R25) for wound treatments. R25 resided in the facility from [DATE] to 10/3/20. * There was no RN assessment of R25's wounds on admission on 9/15/20. There were no measurements of the wounds until 9/21/20 and there was no wound treatment to the areas until 9/24/20. * On 9/15/20, R25's physician gave a telephone order to hold medications on [MEDICAL TREATMENT] days. R25 had a physician's orders [REDACTED]. R25 did not receive these medications on 9/29/20, 10/1/20 and 10/3/20, which were [MEDICAL TREATMENT] days. There was no indication on the Medication Administration Record, [REDACTED]. Staff was not aware of the MD order dated 9/15/20 to hold medications on [MEDICAL TREATMENT] days and indicated the Medications were not administered because R25 was out of the building. There was no indication as to whether these medications could be scheduled around R25's [MEDICAL TREATMENT] time frames. * The facility did not ensure that R25 was seen by wound specialist per a 9/24/20 MD order while in facility. On 10/3/20, R25 was hospitalized with a [DIAGNOSES REDACTED]. The facility did not accurately assess, monitor, document or follow physician orders [REDACTED]. Findings include: The Facility's Policy titled Skin Management Practice Guidelines initiated February 2016 with a Revision date of July 2017 reads as follows: Newly admitted residents: Upon admission, all residents are assessed for skin integrity by completing an assessment and documentation in the EHR .Residents admitted with skin impairments will have: Appropriate Interventions implemented to promote healing, a physician's orders [REDACTED].Ongoing monitoring and continuous quality improvement will be achieved by the interdisciplinary team. R25's closed medical record was reviewed. R25 was admitted to the facility 9/15/20 with [DIAGNOSES REDACTED]. R25's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/22/20 indicates a Brief Interview of Mental Status (BIMS) score of 15, indicating resident is cognitively intact and able to participate in daily decision making. Section G of R25's MDS indicates that R25 requires limited assistance of 2 staff for transfers. R25 requires extensive assist of 1 for personal hygiene. Section H of R25's MDS indicates resident is continent of bowel and bladder. Section M of R25's MDS indicates resident is at risk for pressure injuries. R25 requires interventions to maintain skin integrity, including wheelchair cushion and pressure relieving mattress. Per review of initial skin assessment performed on 9/15/20, R25 was admitted to facility with small open areas on right coccyx, abdominal fold and left buttock. Measurements were not performed of R25's open areas to coccyx, abdominal fold and buttock on 9/15/20. On 1/13/21 at 12:30 pm, Surveyor reviewed R25's Potential for Skin integrity care plan. The skin integrity care plan initiated 9/15/20 reads as follows: Resident has potential for impaired skin integrity related to altered nutritional status, decreased mobility, diabetes, dry skin, end stage [MEDICAL CONDITION], small open areas to sacral region and right buttock. The Skin integrity care plan was updated on 10/1/20 as follows: 10/1/20: right side of abdomen excoriation and open area. The Potential for Skin Integrity Care plan interventions include: specialty pressure redistribution mattress, apply cushion to wheelchair, weekly skin assessment. Surveyor reviewed another Care plan initiated 9/27/20 identified as Potential for infection for skin irritation and fungal. This care plan interventions include: Administer antibiotics per physician order, encourage oral intake and provide nutritional support as appropriate. Notify physician or nurse of signs or symptoms of adverse response to antibiotic/treatment. Surveyor reviewed an Impaired Skin Integrity Care plan initiated 9/25/20 which reads as follows: Resident has Impaired Skin integrity: partial thickness wounds to the left side of the lower abdomen x3, partial thickness wound to the left gluteal and right buttocks on admission. Interventions for this Care Plan include: Weekly wound assessment, weekly skin assessment, weekly wound measurements and treatment as ordered. Left Lateral Abdominal Fold: Per review of initial skin assessment performed on 9/15/20, R25 was admitted to facility with small open areas on right coccyx, abdominal fold and left buttock. Measurements were not performed of R25's open areas to coccyx, abdominal fold and buttock on 9/15/20 and was not assessed by an RN on 9/15/20. On 9/25/20 weekly wound assessments were signed by DON-B with a measurement date of 9/21/20. Weekly wound assessment provided measurements for R25's abdominal fold skin condition. Documentation describes left lateral abdominal fold as moisture associated measuring 0.7 cm (length) x 0.9 cm (width) x 0.1 cm (depth). Wound is described as area superficial, slight pain with assessment. Weekly wound assessment dated [DATE] also states .Will get order for Dr. J (Wound Doctor at facility) wound team to follow. Weekly wound assessment dated [DATE] describes left lateral abdominal fold as moisture associated measuring 0.5 cm (length) x 1.2 cm (width) x 0.1 cm (depth). Wound is described as area superficial, slight pain with assessment. Weekly wound assessment dated [DATE] also states .Will get order for Dr. J (Wound Doctor at facility) wound team to follow. Orders for wound treatments to R25's left abdominal fold were initiated on 9/24/20. Skin condition to R25's left abdomen was noted on admission skin assessment without measurements on 9/15/20. Surveyor noted no measurements for the left Lateral Abdominal Fold from R25's admission on 9/15/20 to 9/21/20 and no treatment until 9/24/20. Surveyor noted an increase in width size from 0.9cm on 9/21/20 to 1.2 cm on 9/25/20. Surveyor reviewed a weekly skin check form dated 9/27/20 by unknown staff. Weekly skin check reads as follows: Abdomen, excoriated opens and red [MEDICAL CONDITION] to pannus (abdominal fold). On 1/13/21 at 8:55 am, Surveyor reviewed Weekly wound assessment dated [DATE]. Weekly wound assessment signed by LPN-G. Per weekly wound assessment, wound measurements were performed on 9/28/20 as follows: left lower lateral abdomen measuring 0.9 cm (length) x 1.0 (width) x 0.1 cm. Weekly wound assessment describes area as Moisture associated, area superficial, slight pain with assessment. Weekly wound assessment dated [DATE] also states .Will get order for Dr. J (Wound Doctor at facility) wound team to follow. Left Lower Mid Abdominal Fold: Per review of initial skin assessment performed on 9/15/20, R25 was admitted to facility with small open areas on right coccyx, abdominal fold and left buttock. Measurements were not performed of R25's open areas to coccyx, abdominal fold and buttock on 9/15/20. A Weekly wound assessment dated [DATE] by DON-B describes left lower mid abdominal fold as moisture associated measuring 0.4 cm (length) x 1.2 cm (width) x 0.1 cm (depth). Wound is described as area superficial, slight pain with assessment. Weekly wound assessment dated [DATE] also states .Will get order for Dr. J (Wound Doctor at facility) wound team to follow. Per weekly wound assessment, wound measurements were performed on 9/28/20 as follows: left lower abdomen mid left measuring 0.4 cm (length) x 1.0 cm (width) x 0.1 cm (depth). The Wound is described as area superficial, slight pain with assessment. Weekly wound assessment dated [DATE] also states .Will get order for Dr. J (Wound Doctor at facility) wound team to follow. Surveyor noted there was no RN assessment with measurements perfomed to this area on admission and no treatment started until 9/24/20. Right Coccyx (Right Buttock) Per review of initial skin assessment performed on 9/15/20, R25 was admitted to facility with small open areas on right coccyx, abdominal fold and left buttock. On 1/12/21 at 2:25 pm, Surveyor reviewed wound documentation for R25 from 9/25/20 signed by DON-B with a measurement date of 9/21/20. Documentation describes right buttock (right coccyx) as moisture associated measuring 0.9 cm (length) x 0.4 cm (width) x 0.1 cm (depth). The Wound is described as area superficial, slight pain with assessment. Weekly wound assessment dated [DATE] also states .Will get order for Dr. J (Wound Doctor at facility) wound team to follow. Surveyor reviewed wound documentation for R25 from 10/1/20 signed by LPN-G with a measurement date of 9/28/20. Documentation describes right buttock as moisture associated measuring 0.8 cm (length) x 0.3 cm (width) x 0.1 cm (depth). Wound is described as area superficial, slight pain with assessment. Surveyor noted there were no measurements for the right buttock wound from R25's admission on 9/15/20 to 9/21/20 and no treatment until 9/24/20. Left Gluteal Fold (Left buttock): Per review of initial skin assessment performed on 9/15/20, R25 was admitted to facility with small open areas on right coccyx, abdominal fold and left buttock. On 1/12/21 at 2:25 pm, Surveyor reviewed wound documentation for R25 from 9/25/20 signed by LPN-G with a measurement date of 9/21/20. Documentation describes left gluteal fold as moisture associated measuring 1.8 cm (length) x 1.3 cm (width) x 0.1 cm (depth). The Wound is described as area superficial, slight pain with assessment. The Weekly wound assessment dated [DATE] also states .Will get order for Dr. J (Wound Doctor at facility) wound team to follow. Surveyor noted there were no measurements for the left gluteal fold from R25's admission on 9/15/20 to 9/21/20 and no treatment until 9/24/20. Right side abdomen: Per weekly wound assessment dated [DATE], a new open area was noted to the right side of R25's abdomen. Wound measurements were performed on 10/1/20 as follows: right side of abdomen measuring 4.0 cm (length) x 2.1 (width) x 1.4 cm (depth). The Wound is described as moisture associated [MEDICAL CONDITION]. Per wound assessment, R25's Nurse Practitioner and Primary Physician were notified of R25's right abdominal skin condition on 10/1/20. A wound treatment order was obtained for R25's right abdominal skin condition on 10/1/20. Electronic Medication and Treatment Record (ETAR): On 1/13/21 at 12:40 pm, Surveyor reviewed R25's Electronic Medication and Treatment Records for September 2020 and October 2020. The September 2020 ETAR reads as follows: 9/24/20- Normal Saline wash, pat dry, apply skin prep to periwounds, cover with border gauze dressing. Change daily to open areas on the right and left buttock every evening shift. The September 2020 ETAR reads as follows: 9/24/20- Normal saline wash, pat dry, apply skin prep to periwounds, cover with border gauze dressing. Change daily to three open areas on the left side of the lower abdomen every evening shift. Surveyor noted that R25 did not receive any documented wound treatments to abdomen, coccyx or buttocks from 9/15/20-9/23/20. On 1/13/21 at 11:25 am, Surveyor reviewed R25's Physician order [REDACTED]. On 1/13/21 at 3:00pm, Surveyor requested documentation of wound specialist notes for R25 from DON-B. On 1/14/21 at 11:25 am, DON-B notified Surveyor that there was no documentation of R25 being seen by facility wound specialist. Surveyor was informed R25 was not seen by the wound specialist which was confirmed by DON-B on 1/14/21. R25's Electronic Medication Administration Record [REDACTED]. Per EMAR, R25 was prescribed fluconazole (an oral antifungal medication) daily for 5 days starting 9/29/20 for a fungal infection to the left abdominal fold. Per EMAR, R25 did not receive fluconazole on Tuesday 9/29/20, Thursday 10/1/20 and Saturday10/3/20. EMAR charting code on 9/29/20, 10/1/20 and 10/3/20 reads 5. Per EMAR code key, administration code 5 means resident is out of facility. Per EMAR, R25 was prescribed [MEDICATION NAME] (an oral antibiotic medication) four times daily for 10 days starting 9/28/20. Per EMAR, 2 doses of [MEDICATION NAME] and 1 dose of fluconazole were not administered to R25 at 8 am and 12 pm on Tuesday 9/29/20, Thursday 10/1/20 and Saturday 10/3/20. Surveyor noted R25 went to [MEDICAL TREATMENT] Tuesdays, Thursdays, and Saturdays. On 1/13/21 at 2:45 pm, Surveyor reviewed the facility's [MEDICAL TREATMENT] policy, initiated February 2016. The [MEDICAL TREATMENT] policy does not include additional information related to holding medications prior to [MEDICAL TREATMENT]. On 1/13/21 at 2:45 pm, Surveyor reviewed R25's [MEDICAL TREATMENT] care plan dated 9/15/20. The [MEDICAL TREATMENT] care plan reads as follows: I need [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. Surveyor reviewed interventions for R25's [MEDICAL TREATMENT] care plan. The [MEDICAL TREATMENT] care plan does not address holding R25's medications prior to [MEDICAL TREATMENT]. Surveyor conducted an interview with RN-L on 1/12/21 at 11:05 am. Surveyor inquired about the facility's protocol for assessment of wounds on admission. RN-L replied that all wounds and open areas should initially be measured and assessed by an RN-L at time of admission. Surveyor inquired whether or not medications should be held for residents on [MEDICAL TREATMENT] days. RN-L replied that it would depend on a physician's orders [REDACTED]. Surveyor conducted an interview on 1/14/21 at 9:55 am with LPN-H. Surveyor inquired about the facility's protocol for assessment of wounds on admission. LPN-H replied that unless there are specific orders to not remove a wound dressing, all wounds should be assessed and measured upon admission to facility and that treatment orders should be in place on admission. LPN-H elaborated that if there was no treatment orders for a resident's wound on admission, they would call the primary physician to obtain a treatment order. Surveyor asked LPN-H if there were orders for a resident to be seen by a wound specialist, how would staff ensure resident would receive a wound specialist consultation. LPN-H replied that the facility has a wound specialist who comes to the facility on a weekly basis and that the wound team would alert the wound specialist if a resident needed to be seen. Surveyor asked LPN-H if medications should be held prior to [MEDICAL TREATMENT]. LPN-H responded that it would depend on the physician's orders [REDACTED]. LPN-H responded that this information should be found in a resident's [MEDICAL TREATMENT] orders. Surveyor reviewed the resident [MEDICAL TREATMENT] orders and there was no indication that R25's medications should be held on [MEDICAL TREATMENT] days. Surveyor asked if a resident was to receive antibiotics and they were on antibiotics, should the antibiotic medication be scheduled around a resident's [MEDICAL TREATMENT] appointment. LPN-H responded that it would be up to the doctor to decide when a resident receives their antibiotics on [MEDICAL TREATMENT] days. Surveyor conducted an interview on 1/14/21 at 10:20 am with LPN-G. Surveyor inquired about facility's protocol for assessment of wounds on admission. LPN-G replied that all wounds should be assessed and measured upon admission to facility and that treatment orders should be in place on admission. Surveyor asked if a resident's wounds should be assessed by an RN on admission. LPN-G stated that they and DON-B are part of the facility's wound team and that residents with wounds are seen by wound team on a weekly basis. Surveyor did not see any documentation that R25's wounds were assessed and measured by an RN upon admission to the facility with treatment orders in place. Surveyor asked LPN-G if there were orders for a resident to see a wound specialist, how staff would carry out the order. LPN-G replied that the facility has a wound specialist who comes to the facility on a weekly basis and that the wound team would alert the wound specialist if a resident needed to be seen. Surveyor asked LPN-G if medications should be held prior to [MEDICAL TREATMENT]. LPN-G responded that it would depend on the physician's orders [REDACTED]. LPN-G responded that this information should be found in [MEDICAL TREATMENT] resident's orders. Surveyor did not see any information regarding holding R25's medications on [MEDICAL TREATMENT] days on the physician's [MEDICAL TREATMENT] orders or on the MAR indicated [REDACTED] Surveyor asked if a resident was to receive antibiotics and they were on antibiotics, should the antibiotic medication be scheduled around a resident's [MEDICAL TREATMENT] appointment. LPN-G responded that it would be up to the doctor to decide when a resident receives their antibiotics. Surveyor ask if a resident was missing doses of medications, such as antibiotics, on a consistent basis, should the resident's physician be updated. LPN-G agreed that a physician should be made aware of missing medication doses. On 1/14/21 at 12:02 pm, Surveyor conducted an interview with LPN-I. LPN-I was R25's nurse on day shift 9/29/20, 10/1/20 and 10/3/20. Surveyor asked LPN-I about the facility's protocol for admitting residents to the facility with skin abnormalities and wounds. LPN-I replied that on admission, wounds should be measured and assessed by an RN upon admission to the facility and monitored on a weekly basis thereafter by the wound team. LPN-I indicated R25 should have been assessed on admission by an RN. Surveyor asked LPN-I if medications should be held for residents that are attending [MEDICAL TREATMENT]. LPN-I responded that it would depend on the physician's orders [REDACTED]. LPN-I responded that this information should be found in [MEDICAL TREATMENT] resident's orders in the electronic medical record. Surveyor did not see any physician's orders [REDACTED]. Surveyor asked LPN-I if a resident was to receive antibiotic therapy, should the antibiotic medication be scheduled around a resident's [MEDICAL TREATMENT] appointment to ensure resident receives proper dosage of antibiotic. LPN-I responded that it would be up to the doctor to decide when a resident receives their antibiotics. Surveyor reviewed R25's antifungal and antibiotic medication orders with LPN-I. Surveyor asked why R25 did not receive scheduled morning medications, including pain medications ([MEDICATION NAME]), antifungal (Fluconazole) and antibiotic ([MEDICATION NAME]) medications on day shift 9/29/20, 10/1/20 and 10/3/20. LPN-I responded that R25 had [MEDICAL TREATMENT] on these days and left facility early. Surveyor asked LPN-I if the physician should be notified when a resident is not receiving their medication per order. LPN-I replied a doctor should probably have been told R25 was at [MEDICAL TREATMENT] so changes could be made for that. Surveyor asked if a resident was missing doses of medications, such as antibiotics, on a consistent basis, should the resident's physician be updated. LPN-I agreed that a physician should be made aware of missing doses. On 1/13/21 at 1:00pm. Surveyor reviewed R25's Nursing progress notes. On 10/3/20, the Facility was notified that R25's representative had taken them to the hospital after their [MEDICAL TREATMENT] appointment due to concerns with ringing of the ears and difficulty hearing. Per Hospital records dated 10/3/20, R25 was discovered by emergency room staff with multiple wounds to buttocks and numerous large wounds to the abdominal fold, one of which was noted with purulent drainage and foul odor. R25 was admitted to the hospital related to [MEDICAL CONDITION] of the abdominal fold and was ordered to receive intravenous antibiotics in accordance with the hospital'[MEDICAL CONDITION] protocol per hospital admission record on 10/3/20. On 1/14/21 at 12:30 pm, Surveyor conducted interview with DON-B. Surveyor inquired about facility's protocol for admitting residents to the facility with skin abnormalities/wounds. DON-B responded that a wound assessment, including measurements should be performed on admission. Surveyor asked DON-B if a RN should be performing the assessment of a wound versus an LPN. DON-B responded that either an RN who is in the facility at the time of admission or the wound team should measure and perform an assessment on wounds. On 1/14/21 at 12:35 pm, Surveyor informed DON-B that R25's wounds were not measured or assessed by an RN on 9/15/20, the day of R25's admission to facility. Surveyor asked DON-B if residents receiving [MEDICAL TREATMENT] should be receiving scheduled medications prior to [MEDICAL TREATMENT] appointments. DON-B stated that it would depend on the resident and their physician orders. Surveyor asked where this information should be found. DON-B replied that any orders for holding medication would be able to be seen in the electronic health record of the resident. Surveyor asked DON-B if a resident on [MEDICAL TREATMENT] is receiving medications, such as antibiotic therapy, how the facility ensures residents are receiving their medications per physician order. DON-B stated she would have to look into this. Surveyor and DON-B discussed concerns related to R25's wound assessment, wound treatment, documentation, and missing dosages of medication, including antibiotics on 9/29/20, 10/1/20 and 10/3/20. Surveyor verbalized concerns related to R25's hospitalization on [DATE] which resulted in R25 receiving IV antibiotics related to [MEDICAL CONDITION] from abdominal wounds. On 1/14/21 at 1:25 pm, Surveyor made NHA-A and DON-B aware of the above concerns. On 1/18/21, DON-B sent an email to surveyor with additional documentation, including a telephone order dated 9/15/20 which stated Hold meds before [MEDICAL TREATMENT] signed by R25's primary physician. Surveyor noted the hold of the meds were not reflective in R25's MAR indicated [REDACTED]. DON-B also supplied a letter from the facility's current Medical Director dated 1/17/21 related to R25's hospitalization on [DATE]. The Medical Director's letter indicated in part that R25 did not [MEDICAL CONDITION]. The Medical Director's letter also stated R25 had [MEDICAL CONDITION] related to [MEDICAL CONDITION] and infections forming between skin folds. The Medical Director also referenced in the letter that he was working with the facility on missed medications which are delayed or missed due to [MEDICAL TREATMENT]. R25's primary physician during their stay at facility is no longer working at facility and was unavailable for interview.

Based upon observation, interview, and record review, the facility did not ensure proper prevention and treatment for 3 (R14, R49 and R24) of 4 Residents reviewed for pressure injuries. R14 was admitted to the facility for rehabilitation following hospitalization for supratherapeutic [MEDICATION(S)] levels with tarry stools. R14 had a previous left below the knee amputation and a right below the knee amputation earlier in 2019. At the time of admission R14 had no open pressure injuries. Initial assessments of R14 placed her at low risk for pressure injuries. An alternating pressure mattress was put in place. R14 was transferred via assist of two staff with a Hoyer lift. R14 also wore stump shrinking devices to both amputation stumps. There was no care plan put in place to monitor under these devices for R14 or to ensure the sling fit properly to prevent potential shearing. On approximately 5/14/19 R14 sustained a mechanical device pressure injury from the Hoyer sling to the right and left inner/posterior thigh and right lower back. R14 continued to have these pressure areas throughout her admission to the facility. Both areas deteriorated to unstageable areas. The facility's plan was to place a bath blanket within the Hoyer sling for padding. Interviews indicate R14 sat on a cushion in her wheelchair with a sling and bath blanket on top of the cushion decreasing the effectiveness of the cushion and creating layers that could increase pressure. There is no indication the facility looked into obtaining a padded Hoyer sling or a device to help decrease the potential for shearing when transferring. On 5/17/19 therapy noticed the start of R14 developing wounds under her stump shrinking devices. The facility nursing staff did not initiate a weekly wound evaluation until 5/22/19. At this time R14's right thigh wound measured 33 cm x 2 cm as a suspected deep tissue injury. This area would progress to an area that became infected requiring hospitalization on [DATE] for IV antibiotic treatment and oral antibiotic treatment. This area would deteriorate to a facility acquired Stage 4 pressure injury. The left thigh/stump area was initially measured on 5/16/19 as a Stage 1 area with a measurement of 1.2 x 21.5 x 0.5. By 5/23/19 the area progressed to have 50% slough present. The facility did not develop a plan of care for staff to monitor R14's skin under the stump shrinkers. On 5/29/19 it is indicated R14 obtained a Roho type cushion and a larger stump shrinker. The record and plan of care does not clearly indicate if or when R14 stopped wearing the stump shrinkers. Therapy notes indicate communication with R14's prosthetist regarding the amputation sites and swelling and the benefit of wearing the devices however it is not clear when or if R14 stopped wearing the devices or what the frequency of wearing was. In addition to these areas R14 developed facility acquired Stage 3/unstageable areas to the sacrum, right iliac crest, right medial buttock, right lateral buttock, right inner buttock and left buttock. It was not until September 2019 when the facility implemented a repositioning plan of care to reposition every two hours instead of the Certified Nursing Assistant task documented reposition each shift. Review of R14's records indicate R14 expressed recurring pain with her various wounds. On 6/6/19 the facility indicated they would pre-medicate R14 for pain prior to treatments. There is no indication this plan was established. On 7/24/19 the facility obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, this was a PRN (as needed) order and review of R14's medication/treatment (MAR/TAR) records and interview of nursing staff indicate it was not routinely offered to R14 with treatment changes. In August R14 expressed that her wounds Hurt a whole lot. The facility's pain management plan was to add [MEDICATION(S)]. Review of R14's pain management plan indicates R14's pain was not effectively managed causing her to express she had uncontrolled pain and refusal of dressing changes and cares (Cross-reference F697). Review of R14's plan of care indicates the facility did not establish a comprehensive plan of care based upon assessment of R14 to prevent the development of pressure injuries and to help heal areas when developed. The facility's failure to prevent R14 from developing 11 facility acquired pressure injuries that progressed to an infected, stage 4 pressure injury and multiple Stage 3/unstageable areas created a situation of immediate jeopardy. The immediate Jeopardy started on 6/27/19. Nursing Home Administrator (NHA)-A and Assistant Director of Nursing (ADON)-I were notified of the Immediate Jeopardy on 9/9/19 at approximately 3:45 pm. The immediate Jeopardy was removed on 9/11/19 as the facility implements its action plan related to wounds. The deficient practice continues at the scope and severity of a D (potential for harm/isolated) based upon the additional examples regarding R49 and R24. R49 has a long standing Stage 4 pressure injury on her coccyx that is not healing. On 8/8/19 R49 was seen by the facility's wound physician who recommended R49 receive a Roho cushion for their wheelchair rather than the pressure reducing blue foam cushion R49 was sitting on. During the survey, R49 was observed sitting in her wheelchair still on the blue foam cushion. When asked if R49 had received a cushion that had air cells to sit on R49 indicated no, but it sounded interesting. Interviews indicate R49 did not receive the Roho cushion as ordered because of the cost associated with the device. One was ordered during the survey. R24 was admitted with four (two Stage 4 and two Stage 2) pressure injuries 5/7/2019. The four pressure injuries were not assessed until 5/9/2019. Treatment was not provided to the four pressure injuries until 5/11/2019. Findings include: 1.) R14 was admitted to the facility on [DATE] following hospitalization for elevated INR (international normalization rate) related to anticoagulant therapy. R14 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 wore a stump shrinker to the right and left amputation stumps. Review of R14's hospital discharge summary and facility admission documentation indicates R14 was not admitted to the facility with any pressure injuries, just old skin tears to left upper arm. R14's additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's progress note dated 4/24/19 at 18:50 indicates: admitted at 16:30. Pacemaker, left jugular [CONDITION(S)] port. Scattered bruising throughout body happened before going to ER (emergency room ). Both legs below the knee. Old skin tears on left upper arm. Now resting well/will monitor. R14's admission assessment was completed by Licensed Practical Nurse (LPN)-D. R14's admission Minimum Data Set (MDS) dated [DATE] indicates R14 has a Brief Interview for Mental Score of a 14 indicating R14 was cognitively intact. R14 has no mood or behavior problems including no refusals of care. R14 requires extensive assist of two plus staff for bed mobility, personal hygiene and toilet use and total dependence of two staff for transfers. The MDS indicates R14 is frequently incontinent of bowel and bladder and is not on a toileting plan. R14 has no open areas and is at risk for pressure injuries. The MDS indicates pressure relieving bed and chair. Review of the Care Area Assessment (CAA) for activities of daily living (ADL's) dated 5/6/19 indicates: the resident has an ADL self-care deficit evidenced by assistance related to physical limitations secondarily to weakness. Continuing with plan of care in pcc (Point Click Care). The CAA for pressure ulcers dated 5/6/19 indicates: The resident is at risk for alteration in skin integrity related to impaired mobility and incontinence. Continuing with plan of care in pcc. The CAA also indicates according to documentation the resident has been requiring extensive assistance with toileting and has been frequently incontinent of bladder. Continuing with plan of care in pcc. Surveyor noted the CAA summaries do not fully analyze R14's factors that contribute to her increased need for assistance and increased risk for developing pressure injuries to assist in developing a comprehensive, preventative plan of care for R14. On 4/24/19 a Braden Assessment indicated R14 has total score of 18 indicating R14 is at low risk for pressure injuries. The care plan for Resident has impaired skin integrity initiated on 4/26/19 indicates for the goal area dated 4/26/19: will show s/sx (signs/symptoms) of healing by next review date. Surveyor noted there is no indication R14 had an open area as of 4/26/19. Interventions include: APM (alternating pressure mattress) check function Q (each) shift, initial Braden and per facility protocol, monitor s/sx of infection, monitor s/sx worsening skin tissue, monitor pain and offer [MEDICATION(S)] as ordered, w/c (wheelchair) cushion, treatment as ordered and update MD with changes in wound status and PRN. Surveyor reviewed R14's Comprehensive Plan of Care with a creation date of 5/13/19 that documents for pain management, Explore non pharmacological pain alleviating interventions such as heat, ice, repositioning, massage, elevation, relaxation, food. Update MD PRN and/or if pain is not controlled. A Progress note dated 5/14/19 at 12:01 indicates: Resident on board for increased congestion and decreased pulse ox, lung sounds crackles and wheezing noted. Pulse ox 92% at 3 L (liters) of O2 via nasal cannula resident also had a low blood sugar of 36. One dose [MEDICATION(S)] given. Also noted to have an open area to bilateral gluteal folds - linear in size. MD and family updated and NOR (new order). Surveyor noted this was completed by Licensed Practical Nurse (LPN)- G. Surveyor noted there is no indication an assessment was completed by a registered nurse. Review of R14's record does not clearly indicate the facility recognized R14's change in condition regarding her respiratory status and potential increased risk to R14's skin if she became more dependent upon staff or spent more time in bed. Lower back and left and right posterior and inner thigh: *Note: All pressure injury wounds are measured in centimeters (CM) per facility weekly wound documentation. Revision to R14's impaired skin integrity care plan dated 5/14/19 includes: place barrier between resident and the sling, leave brief open in bed. The Focus area initiated 5/14/19 MDRPI (medical device related pressure injury) to the lower back and left and right posterior and inner thigh secondary to mechanical lift sling. Right posterior/inner thigh: Weekly wound evaluation dated 5/16/19 indicates pressure injury right posterior and inner thigh 1 x 16 x 0, Stage 1. The evaluation indicates no abnormalities to wound edge or periwound. No exudate or odor. The evaluation asks has the DPOA/responsible party been notified of a decline in the wound. NA (not applicable) is indicated. The form also asks has the physician been notified of no change or deterioration over the past 2 weeks. NA is indicated. Wound progress is documented as stable/no change despite indications this is an initial assessment. Date of onset for treatments is 5/14/19 and indicated is chair pressure reduction/redistribution, turning and repositioning, positioning/splinting device, wound treatment/application of dressing and APM (alternating pressure mattress). Has the treatment changed in the past two weeks? No. No pain is indicated. Comments: DTI/1: apply barrier cream with [MEDICATION(S)]. Signed by DON-B in 7/30/19. A physical therapy progress note dated 5/16/19 indicates: pt (patient) states having new wound care precautions as stated by wound care (consulted nurse for verification), pt has wounds @ (at) post sacral and B (bilateral) med inner thigh. [MEDICATION(S)] being applied. Pt allowed to transfer to w/c (wheelchair) with blanket barrier between pt and sling. Discussed with pt current sx's (symptoms) and determined slide board unviable due to requiring brief/pants (these being donned would cause undo friction to inner thigh and sacrum w/mvmt (with movement), determined no lower body clothing to be used and Hoyer w/sheet-blanket covering advisable at this time. Revisions to R14's care plan dated 5/17/19 include: apply a bath blanket between the Hoyer sling and the resident for transfers and apply [MEDICATION(S)] barrier to bruising and abrasion tid (three times daily) and as needed and leave brief open when in bed. Surveyor noted all three interventions were canceled on the plan of care with a system cancel date by Director of Nursing (DON)-B. Surveyor noted if the open areas were caused by shearing or abrasions by the Hoyer sling, Surveyor noted there is no indication the facility looked into obtaining an actual padded sling for R14 rather than adding a bath blanket to R14's sling increasing risk for the sling to not be used properly and increase pressure from added bulk. The 5/23/19 weekly wound sheets indicates pressure injury 1 x 15.9 x 0, Stage 1. MDRPI. No abnormalities to wound edges or peri wound. No exudate or odor. NA to notification to DPOA and physician. Wound progression indicates: stable/no changes Is pain associated with the wounds? Yes. Hurts a little bit is indicated. The pain management plan is blank. Comments indicate: DTI/1 stable continue POC. Signed by DON-B on 7/30/19. Surveyor noted there is no plan of care to address R14's pain with her wounds. A revised intervention to R14's skin integrity care plan dated 5/29/19 includes Roho cushion when up in chair check inflation am and pm. Surveyor noted there is no indication an assessment of R14 sitting on a bath blanket and sling in the chair potentially on top of the Roho was assessed to ensure effectiveness of the Roho cushion. The next weekly wound evaluation has an effective date of 5/30/19. This document indicates the date of measurement as being 5/23/19. Pressure injury of right inner thigh. 6.9 x .7 x .3, Stage 3. MDRPI. 25% granulation, 50% slough, 25% eschar. Scant serous exudate with no odor. Progress of wound is indicated as being improved. Surveyor noted this is despite the area progressing to a stage 3 with necrotic tissue. Is pain associated with the wound? Yes/no is blank. The facial pain scale indicates hurts a little bit. The pain management plan is blank. Comments include: DTI/3 continue barrier cream with [MEDICATION(S)]. Signed DON-B on 7/30/19. Surveyor noted there still is no care plan related to pain Surveyor noted there are no changes to R14's overall plan of care regarding preventing shearing/abrasions despite a decline in the wound. The 6/6/19 weekly wound evaluation indicates pressure injury to right inner posterior thigh 9 x .6 x .3, Stage 3. MDRPI. 25% granulation, 75% slough. Is pain associated with the wound? Yes. Level of pain is hurts a little bit. The pain management plan indicates medicate before assessment. Comments: DTI/3 continue barrier cream with [MEDICATION(S)]. Signed by DON-B on 7/30/19. Review of R14's record indicates no order for pain medication was obtained at this time. The weekly wound evaluation dated 6/13/19 indicates pressure injury to right inner thigh 1.8 x 6.4 x .2, Stage 3. MDRPI. 100% granulation is documented. No assessment of the periwound or edges is indicated. Exudate is identified as small serous. Odor is not assessed. The facial pain scale indicates hurts a little. Pain management plan is blank. Surveyor noted there still is no plan of care for R14's pain. R14's plan of care for skin integrity includes a revision dated 6/12/19 indicating MDRPI to the left and right posterior inner thighs now presents as a DTI/3 (deep tissue injury/stage 3) secondary to mechanical lift sling. Surveyor noted the revised plan of care does not address R14's pain or interventions to prevent further deterioration of the wound. Surveyor noted there is no weekly evaluation for the week on 6/20/19. On 6/20/19 R14 was hospitalized for a left extremity loop graft. During this hospitalization the hospital documentation identified R14 as having multiple unstageable and stage 3 pressure injuries. During this hospitalization a referral was made to the wound clinic for R14. The weekly wound evaluation dated 6/27/19 at 09:29 indicates pressure injury of right post inner thigh. 1.2 x 2 x 0, Stage 3. 100% granulation. No abnormalities to wound edges/peri wound. Small serous exudate is noted, odor is not assessed. Comments: DTI/3 presents as st (stage) 2, much improved, smaller in size to see wound clinic today. Signed by DON-B on 7/30/19. A weekly wound summary with an effective date of 7/4/19 has a wound measurement date listed as 7/11/19 indicates pressure injury to right inner thigh .5 x .1 x .1, stage is N/A. DTI mech injury is listed. 75% granulation, 25% slough. Moderate serous exudate noted. Odor is not assessed. Has treatment changed in past two weeks? No. Comments: small amount of slough remains, area much smaller than previous assessment, goes to wound clinic. Signed by DON-B on 7/28/19. The weekly wound evaluation form dated 7/11/19 indicates pressure injury to right inner thigh.7 x 4.5 x .2, Stage 3. MDRPI. 76% granulation, 25% slough (surveyor noted percentage is greater than 100%). Scant serous exudate is noted. Odor is not assessed Comments: small amount of slough noted this week at the base, goes to wound clinic. Signed DON-B 7/30/19. Surveyor noted the measurement increased this past week and there still are no notable changes to R14's plan of care. The weekly wound evaluation dated 7/18/19 indicates pressure injury.9 x 4.3 x 0, Stage 3. MDRPI. 95% granulation is identified. The remaining 5% is not identified. Small serous exudate is indicated, no odor The weekly wound evaluation dated 7/24/19 indicates pressure injury to right posterior thigh 1 x 5 x .1, stage 3. MDRPI. 25% granulation, 75% slough. Small serous exudate is noted with no odor. Wound progress is indicated as deteriorated/declined. Comments: DTI/3 area had declined wound clinic aware and will see at next appointment. Signed DON-B on 7/31/19. The 7/31/19 weekly wound evaluation indicates pressure injury to right post thigh. 1 x 6.2 x .2, Stage 3. 50% granulation, 50% slough. Small serous exudate is noted with no odor. The weekly wound assessment dated [DATE] indicates pressure injury 2.5 x 5.9 x .1, Stage 3. MDRPI. 25% granulation, 75% slough. Are abnormalities noted to wound edges/peri-wound? No. Small serosanguineous exudate with no odor. Wound progress is noted as deteriorated/declined. The 8/14/19 weekly wound evaluation indicates pressure injury right post thigh. 2.3 x 6 x .1, Stage 3. MDRPI. 50% granulation, 20% slough and 30% eschar. Small serosanguineous exudate with no odor. Yes is indicated for notification of DPOA and physician. Wound progress is noted as deteriorated/declined. Continue POC & f/u with the wound clinic. Gently wash the right leg wound and bilateral ischial wounds daily. Place Iodosorb or pre-mixed [MEDICATION(S)]/wound gel in the wound follow by ABD and [MEDICATION(S)] tape. Signed ADON-K 8/14/19. The 8/21/19 weekly wound assessment indicates pressure injury Right post thigh. 1.7 x 6 x .1, Stage 3. 5% granulation, 90% slough, 5% eschar. Are abnormalities noted to wound edges/peri-wound? No. No exudate is indicated along with no odor. Wound progress is indicated as stable/no change. Surveyor noted this is despite the overall increase in necrotic tissue. Onset date for treatments is now listed as 6/12/19 and indicates same treatment devices as previous week. The next weekly wound evaluation has an effective date of 8/28/19 with a wound measurement date of 8/21/19. The wound is a pressure injury of the right post thigh. 1.4 x 6.7 x .1, Stage 3. 100% eschar is indicated. No exudate is indicated along with no odor. Wound progress is noted as deteriorated/declined. Has treatment changed in past two weeks? No is indicated despite change to [MEDICATION(S)] as a treatment on previous evaluation. Is pain associated with the wound? Yes. The facial pain scale indicates hurts a whole lot. The pain management plan is new order for [MEDICATION(S)]. Comments include: DTI/3 area stable. Continue POC & f/u with the wound clinic. The 9/4/19 weekly wound evaluation indicates pressure injury right post thigh. 0.9 x 6.7 x 0.3, Stage 3. MDRPI. 20% granulation, 75% slough, 5% eschar. No exudate is indicated along with no odor. Wound progress is indicated as deteriorated/declined. Has treatment changed in the past two weeks? No is indicated. Is pain associated with wound? Yes. The facial pain scale indicates hurts a whole lot. Pain management plan is: [MEDICATION(S)]. Comment indicates: DTI/3 area improved 5% eschar. Continue POC f/u with the wound clinic On 10/8/19 Surveyor interviewed Certified Nursing Assistant (CNA)-J regarding 14's pressure injuries. CNA-J indicated a normal day for R14 would be for R14 to be up in her chair until she was too uncomfortable and then they would lay her down. CNA-J indicates they used a sling to transfer R14 and would put a bath sheet in it and it seemed to help. When asked about pain, CNA-J indicated towards the end of her stay at the facility R14 was in a lot of pain. When asked if CNA-J was familiar with all of R14's wounds and needs for those wounds CNA-J shrugged her shoulders. On 10/8/19 at approximately 1:28 pm Surveyor interviewed CNA-L. CNA-L indicated R14 would get up just before or after breakfast and stay up in her wheelchair. CNA-L indicated R14 would stay up in her chair but also it was R14 who said after the wound clinic visit in June that they wanted her on bed rest and to get up just before [CONDITION(S)]. Surveyor asked CNA-L if this was on her plan of care and CNA-L indicated she didn't think so. CNA-L indicated R14 knew what she wanted and that she got worse as time went on. Surveyor asked CNA-L about providing cares to R14. CNA-L indicated it was hard with all of the wounds and the pain. Surveyor asked CNA-L if they used any special sheets to prevent shearing or to help boost R14 in bed. CNA-L indicated no they used a sheet and a small pad/sheet that was on the bed. CNA-L indicated in her wheelchair, R14 sat on a bath sheet with a sling on top of her wheelchair cushion. Right Iliac Crest/Rear The Weekly wound evaluations for R14 include a facility acquired area that is also considered a medical device related pressure injury. The weekly assessments contain the same questions as answered weekly for the Right thigh wound. Surveyor noted the evaluation, despite indicating the cause is from a medical device, an explanation of what device lead to the area is not specified. Surveyor noted all weekly sheets associated with this wound are signed by DON-B on 7/30/19. Details of the wound indicates: 5/16/19: 1.5 x 2.5 x 0 - Stage 1 Wound team to follow. Pain is associated with the wound hurts a little bit. DTI/1: purple intact, barrier cream with [MEDICATION(S)]. 5/23/19: 1x 1.6 x 0 - Stage 1. DTI/1: improved. Continue plan of care (POC). 5/30/19: .8 x .5 x .1 - Stage 2. 20% granulation. Surveyor noted the rest of the characteristics are not specified. Comments on evaluation include: DTI/2: Area smaller in size now superficially open. A Focus area of R14's skin integrity care plan dated 6/2/19 includes st (stage) 2, sacrum and iliac crest. (Iliac crest resolved 6/27/19). Surveyor noted the care plan entry is a log of the wound without any added intervention related to the area (s) 6/6/19 1 x 1 x .1 - Unstageable. 5% slough 100% eschar (Surveyor noted the % is greater than 100%). Comments: DTI/U (unstageable) intact scab beginning to slough off. 6/13/19: 2.3 x .8 x 0 - Stage 3. 50% granulation, 50% slough. DTI/3: add medi-honey wound base. There are no wound measurements for the week of 6/20/19 as R14 was admitted to the hospital on 6/20 and released on 6/21/19. The 6/27/19 weekly wound evaluation indicates the DTI/1 is resolved. Anterior and posterior Right Stump Review of R14's therapy treatment encounter notes dated 5/17/19 indicates: w/pt present called prosthetist, left message about obtaining larger stump shrinkers for R (right) stump as the lvl (level) 1 was demoing (demonstrating) skin breakdown at medial thigh . Surveyor noted there is no indication a change was made to R14's care plan to address her stump shrinker potentially causing skin breakdown. A 5/21/19 therapy treatment encounter note indicates: pt in presence contacted prosthetist by telephone, discussed pt adverse reaction to current stump shrinkers and other issues, prosthetist available to reassess the pt this date, will meet w/pt and prosthetist. This inc's pt progress w/ability to met (sic) w/prosthetist and RLE (right lower extremity) stump shaping prep for prosthetic creation. Met with prosthetist/pt, pros. Decided to provide alternative compression stump shrinker, education for pt/therapist was provided. Surveyor noted the changed stump shrinker was not added to R14's plan of care for nursing staff at this time to include monitoring with change in device. There is no indication/assessment by nursing regarding this issue until 5/22/19. Progress note dated 5/22/19 at 9:59 am indicates R14 has new mechanical pressure injury secondary to stump shrinker to R stump posterior and anterior. New bruise with hematoma to right elbow secondary top (sic) transfer at [CONDITION(S)]. This was noted by Director of Nursing (DON)-B. There is no initial wound assessment document for this wound. The initial weekly wound evaluation is dated 5/22/19 and indicates the posterior right stump measures 33 x 2 x 0 suspected deep tissue injury (DTI) is the identified stage. The evaluation indicates DTI mechanical injury. The evaluation indicates the peri wound is normal with no exudate and description of odor is blank. The form asks if the designated power of attorney (DPOA) has been notified of a decline in the wound and indicates not applicable. The form asks has the physician been notified of no change or deterioration over the past two weeks. This also indicates not applicable. Treatments with an onset date of 5/22/19 include chair/pressure reduction/redistribution cushion, turning and repositioning and positioning/splinting device are all checked. Surveyor noted there is no indication these treatments are on a plan of care for R14. Has treatment been changed in last two weeks? No. The evaluation asks is pain associated with the wound and yes is indicated with a facial scale of it hurts a little bit checked. The identified pain management plan is stump shrinker removed. Comments include: wound team will follow, area goes around her stump intact purple in color. Skin prep applied. There is a new order dated 5/22/19 to apply skin prep to the DTI to right posterior and anterior right stump BID. This order was discontinued on 6/5/19. R14's care plan interventions dated 5/22/19 include: MDRPI DTI (deep tissue injury)/1 (stage 1) x (times) 2 (anterior and posterior to the right stump (anterior right stump dti resolved 5/23/19) bruise with hematoma to right elbow. Interventions dated 5/22/19 include: stump shrinker removed, [CONDITION(S)] updated on bruise. Surveyor noted there was no prior care plan or treatment order to monitor R14's skin under the stump shrinker. On 5/22/19 the physical therapy encounter note indicates: New BLE compression stocking doffed (removed) and noted RLE skin reddening almost full circumference of thigh, mid-thigh where stocking most restrictive, noted pt may have lymph [CONDITION(S)] and would need to be addressed. OT (occupational therapy) stated would contact prosthetist to inform of pt current condition, follow up. During observation nurse present to witness and acknowledge. On 5/23/19 the physical therapy encounter note indicates: observed RLE med skin integrity, pt has 8 by ¾ wide intact blister .nursing aware. Posterior Right Stump On 5/23/19 a weekly wound assessment was completed on the right posterior stump indicating this area measures 1.9 x 8 x 0 Stage 1. MDRPI (medical device pressure injury). The evaluation indicates there are no abnormalities to the peri wound with no exudate. Question of whether the DPOA or physician is notified is checked as not applicable. Treatments indicates an onset date of treatment to be 5/23/19 with chair pressure reduction/redistribution cushion, turning and repositioning, positioning/splinting device and wound treatment/supplication of dressing indicated along with other APM (alternating pressure mattress) Treatment changed in last two weeks? Yes however there is no date to indicate change. Is pain associated with the wound? Yes hurts a little bit. Pain management plan is blank. DTI/1 (DTI/stage 1) a portion of this DTI is now fluid filled. Continue skin prep. Signed DON-B on 7/30/19. Surveyor noted there is no indication the treatments were added to R14's plan of care or that a physician was consulted with. A 5/27/19 physical therapy encounter note indicates: reviewed recent updates of goals, assisted pt w/dressing and prep for bed to w/c transfer, multiple rolls to address wounds, SBA (stand by assist) w/bed rails, set up for shirt, [NAME] (maximum assist) for pants due to wound concerns, Hoyer placement w/ blanket barrier for transfer, Hoyer to s/c Ax2 (assist times two). Comments: due to pt fragile skin integrity state, present wound progress and stump reduction plan, pt requires continual skin assessment. Advised nurse of pt wound dressing, required changing, nurse observed pt wounds and addressed as necessary. Surveyor noted this not indicates multiple opportunities for R14 to shear while rolling and dressing. Additionally, this note still references use of a bath blanket for padding with a sling present in her chair despite the potential for added pressure concerns with the layers under R14. There is no indication these concerns are addressed on R14's skin plan of care. On 5/29/19 a Roho cushion was ordered. R14's care plan includes a revision dated 5/29/19 indicating a larger stump shrinker applied by therapy. Surveyor noted there is no plan for monitoring R14's skin under the stump shrinker or to assess for fit. The 5/30/19 weekly wound evaluation for the right posterior stump indicates 1.5 x 11 x na - Stage 2. No abnormal peri wound. No exudate. DPOA/physician notification indicates not applicable. Wound progress indicates improved. Treatments listed with a blank onset date include bed pressure reduction/redistribution mattress, chair pressure reduction/redistribution, turning and repositioning, wound treatment/application of dressing and APM. Has treatment changed in last two weeks? No. Is pain associated with wound? No. Comments include: DTI/2 (DTI/stage 2) area has improved, fluid filled blister has deflated for the most part a small amount of fluid remain, decrease in size. Surveyor noted the overall size of the area has increased. Signed DON-B on 7/30/19. The 6/6/19 weekly wound measurement for right posterior stump indicates 1.5 x 12.2 x na now identified as unstageable with 100% eschar. Still MDRPI. No abnormalities with peri wound. No exudate or odor. The question of has the DPOA or physician been notified indicates NA (not applicable). Wound progress indicates stable/no change despite 100% eschar. Has treatment changed in last two weeks? No Is pain associated with the wound? No. Comments include: DTI/U (DTI/unstageable) intact dried scab. Signed DON-B on 7/30/19. Right anterior stump Weekly wound assessment dated [DATE] indicates this is a pressure injury. 2.4 x .5 x 0 - suspected deep tissue injury. DTI mech injury is identified. The evaluation indicates no abnormal peri wound. Notification of DPOA and physician are not applicable. Treatments include an onset date of 5/22/19 indicating chair pressure reduction/redistribution cushion, turning and repositioning, positioning/splinting device and wound treatment/application of dressing and APM. Is

Based on interview, record review, and observation, the facility failed to ensure that 3 of 6 sampled residents (R14, R24, R47) received appropriate medication and lab monitoring and follow up on physician orders. * The facility failed to monitor [MEDICATION NAME] ([MEDICATION NAME]) and R14 missed doses on [DATE] through [DATE]. R14 had an IV graft completed on her left arm fistula on [DATE] for occlusion. R14's fistula occluded again on [DATE] and a left internal jugular port was placed. Failure to ensure that INR (International normalization rate - lab to monitor clotting factor when on an anticoagulant) blood-work was done on [DATE] led to her [MEDICATION NAME] being abruptly stopped. This increased her risk that another clot would form - which, indeed, happened. It also placed her at risk for development of additional clots. Due to RN error, [MEDICATION NAME] was not administered to R14 from [DATE] through [DATE]. As a result R14 was admitted to the hospital on [DATE] with a blocked left fistula with critical limb ischemia. (Cross-reference F684.) The resident passed away on [DATE]. The facility's failure to follow physician orders [REDACTED]. Nursing Home Administrator (NHA)-A and Assistant Director of Nursing (ADON)-I were informed of the Immediate Jeopardy on [DATE] at 3:35 PM. The Immediate Jeopardy was removed on [DATE] when the facility put a system in place for monitoring blood-thinning medications, needed lab work, and lab work results. However, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan and and related to the following examples:. * R24 complained of tooth pain on [DATE] and nursing staff contacted the Nurse Practitioner (NP) to request an order for [REDACTED]. * R47 who on [DATE] had an increase in [MEDICATION NAME] to three times a day as a result of a low iron and a low percentage of iron saturation. The physician ordered a follow up iron panel to be conducted on [DATE]. As of [DATE], the facility was not monitoring the [MEDICATION NAME] as the iron panel lab had not been followed up on. Findings include: Critical Limb Ischemia (CLI) is a severe obstruction of the arteries which markedly reduces blood flow to the extremities (hands, feet, and legs) and has progressed to the point of severe pain and even skin ulcers or sores .Critical limb ischemia is the advanced stage of peripheral artery disease (PAD), which results from a progressive thickening of an artery's lining (caused by a buildup of plaque). This buildup of plaque, also known as [MEDICAL CONDITION], narrows or blocks blood flow, reducing circulation of blood to the legs, feet, or hands . Critical limb ischemia is a serious condition that requires immediate treatment to re-establish blood flow to the affected area or areas (most patients with CLI have multiple arterial blockages). treatment for [REDACTED]. The number one priority is to preserve the limb .The earlier a [DIAGNOSES REDACTED]. https://surgery.ucsf.edu/conditions--procedures/critical-limb-ischemia.aspx Surveyor reviewed facility's Medication Error and Adverse Drug Reaction Reporting policy with a date of ,[DATE]. Documented under Guidelines and Definitions was 3. Medication errors and adverse drug reactions are considered significant if they: a. Require discontinuing a medication or modifying a dose. b. Require hospitalization . c. Result in a disability. d. Require treatment with a prescription medication. e. Result in cognitive deterioration or impairment. f. Are life threatening. g. Result in death. 1.) Surveyor reviewed R14's Aurora Burlington Medical Hospital paperwork. R14 was admitted to hospital on [DATE] after Home Care nurse assessed the INR at above 8.0 and resident was having black, tarry and blood streaked stools. Resident was discharged to the facility on [DATE]. R14 was admitted to the facility [DATE] for End Stage [MEDICAL CONDITIONS], Uremia, Toxic Metabolic [MEDICAL CONDITION], Long Term use of [MEDICATION NAME] ([MEDICATION NAME]), Supratherapeutic INR, Occult Blood in Stool, Diabetes Mellitus 2, Bilateral Below Knee Amputations and [MEDICAL TREATMENT]. R14's Hospital Discharge Summary with a discharge date of [DATE] included orders for [MEDICATION NAME] with INR Monitoring. R14's Admission Minimum Data Set (MDS) with an assessment date [DATE] documents a Brief Interview for Mental Status (BIMS) of 14 which indicates cognitively intact. Surveyor reviewed R14's Comprehensive Plan of Care with a creation date of [DATE] that documents Resident is at risk for abnormal bleeding, spontaneous bleeding, potential hemorrhage and/or increased/easy bruising r/t Afib on [MEDICATION NAME]. PT and INR values will be maintained within therapeutic range, As determined by the physician. Administer anticoagulant as currently prescribed by the resident's physician (see current physician orders [REDACTED]. Monitor labs as ordered. Schedule lab tests as ordered by the physician to monitor coagulation factors. Updated MD (as needed (PRN)). Surveyor reviewed Progress Notes for R14. On [DATE] at 11:15 AM documented order to continue [MEDICATION NAME] dose of 4 mg Tuesday/Thursday. [MEDICATION NAME] 3 mg Monday, Wednesday, Friday, Saturday and Sunday. Redraw PT INR (labs) in a week [DATE]. On [DATE] R14 was transferred to Aurora Burlington Medical Hospital from DaVita [MEDICAL TREATMENT] Lake [MEDICATION NAME] for fistula not functioning. An IV graft was done and resident was discharged back to facility. On [DATE] R14 was transferred to Aurora Burlington Medical Hospital from DaVita [MEDICAL TREATMENT] Lake [MEDICATION NAME] for fistula not functioning again. Hospital discharge paperwork documents Recurrent [MEDICAL CONDITION] of AV graft. Left internal jugular tunneled catheter exchange placed. Documented was follow up with MD to possibly revise fistula and new orders for [MEDICAL TREATMENT] on Monday [DATE]. On [DATE] an MD order was given for continue current [MEDICATION NAME] dose, recheck INR Friday ([DATE]). This order was not entered into electronic record and resident did not receive [MEDICATION NAME] from [DATE] thru [DATE] at discharge. On [DATE] at 9:08 AM Surveyor interviewed Licensed Practical Nurse (LPN)-[NAME] Surveyor asked LPN-G why she did not enter the [DATE] orders into the electronic record or order the INR for [DATE]. LPN-G stated she passed that task on to second shift because she ran out of time. LPN-G stated the nurse on second shift was agency staff but noted she acknowledged to her she knew the process for medications and ordering labs. Second shift agency nurse was not available for interview. On [DATE] R14 underwent a thrombectomy to left fistula for occlusion. On [DATE] no INR lab draw was completed. On [DATE] the missed INR and doses of [MEDICATION NAME] were found and investigated. an order for [REDACTED]. Lab noted INR on [DATE] collected at 9:50 AM was 1.6. New order for [MEDICATION NAME] 4mg (by mouth (PO) every (Q)) Mon, Wed, Fri, Sun. [MEDICATION NAME] 3mg PO Q Tues, Thurs, Sat. Recheck INR [DATE] was received on [DATE] from Nurse Practitioner (NP)-O. Surveyor reviewed MAR for R14 for September. [MEDICATION NAME] dose for [DATE] was not given. On [DATE] at 3:19 PM Surveyor interviewed Driver-M. Surveyor asked Driver-M if he was R14's main driver for appointments. Driver-M stated yes, he drove her to all her [MEDICAL TREATMENT] appointments and some MD appointments. Surveyor asked if Driver-M noticed her in pain or if R14 had mentioned she was in pain. Driver-M stated she was guarding her left arm and she had said she was in pain when he picked her up from her left arm fistula surgery on [DATE]. Surveyor asked about [DATE] [MEDICAL TREATMENT] ride. Driver-M stated she was guarding her left arm still and complaining of pain in that arm. On [DATE] R14 was seen in Wound Physician-N's clinic accompanied by R14's two daughters and Assistant Director of Nursing (ADON)-I from facility. Record review indicates, .The patient arrived to her wound care appointment with manager from facility at which she resides and her two daughters. The patient is in pain to her left arm and her buttocks. On [DATE] at 12:08 PM Surveyor interviewed Complainant-Q who was the daughter of R14. Complainant stated prior to arrival and during Wound Clinic appointment, R14 complained her left arm felt like it was broken. Complainant-Q stated she felt R14's left hand and it was cold to the touch. On [DATE] R14 was admitted to the ER directly from Wound Clinic. ER documentation states The patient (complains of) pain everywhere from the neck down here but was able to isolate the left wrist and hand as an ,[DATE]. Resident was admitted to ICU following ER visit. On [DATE] hospital documentation stated Hospital Course: Upon my evaluation this morning patient was found to be in [MEDICAL CONDITION] requiring IV [MEDICATION NAME] and IV [MEDICATION NAME] to maintain pressure. Patient was being evaluated by vascular surgery for [REDACTED]. Patient has a blocked AV fistula. Patient was only barely arousable, however she did respond to pain. Patient underwent a fistulogram/left upper extremity angiogram with temporary intraprocedural fistular acute occlusion. Findings of this study were consistent with critical limb ischemia. It was determined that patient needed an emergent thrombectomy of her left upper extremity. Patient was evaluated by Cardiology. Echo was performed at bedside which revealed (ejection fraction) of 25%. Patient determined to be extremely high risk for surgery. Patient subsequently continued to decompensate throughout the day. Patient's pressor requirement continued to increase. Patient had to be placed on [MEDICATION NAME] along with the [MEDICATION NAME] and [MEDICATION NAME] drip and MAP still remained below 55. Patient was then evaluated by vascular surgery and anesthesia who both determined that given her extremely high risk for surgery and it would be detrimental to proceed with surgery. At this time it was determined that no lifesaving measures would or could help. The family was contacted and the patient's [DIAGNOSES REDACTED]. According to the patient's daughter yesterday she had expressed her wishes, stating that she did not want to be intubated or have CPR performed on her. At this time decision was made to transition to comfort care. Family was in agreement with this and verbalized understanding. We will proceed with comfort measures at this time. Patient passed away overnight while I was off shift. On [DATE] at 10:57 AM Surveyor interviewed Nurse Practitioner (NP)-O. Surveyor asked if she was aware that the [MEDICATION NAME] was not restarted until [DATE]. NP-O stated no and it should have started [DATE] as she ordered. Surveyor asked if missing 10 days of [MEDICATION NAME] could have attributed to her left arm fistula occlusion and ischemia. NP-O stated yes. The Immediate Jeopardy was removed on [DATE] when the facility put a system in place for monitoring blood-thinning medications, needed lab work, and lab work results. This deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan and and related to the following examples: 2.) R24 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. R24's admission Minimum Data Set (MDS) assessment dated [DATE] had a Brief Interview for Mental Status (BIMS) score of 15 indicating R24 was cognitively intact. On [DATE] at 6:53 PM in the progress notes, nursing charted R24 complained of tooth pain. The nurse practitioner (NP) was notified and an oral antibiotic was requested and ordered. The progress note states R24 needs to see the dentist, but no documentation was found in R24's medical chart stating R24's mouth was examined by the NP or a physician. R24 received [MEDICATION NAME] 500 mg twice daily for 10 days from [DATE] to [DATE]. On [DATE] at 11:30 AM, Surveyor interviewed R24 in R24's room. R24 stated R24 had requested to see the dentist in July, 2019. (Record review indicates R24's request for the dentist was [DATE] when R24 complained of tooth pain and the facility dentist was scheduled to see R24 on [DATE].) R24 stated tooth pain continues and R24's spouse brings in an oral [MEDICATION NAME] which was observed on the bedside table. R24 stated the teeth are chipped and cracked and one tooth needs a filling. On [DATE] at 12:59 PM, Surveyor met with Director of Nursing (DON)-B to discuss concern with R24's antibiotic use [DATE] to [DATE] with no assessment by the NP or a physician. R24 complained of tooth pain [DATE] and nursing staff contacted the NP to request an order for [REDACTED]. On [DATE] at 1:24 PM, Surveyor interviewed Registered Nurse (RN) Supervisor-Y regarding R24's antibiotic use on [DATE] to [DATE]. RN Supervisor-Y stated she didn't know how the NP keeps notes and had no documentation to show an assessment was done to warrant the use of an antibiotic. R24 continues to complain of oral pain. No further information was provided at that time. 3.) On [DATE], Surveyor reviewed R47's medical record in regards to the monitoring of R47's medications. R47 has physician's orders [REDACTED]. Give 1 tablet by mouth three times a day for supplement, date [DATE]. The (MONTH) 2019 Medication Administration Record [REDACTED]. R47 has been getting it 3 times a day throughout the month of (MONTH) 2019. On [DATE] a lab test final report indicated a Complete Metabolic Panel (CMP) and a Complete Blood Count (CBC), along with an Iron Panel was performed. R47's Iron was low at 45 with a reference range of ,[DATE]. R47's Iron Binding capacity was within range at 314 and the R47's % of Iron Saturation was low at 14 with a reference range of ,[DATE]. The physician was contacted with orders to increase the [MEDICATION NAME] sulfate to three times a day and to recheck R47's iron panel on [DATE]. On [DATE], Surveyor was not able to locate the Iron panel follow up lab results for R47. On [DATE] at 11:27 AM, informed Director of Nursing B that Surveyor could not locate the follow up Iron panel lab for [DATE]. On [DATE] at 2:01 pm, Director of Nursing B informed Surveyor the Iron panel due on [DATE] was not done. On [DATE], Surveyor observed a [DATE] 11:11 Nurses Note which stated, Iron panel, CBC, CMP re-ordered for [DATE] as it was not done [DATE]. NP (Nurse Practitioner) notified. Order faxed to ACLS (lab). The facility was not monitoring the increase in the [MEDICATION NAME] (Iron) Tablet by ensuring follow through on the Iron panel lab ordered on [DATE] and was due on [DATE].

Based on interview and record review, the facility failed to ensure that 1 of 3 sampled residents (R14) received appropriate pain management provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Ineffective pain management may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. The Facility failed to implement an effective pain management regime for R14. R14 developed 11 facility acquired pressure injuries (cross-reference F686) during her admission to the facility. Shortly after R14 developed her first areas R14 indicated she was in pain. The facility failed to implement an effective pain management plan of care. Eventually, the facility received orders for as needed pain medications which R14 stated the pain medication was not effective and she was in continuous pain. R14 indicated she had notified staff of the pain, but nothing was done. Interview of staff indicated no one had contacted the practitioner to discuss the ineffective pain relief and complaints of 10/10 pain. R14 experienced constant, excruciating pain that affected her ability to sleep and her willingness to cooperate with repositioning or treatment. While CNAs stated the resident's pain was continuous and excruciating, nursing was charting that the resident's pain was a 0-1 on a scale of 10. R14 was observed on multiple occasions to, hold her hip area, left arm, moan and cry out when staff attempted to move her. This created a situation of Immediate Jeopardy. The Immediate Jeopardy began on 9/6/19 when R14 indicated her pain was constant and excruciating without effective measures to address her pain. Nursing Home Administrator (NHA)-A and Assistant Director of Nursing (ADON)-I were informed of the Immediate Jeopardy on 10/9/19 at 3:35 PM. The Immediate Jeopardy was removed on 10/11/19 when the facility implemented an action plan related to assessment of a resident's pain and pain management. This deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: According to the article, Pain Management in the Elderly Population: A Review [DATE] (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 11/), The consequences of . pain include impaired activities of daily living (ADLs) and ambulation, depression, and strain on the health care economy. Pain may also be related to complications associated with deconditioning, gait abnormalities, accidents, polypharmacy, and cognitive decline. Surveyor reviewed facility's policy for Pain Management Guidelines. Documented under Purpose was To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: a. Recognize when a resident is experiencing pain. b. Identify circumstances when pain can be anticipated. c. Evaluate existing pain and cause. Practice Guidelines document 3. If any resident reports inadequate pain control, resident will have a full evaluation of the pain using the Pain Evaluation form and SBAR (Situation, Background, Assessment, Recommendation) in PCC (Point Click Care.) 4. Following the pain evaluation, notify the physician of the findings. 5. Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan may include both pharmacological and non-pharmacological pain management interventions. R14 was admitted to the facility 4/24/19 for End Stage [CONDITION(S)] (ESRD), Uremia, Toxic Metabolic [CONDITION(S)], Long Term use of [MEDICATION(S)], Supratherapeutic INR, Occult Blood in Stool, Diabetes Mellitus 2, Bilateral Below Knee Amputations and Hemodialysis. R14's Admission Minimum Data Set (MDS) with an assessment date of 5/1/19 documents a Brief Interview for Mental Status (BIMS) of 14 which indicates cognitively intact. R14's Admission MDS with an assessment date of 5/1/19 documents J0300 Pain Presence as No for Have you had pain or hurting at any time in the last 5 days? No Care Area Assessment was completed for Pain on the Admission MDS. J0300 Pain Presence was also documented No for MDS's assessed on 5/21/19, 6/25/19, 7/1/19 and 7/19/19. R14's Pain Assessment with an effective date of 4/24/19 documented a score of 1 which means No pain indicated - very mild pain. R14's 4/24/19 Baseline Care Plan documents Pain: general discomfort with no added interventions. Surveyor reviewed R14's Comprehensive Plan of Care with a creation date of 5/13/19 that documents for pain management, Explore non pharmacological pain alleviating interventions such as heat, ice, repositioning, massage, elevation, relaxation, food. Update MD PRN and/or if pain is not controlled. On 5/16/19 the first weekly wound evaluation for the left posterior thigh and inner thigh indicates: pressure injury, 1.2 x 21.5 x 0.5 - Stage 1. MDRPI (medical device related pressure injury). Wound progress indicates stable with no change despite this being an initial evaluation. Pain is associated with the wound indicating hurts a little bit. Pain management plan indicates: apply barrier and use a protective barrier (bath blanket for transfers). DTI/1: wound team will continue to follow bruising and abrasion. Signed DON-B on 7/30/19. Surveyor noted there was not review of R14's pain plan of care to address pain specific to a pressure injury. On 5/22/19 R14 was evaluated for a pressure injury to her right posterior stump measuring 33 x 2 x 0 as a suspected deep tissue injury. During this assessment R14 indicates pain is associated with the wound with a facial scale of it hurts a little bit checked. The identified pain management plan is stump shrinker removed. On 5/23/19 weekly wound assessments indicate areas to R14's right posterior stump, right posterior inner thigh and left posterior stump and inner thigh all indicate there is pain associated with the wounds with sections for a pain management plan being blank. Surveyor noted there is no plan of care to address R14's pain with her wounds. On 5/30/19 the weekly wound assessments for the right inner thigh and the left posterior stump/thigh indicate R14 has pain associated with the wounds. The section for the pain management plan is blank and Surveyor noted there continues to be no changes to R14's plan of care related to pain management. On 6/6/19 the weekly wound evaluation for R14's right inner/posterior thigh indicates pain is associated with the wound. The level of pain is indicated as being hurts a little bit. The pain management plan indicates medicate before assessment. Review of R14's record indicates no order for pain medication was obtained at this time. The 6/13/19 weekly evaluation for the same area (right inner/posterior thigh) indicates R14 is experiencing pain in the rating of hurts a little again, the pain management plan is blank. Surveyor noted there still is no plan of care for R14's pain from her wounds. Also on this date R14 indicated there was pain associated with her right stump and left inner thigh pressure injury area. R14 was admitted [DATE] to Aurora [NAME] Medical Hospital for planned left upper extremity fistula loop graft surgery. She was discharged back to the facility on [DATE]. Documented under Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Pain Assessment with an effective date of 6/21/19 documented a score of 1 which means No pain indicated - very mild pain. R14's Pain Assessment with an effective date of 7/2/19 documented a score of 5 which means mild pain indicated. The 7/11/19 weekly wound evaluation for R14's sacrum pressure injury indicates R14's wound hurts a little bit. Surveyor noted there is no pain assessment or plan of care related to this wound. R14's Pain Assessment with an effective date of 7/22/19 documented a score of 12 which means moderate pain indicated. On 7/22/19 at 9:19 PM, R14's Progress Notes document refused treatment to be completed tonight. [Complaints of] burning. Wounds were cleansed and barrier cream applied. MD called and awaiting returned call. Resident was given [as needed] Tylenol and effective. Request for [MEDICATION(S)] ointment to be put on or around wound prior to treatment. On 7/24/19 the facility obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, this was a PRN (as needed) order and review of R14's medication/treatment (MAR/TAR) records and interview of nursing staff indicate it was not routinely offered to R14 with treatment changes. On 10/7/19 at 3:40 pm Surveyor asked LPN-H about R14's pain with treatments. LPN-H indicated R14 had pain and that she would offer R14 Tylenol but R14 would hesitate and say that was all she could take because of her [CONDITION(S)]. LPN-H indicated she thought R14 eventually was given [MEDICATION(S)]. Surveyor asked about the eventual PRN order for [MEDICATION(S)]. LPN-H indicated she did occasionally use it but it didn't really seem to do anything. R14's Pain Assessment with an effective date of 8/27/19 documented a score of 10.5 which means moderate pain indicated. On 8/27/19 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/5/19 R14 was having 10/10 pain. On 9/5/19 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/5/19 the PRN [MEDICATION(S)] was discontinued. The weekly wound evaluations dated 8/28/219 indicate R14's pressure injuries to her right and left posterior thigh pressure injuries caused pain that hurts a whole lot. The pain management plan is new order for [MEDICATION(S)]. On 9/4/19 R14's weekly wound evaluations indicate R14 was experiencing pain that Hurts a whole lot to areas including left and right posterior thigh, sacrum, right buttocks (2 areas), and left buttocks. On 9/6/19 R14's TAR indicated resident having 6/10 pain on day shift. R14 was sent to [CONDITION(S)]. PM shift documents 1/10 pain. From 9/6/19 PM to 9/8/19 AM nurses document 0/10 or 1/10 pain on every shift. Progress Note on 9/9/19 at 10:00 AM states [Resident] states pain at 10. States [MEDICATION(S)] patch is ineffective. Unable to do resident [dressing] change due to pain. Resident was on [MEDICATION(S)] previously and states pain was better controlled with it. [Nurse Practitioner (NP)-O] updated and new order received for [MEDICATION(S)] PRN. R14's Pain Assessment with an effective date of 9/9/19 and time of 10:53 AM documented a score of 20 which means severe pain indicated. Pain assessment documents almost constant pain over past 5 days. Pain was described as constant, sharp, burning, tingling pain to buttocks. Documented under effectiveness was Pain medication is not working. Resident often experiences break-through pain, any movement causes the resident pain. Is the pain medication effective? No. On 9/9/19 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/9/19 at 11:32 AM a dose of [MEDICATION(S)] was administered for 8/10 pain and charted as effective. R14's Pain Assessment with an effective date of 9/9/19 and time of 4:59 PM documented a score of 18 which means severe pain indicated. No update to MD, care plan or increased dose or PRN medications were administered. On 9/10/19 at 7:09 AM, R14's Progress Notes document refused wound treatment to bottom and arms requested not to be touched. Writer explained to resident the risks. On 9/10/19 at 8:52 AM a dose of [MEDICATION(S)] was administered for 8/10 pain and charted as effective. Documented in R14's Certified Nursing Assistant (CNA) charting on 9/10/19 at 1:27 PM was What is the pain intensity? 4. Severe. Resident complained of pain? Yes. Did the resident make non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) indicating pain? Yes. Did the resident voice complaints of pain (e.g., that hurts, ouch, stop)? Yes. Did the resident display facial expression (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) of pain? Yes. Did the resident display productive body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body party part during movement) indicating the presence of pain? Yes. Documented in Progress Notes on 9/10/19 at 1:47 PM was resident is lethargic but responsive to staff when spoken to but falls asleep in midsentence. Resident has not eaten breakfast and lunch, blood sugar stable. Resident refused shift dressing change. Resident complains of pain but is resting soundly. Resident received prn [MEDICATION(S)] and has a [MEDICATION(S)] patch for pain management. No update to MD, care plan or increased dose or PRN medications were administered. At 4:15 PM R14's 25 mcg [MEDICATION(S)] patch was removed. Documented in Progress Notes on 9/10/19 at 5:27 PM was [Nurse Practitioner (NP)] updated to current status of resident, lethargic but responsive, not eating and falling asleep mid conversation, New order [MEDICATION(S)] patch 25 mcg every 72 hours [discontinued], [MEDICATION(S)] patch 12 mcg every 72 hours, continue with current [MEDICATION(S)] order, will continue to monitor . No 12mcg [MEDICATION(S)] patch was placed. Charted under Pain Evaluation for R14's Evening of 9/10/19 was 0/10 pain. Charted under Pain Evaluation for R14's Night of 9/10/19 was 0/10 pain. On 9/11/19 at 8:57 AM a dose of [MEDICATION(S)] was administered for 7/10 pain and charted as effective. R14's Pain Assessment with an effective date of 9/11/19 and time of 12:21 PM documented a score of 20 which means severe pain indicated. No update to MD, care plan or increased dose or PRN medications were administered. Progress Notes document on 9/11/19 at 1:41 PM, Patient alert and orientated; no lethargy noted this shift [due to] recent [MEDICATION(S)] order. [Pharmacy] called for [authorization number] to pull 12 mcg out of contingency; awaiting call back from MD, will [continue] to evaluate. [MEDICATION(S)] patch had not yet been placed on resident. Charted under Pain Evaluation for R14's Evening of 9/11/19 was 6/10 pain. Charted under Pain Evaluation for R14's Night of 9/11/19 was 2/10 pain. No update to MD, care plan or increased dose or PRN medications were administered. On 9/12/19 at 8:27 AM a dose of [MEDICATION(S)] was administered for 7/10 pain and charted as effective. Progress Note on 9/12/19 at 1:33 PM documents Returned from [CONDITION(S)] with [no new orders.] Remains very lethargic this shift. [MEDICATION(S)] patch not yet in from pharmacy. Progress Notes document on 9/12/19 at 2:14 PM, Patient alert and orientated; no lethargy noted this shift [due to] recent [MEDICATION(S)] order. Continue to wait for [authorization number] to pull 12 mcg patch. Another call placed to pharmacy and awaiting return call. Pt out [with] Unit [Registered Nurse (RN)] for wound care appointment. Will [continue] to evaluate. On 9/12/19 R14 was seen in Wound Physician-N's clinic accompanied by R14's two daughters and Assistant Director of Nursing (ADON)-I from facility. Record review indicates, .The patient arrived to her wound care appointment with manager from facility at which she resides and her two daughters. The patient is in pain to her left arm and her buttocks. The manager states the patient has been declining dressing changes for some time because of pain. The patient has full body [CONDITION(S)] and her wounds that she had are deteriorating and she has new wounds. She has new deep tissue injuries to bilateral AKA's they are unsure how she got these. The patient's full body [CONDITION(S)], fragile skin, and immobility make her prone to pressure injuries and further skin break down. Due to pain, it makes it difficult for the patient to tolerate turning and repositioning. She does have a pressure relieving cushion in her w/c and it was recommended that the patient have a Roho cushion. She should also have a pressure reducing mattress and attempts should be made to frequently turn and reposition the patient. The staff has been working with the patient's MD to try to get her pain under control .(Wound Physician-N) recommended that the patient go to the ER for evaluation and the daughters and the patient were in agreement . On 9/12/19 R14 was admitted to the ER directly from Wound Clinic. ER documentation states The patient [complains of] pain everywhere from the neck down here but was able to isolate the left wrist and hand as an 11/10. Resident was admitted to ICU following ER visit. On 10/3/19 at 3:45 PM Surveyor interviewed RN-F. Surveyor asked if R14 had pain. RN-F stated R14 always had pain. Surveyor asked what interventions were put in place for R14's pain. RN-F stated repositioning and PRN [MEDICATION(S)]. Surveyor asked what increased/caused R14's pain. RN-F stated she was fine until you moved her. Anytime you moved her she was in pain. On 10/8/19 at 12:46 PM Surveyor interviewed Certified Nursing Assistant (CNA)-J. Surveyor asked if R14 had pain. CNA-J stated yes, she was in pain every time they attempted to roll her and clean her up. She was in a lot more pain the couple days leading up to her discharge. On 10/8/19 at 1:28 PM Surveyor interviewed CNA-L. Surveyor asked about R14's routine day. CNA-L stated she was in pain every day when they were rolling her. CNA-L stated the pain was from her wounds. CNA-L stated her pain got worse as time went on; it was not bad at the beginning and was severe at the end. On 10/8/19 at 3:19 PM Surveyor interviewed Driver-M. Surveyor asked Driver-M if he was R14's main driver for appointments. Driver-M stated yes, he drove her to all her [CONDITION(S)] appointments and some MD appointments. Surveyor asked if Driver-M noticed her in pain or if R14 had mentioned she was in pain. Driver-M stated she was guarding her left arm and she had said she was in pain when he picked her up from her left arm fistula surgery on 9/5/19. Driver-M stated when he returned to the facility with her he brought her to a nurse and asked if her arm was supposed to be that swollen. Driver-M stated the nurse responded it can be. Surveyor asked about 9/12/19 [CONDITION(S)] ride. Driver-M stated she was guarding her left arm still and complaining of pain in that arm. On 10/9/19 at 8:12 AM Surveyor interviewed ADON-I. Surveyor asked why the 12 mcg [MEDICATION(S)] patch was not put on. ADON-I was unsure but stated they did reorder the [MEDICATION(S)] for her. Surveyor noted that the [MEDICATION(S)] was supposed to be taken out of contingency per Progress Notes. ADON-I explained contingency process for removing narcotic but states it was not done for R14's 12 mcg [MEDICATION(S)]. Surveyor asked why pain interventions per plan of care were not completed. ADON-I stated she was unsure. On 10/9/19 at 9:08 AM Surveyor interviewed Licensed Practical Nurse (LPN)-G. Surveyor asked where R14's pain was located. LPN-G stated her wounds mostly. On 10/9/19 at 10:57 AM Surveyor interviewed NP-O. Surveyor asked about pain management for R14. NP-O stated it was hard to find something to control her pain. Surveyor asked if NP-O was aware that the 12 mcg patch was not put on her and she was having 10/10 pain. NP-O stated she was not aware or updated. NP-O stated the facility could have taken it out of contingency and she would have given the order and/or called the pharmacy to get the patch for her. On 10/9/19 at 1:03 PM Surveyor interviewed RN-E. Surveyor asked about R14's pain. RN-E stated R14 was in excruciating pain with the amount of wounds she had and complained of pain all over her body. Surveyor asked if she reported this to anyone. RN-E stated she was unsure but stated the Director of Nursing (DON)-B was aware because she was working on the unit. Surveyor asked if RN-E ever did her dressing changes to her wounds. RN-E stated the last time she was scheduled to do her dressing change R14 refused because she was in so much pain. RN-E stated R14 would cry out no, no, no! when staff would try to touch her. The facility's failure to ensure R14 received appropriate pain management created a situation of immediate jeopardy that started on 9/6/19 when R14's pain became excruciating and impacted her quality of life. The facility removed the immediate jeopardy on 10/11/19 when the implemented the following plan. ~ The facility established a system to ensure timely assessment of pain and follow up to update the plan of care and consultation with the physician. The facility will assess for non-pharmacological and pharmacological interventions. ~ Education was initiated to all licensed staff regarding the facility pain policy. ~ A system was established to audit pain management.

Based upon observation, interview and record review, the facility failed to ensure 2 of 6 (R14 and R5) sampled residents received care and treatment based off of a comprehensive assessment and in accordance with professional standards of practice, a comprehensive person-centered care plan and the resident's choice. R14 had an IV graft completed on her left arm fistula on [DATE] with instructions for aftercare that were not followed by facility. R14's fistula occluded again on [DATE] and a left internal jugular port was placed. On [DATE] a thrombectomy was completed on the left fistula. There was no monitoring of either site for bruit or thrill, no care plan for left chest port and no assessments completed on fistula or port. Due to RN error, [MEDICATION(S)] was not administered to R14 from [DATE] thru [DATE]. As a result R14 was admitted to the hospital on [DATE] with a blocked left fistula with critical limb ischemia and severe [CONDITION(S)]. The resident passed away on [DATE]. The facility's failure to complete assessments, including the monitoring of [MEDICATION(S)] and fistula patency, and not providing her with appropriate medical care created a finding of Immediate Jeopardy beginning on [DATE]. Nursing Home Administrator (NHA)-A and Assistant Director of Nursing (ADON)-I were informed of the Immediate Jeopardy on [DATE] at 3:35 PM. The Immediate Jeopardy was removed on [DATE] when the facility implemented an action plan related to assessment of a resident when there is a change in condition. This deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan and related to the following example: The facility did not ensure 1 of 3 residents (R5) reviewed for [CONDITION(S)] had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Critical Limb Ischemia (CLI) is a severe obstruction of the arteries which markedly reduces blood flow to the extremities (hands, feet, and legs) and has progressed to the point of severe pain and even skin ulcers or sores .Critical limb ischemia is the advanced stage of peripheral artery disease (PAD), which results from a progressive thickening of an artery's lining (caused by a buildup of plaque). This buildup of plaque, also known as atherosclerosis, narrows or blocks blood flow, reducing circulation of blood to the legs, feet, or hands . Critical limb ischemia is a serious condition that requires immediate treatment to re-establish blood flow to the affected area or areas (most patients with CLI have multiple arterial blockages). treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The number one priority is to preserve the limb .The earlier a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . https://surgery.ucsf.edu/conditions--procedures/critical-limb-ischemia.aspx Surveyor reviewed facility's Policy and Procedure: Change in Condition with a revision date of ,d+[DATE]. Documented was Purpose: The facility will make every effort to inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is the following: 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2. A significant change in the physical, mental or psychosocial status, that is a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications. 3. A need to alter treatment significantly, that is a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment Surveyor reviewed R14's Aurora [NAME] Medical Hospital paperwork. R14 was admitted to hospital on [DATE] after Home Care nurse assessed INR (International Normalization Rate - test to monitor clotting factor in blood) at above 8.0 and resident was having black, tarry and blood streaked stools. Resident was discharged to the facility on [DATE]. R14 was admitted to the facility [DATE] for End Stage Renal Disease ([CONDITION(S)]), Uremia, Toxic Metabolic [CONDITION(S)], Long Term use of [MEDICATION(S)], Supratherapeutic INR, Occult Blood in Stool, Diabetes Mellitus 2, Bilateral Below Knee Amputations and Hemodialysis. R14's Hospital Discharge Summary with a discharge date of [DATE] included orders for [MEDICATION(S)] with INR Monitoring and three time weekly hemodialysis. R14's Admission Minimum Data Set (MDS) with an assessment date [DATE] documents a Brief Interview for Mental Status (BIMS) of 14 which indicates cognitively intact. Surveyor reviewed R14's Comprehensive Plan of Care with a creation date of [DATE] that documents I need [CONDITION(S)] r/t [CONDITION(S)] & hypercalcemia: auscultate bruit and palpate thrill daily and [as needed (PRN)]. (Note: Bruit and thrill indicate how well the blood is flowing through the fistula. Changes may indicate that stenosis has occurred.) Surveyor reviewed Progress Notes, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May and June. There was no documented assessment of bruit or thrill for either month. R14 was admitted [DATE] to Aurora [NAME] Medical Hospital for planned left upper extremity loop graft surgery. She was discharged back to the facility on [DATE]. Surveyor reviewed Progress Notes, MAR and TAR for July and [DATE]. There was no documented assessment of bruit or thrill for either month. On [DATE] R14 was transferred to Aurora [NAME] Medical Hospital from DaVita [CONDITION(S)] Lake [MEDICATION(S)] for fistula not functioning. An IV graft was done and resident was discharged back to facility with the following discharge instructions, Keep arm elevated for at least a week; check arm and hand for blood flow by checking thrill daily; hand and arm exercises as instructed; call MD if signs of infection, you can't feel a thrill; pain or numbness in fingers, hand or arm. Surveyor reviewed the Comprehensive Care Plan, Progress Notes, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for R14. There were no updates made to care plan or assessments completed for graft completed on [DATE]. On [DATE] R14 was transferred to Aurora [NAME] Medical Hospital from DaVita [CONDITION(S)] Lake [MEDICATION(S)] for fistula not functioning again. Hospital discharge paperwork documents Recurrent [CONDITION(S)] of AV graft. Left internal jugular tunneled catheter exchange placed. Documented was follow up with MD to possibly revise fistula and new orders for [CONDITION(S)] on Monday [DATE] and restrict fluids for weekend to prevent fluid volume overload. Surveyor reviewed the Comprehensive Care Plan for R14. On [DATE] an intervention was added that states returned from ER with temporary line in left neck. There is no care plan for monitoring or assessing port. Surveyor reviewed Progress Notes, MAR and TAR for R14. There were no updates made or assessments completed for left jugular port placed on [DATE]. There were no assessments of or monitoring completed to the left fistula. On [DATE] an MD order was given for continue current [MEDICATION(S)] dose, recheck INR Friday [[DATE]]. This order was not entered into electronic record and resident did not receive [MEDICATION(S)] from [DATE] thru [DATE] at discharge. No INR was drawn on [DATE]. (Cross-reference F757). On [DATE] R14 underwent a thrombectomy to left fistula for occlusion. No specific discharge instructions were given. On [DATE] no INR lab draw was completed. Surveyor reviewed Progress Notes, MAR and TAR for R14 for [DATE]. Progress notes state dressing intact but no updates were made to care plan or assessments completed for left jugular port placed or bruit or thrill assesses for revised fistula to left arm. Documented in Progress Notes on [DATE] at 1:47 PM was resident is lethargic but responsive to staff when spoken to but falls asleep in midsentence. Resident has not eaten breakfast and lunch, blood sugar stable. Resident refused shift dressing change. Resident complains of pain but is resting soundly. Resident received prn (as needed) [MEDICATION(S)] and has a [MEDICATION(S)] patch for pain management. Documented in Progress Notes on [DATE] at 5:27 PM was [Nurse Practitioner (NP)] updated to current status of resident, lethargic but responsive, not eating and falling asleep mid conversation, New order [MEDICATION(S)] patch 25 mcg every 72 hours [discontinued], [MEDICATION(S)] patch 12 mcg every 72 hours, continue with current [MEDICATION(S)] order, will continue to monitor . No further assessments, Progress Notes, Neurological checks or other monitoring for change in condition was documented. On [DATE] the missed INR and doses of [MEDICATION(S)] were found and investigated. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD or NP were not updated on [DATE]. Lab noted INR on [DATE] collected at 9:50 AM was 1.6. New order for [MEDICATION(S)] 4mg [by mouth (PO) every (Q)] Mon, Wed, Fri, Sun. [MEDICATION(S)] 3mg PO Q Tues, Thurs, Sat. Recheck INR [DATE] was received on [DATE] from NP-O. Surveyor reviewed MAR for R14 for September. [MEDICATION(S)] dose for [DATE] was not given. Documented in Progress Notes on [DATE] at 1:34 PM, R14 was Returned from [CONDITION(S)] with [no new orders]. Remains very lethargic this shift. On [DATE] at 3:19 PM Surveyor interviewed Driver-M. Surveyor asked Driver-M if he was R14's main driver for appointments. Driver-M stated yes, he drove her to all her [CONDITION(S)] appointments and some MD appointments. Surveyor asked if Driver-M noticed her in pain or if R14 had mentioned she was in pain. Driver-M stated she was guarding her left arm and she had said she was in pain when he picked her up from her left arm fistula surgery on [DATE]. Driver-M stated when he returned to the facility with her he brought her to a nurse and asked if her arm was supposed to be that swollen. Driver-M stated the nurse responded it can be. Surveyor asked about [DATE] [CONDITION(S)] ride. Driver-M stated she was guarding her left arm still and complaining of pain in that arm. On [DATE] R14 was seen in Wound Physician-N's clinic accompanied by R14's two daughters and Assistant Director of Nursing (ADON)-I from facility. Resident's daughter, Complainant-Q, stated on [DATE] at 12:08 PM that prior to arrival and during Wound Clinic appointment, R14 complained her left arm felt like it was broken. Complainant-Q stated she felt R14's left hand and it was cold to the touch. On [DATE] at 2:06 PM Surveyor interviewed Wound Physician-N. Wound Physician-N stated when R14 presented in the clinic she was somnolent, had low blood pressure(s), about ,d+[DATE]'s, and multiple new wounds. Wound Physician-N states we turned her to see her peri-area and copious, copious amounts of purulent drainage was coming from her peri-area. Wound Physician-N stated since the resident was extremely ill with drainage, low blood pressures and worsening wounds she discussed with the daughters the plan to send her to the ER. On [DATE] R14 was admitted to the ER directly from Wound Clinic. ER documentation states The patient [complains of] pain everywhere from the neck down here but was able to isolate the left wrist and hand as an ,d+[DATE]. Resident was admitted to ICU following ER visit. On [DATE] hospital documentation stated Hospital Course: Upon my evaluation this morning patient was found to be in profound [CONDITION(S)] requiring IV [MEDICATION(S)] and IV [MEDICATION(S)] to maintain pressure. Patient was being evaluated by vascular surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient has a blocked AV fistula. Patient was only barely arousable, however she did respond to pain. Patient underwent a fistulogram/left upper extremity angiogram with temporary intraprocedural fistular acute occlusion. Findings of this study were consistent with critical limb ischemia. It was determined that patient needed an emergent thrombectomy of her left upper extremity. Patient was evaluated by Cardiology. Echo was performed at bedside which revealed [ejection fraction] of 25%. Patient determined to be extremely high risk for surgery. Patient subsequently continued to decompensate throughout the day. Patient's pressor requirement continued to increase. Patient had to be placed on [MEDICATION(S)] along with the [MEDICATION(S)] and [MEDICATION(S)] drip and MAP still remained below 55. Patient was then evaluated by vascular surgery and anesthesia who both determined that given her extremely high risk for surgery and it would be detrimental to proceed with surgery. At this time it was determined that no lifesaving measures would or could help. The family was contacted and the patient's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time decision was made to transition to comfort care. Family was in agreement with this and verbalized understanding. We will proceed with comfort measures at this time. Patient passed away overnight while I was off shift. On [DATE] at 8:12 AM Surveyor interviewed ADON-I. Surveyor asked what assessments should be completed for a resident with a fistula. ADON-I stated assessment for bruit and thrill. Surveyor noted to ADON-I that there were no assessments of the left arm, fistula, left jugular port, only assessments of the dressing. ADON-I stated assessments should have been completed. On [DATE] at 10:57 AM Surveyor interviewed Nurse Practitioner (NP)-O. Surveyor asked if she was aware that the [MEDICATION(S)] was not restarted until [DATE]. NP-O stated no and it should have started [DATE] as she ordered. Surveyor asked if missing 10 days of [MEDICATION(S)] could have attributed to her left arm fistula occlusion and ischemia. NP-O stated yes. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following: ~ The facility developed a system to ensure residents with fistulas are assessed and monitored in accordance to standards of practice and physician orders. ~ Education was provided to all licensed staff regarding care of residents with fistulas. ~ A system was established to ensure anticoagulant medications are administered and monitored as ordered. ~ The facility established an audit system to ensure implementation of the plan. This deficient practice continues at a scope/severity of D (potential for harm/isolated) related to the following; 2.) On [DATE] 03:06 PM, Surveyor interviewed R5 in her room. R5 was lying in bed. R5 was observed to have both of her legs wrapped. R5 informed Surveyor her legs are wrapped daily by the nurse because of her [CONDITION(S)] and the only treatment she is getting for the [CONDITION(S)] are the leg wraps. R5 stated the wraps come off for a couple of hours on the PM shift. Surveyor reviewed R5's medical record. R5 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] indicated R5 has a Brief Interview for Mental Status (BIMS) score of 12 indicating R5 is moderately cognitively impaired. The MDS indicates no behaviors nor rejection of cares. R5 requires extensive assistance with bed mobility, and with personal hygiene. On [DATE] 09:14 AM, Surveyor interviewed RN Supervisor Y regarding the treatment R5 receives for her [CONDITION(S)]. RN Supervisor Y stated R5 is not getting any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN Supervisor Y informed Surveyor R5 is not receiving any leg wraps. Surveyor discussed the observations of R5 wearing bilateral leg wraps with R5 indicating they are applied daily and removed on the pm shift with RN Supervisor Y. On [DATE] 09:23 AM, RN Supervisor Y and Surveyor went into R5's room to view R5's legs. R5 was observed wearing bilateral leg wraps. RN Supervisor Y stated R5 decides when they (the wraps) are applied and when they are taken off. R5 informed RN Supervisor Y and Surveyor that the leg wraps are on all the time and they come off if I am going out or if they slide down. They are taken off a couple of hours on the evening shift. RN Supervisor Y then went to the nurse administering the meds, Licensed Practical Nurse (LPN) JJ who acknowledged R5 having the leg wraps on saying she has been wearing them since being here. RN Supervisor Y informed Surveyor that RN Y would have to look in R5's her chart as she did not see orders for such on her first glance at the Medication Administration Record (MAR) or on the Treatment Administration Record (TAR). RN Supervisor Y with Surveyor started reviewing R5's care plan and physician orders. RN Supervisor Y stated, I will have to look into her chart she is her own person and is particular with cares. I did not see the leg wraps on her care plan. On [DATE] at 09:30AM, Surveyor and RN Supervisor Y discussed that on [DATE] there were Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN Supervisor Y stated that the leg wraps were discontinued on [DATE] and were taken off R5's care plan as resolved. RN Supervisor Y stated she needs to look into this because she was unsure if the wraps were just left in R5's room. RN Supervisor Y stated she will be talking to the MD and adding it to the TAR and the care plan. On [DATE] at 1500, new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Apply Solaris Wraps to bilateral lower legs, take off for approx. 2 hours a day then re-apply. Every shift for [CONDITION(S)] AND at bedtime for [CONDITION(S)]. Remove Solaris wraps at 2000 and reapply 2 hours later at 2200 AND every shift for [CONDITION(S)]. Check Solaris leg wraps for proper placement and CMS checks Other Active [DATE] 15:00 On [DATE], R5's TAR included the following order; Apply Solaris Wraps to bilateral lower legs take off approximately 2 hours a day then re-apply remove solaris at 2000 & reapply at 2200 start [DATE]. Surveyor noted R5's care plan, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's care plan was updated on [DATE] to the following: Resident has Impaired Skin integrity: [CONDITION(S)] to bilateral lower extremities and excoriation to the buttocks New Intervention: [DATE] Apply Solaris wraps daily, remove for 2 hours a day and check for placement each shift and CMS Heel boots on in bed Monitor for s/sx of infection Monitor for s/sx of worsening skin tissue Monitor pain and offer PRN [MEDICATION(S)] as ordered Resident chooses to not be seen by [CONDITION(S)] clinic as recommended, risks vs benefits provided to resident Treatment as ordered Update MD with changes in wound status and PRN Surveyor identified R5 was receiving [CONDITION(S)] wraps with no current MD orders, no care plan and the application of the [CONDITION(S)] wraps was not addressed on the TAR until after Surveyor discussed the wraps with RN Supervisor Y on [DATE]. On [DATE] at 2:45 pm and on [DATE], Surveyor shared the above concerns with Administrator A, Director of Nursing B and Nurse Consultant C.

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), for 1 of 1 residents (R1) reviewed, in accordance with the resident's directives. A total of 46 residents in the facility were determined to have a Full Code status at the time of survey. R1's Advanced Directives and Physician order [REDACTED]. On [DATE], staff found R1 without a pulse and not breathing. Review of the incident indicates there are conflicting statements of what occurred related to providing CPR to R1 as indicated in R1's advanced directives. Some statements and interviews indicate nursing staff did initiate CPR but then stopped a short time later despite R1's Advanced Directives and Physician order [REDACTED]. In addition the nurse who claims to have administered CPR was not certified to administer CPR. On [DATE] when the police arrived at the facility they asked staff to direct them to R1's room and were told R1's room was the one by the wet floor sign. The police report indicates they started towards the room and noted the room to be dark. Staff then entered into R1's room and turned on the lights at which time Police Officer G observed R1 lying in bed not breathing and a sheet was pulled up to his chest. The police report does not indicate staff were present in the room completing CPR upon their arrival. Review of statements and interviews provide conflicting, inconsistent details of what staff provided what care on [DATE] however, through all reviews it is indicated R1 did not receive CPR in accordance with R1's advanced directive wishes and physician orders [REDACTED]. The facility's failure to ensure R1 received basic life support, including CPR, in accordance with R1's wishes per signed Advanced Directives and Physician order [REDACTED]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the Immediate Jeopardy on [DATE] at 12:17 PM. The Immediate Jeopardy was removed on [DATE], however; the deficient practice continues at a scope/severity of an [NAME] (No actual harm with potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility continues to follow through on its action plan which has the potential to affect all 46 residents currently residing in the facility whose advanced directives include CPR. Findings include: On [DATE] the facility's policy titled Death of Resident CPR/DNR guidelines dated ,[DATE] was reviewed and read: Prior to arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse in accordance to the resident's advanced directives. American Heart Association urges all potential rescuers to initiate CPR unless 1.) A valid do not resuscitate order is in place. 2.) Obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transaction, or decomposition) are present, or 3.) Initiating CPR could cause injury or peril to the rescuer. Procedure for resident who is full code: 1.) upon assessment of no vital signs, a resident who is full code will have CPR initiated immediately. 4.) CPR will continue until EMS arrives to take over CPR. On [DATE] the facility's policy titled [MEDICAL CONDITION] [DATE] was reviewed and read: Upon determination that a resident is in cardiopulmonary or respiratory arrest, CPR will be initiated by a CPR certified staff and 911 called for advanced cardiac life support unless one of the exceptions applies. When there is the presence of obviously clinical signs of irreversible death (defined as rigor mortis or dependent lividity). Compress the chest 30 times, after compressions give breaths using a resuscitation bag attached to the trach. Continue 30 compressions to 2 breaths. Continue CPR until you see signs of life, another rescuer take over for you or help arrives. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Initial Minimum (MDS) data set [DATE] indicated R1 required total assistance with activities of daily living, R1's nutrition was met via a feeding tube and had long and short term memory problems. On [DATE] R1's code status form dated [DATE] was reviewed and indicated R1 wanted to be a full code. This form was signed by R1's guardian and stated: I understand that full code status means that if my heart stops beating or if I stop breathing CPR will be used. On [DATE] R1's signed physician orders [REDACTED].>On [DATE] R1's progress note written by Licensed Practical Nurse (LPN)-D was reviewed and indicates: [DATE] at 6:02 AM: At 5:30 AM CNA (Certified Nursing Assistant) called me to resident's room to check on him. He is a full code so I initiated CPR on resident. RN took over while writer called 911/Administrator. Notice of removal of human corpse filled awaiting medical examiner. A progress note written by LPN-D on [DATE] at 12:17 AM indicates: Compressions were stopped by writer due to rigor mortis setting in. Known by compressions difficult to perform. Tried to obtain vital signs, not able. Medical Doctor called and aware and pronounced death at 5:35 AM on [DATE]. Surveyor noted this note was written more than two shifts after the incident with R1 and after law enforcement had started to question facility staff. There is no other assessment of R1 on [DATE] when he was found without vital signs documented in his medical record. No assessment was documented in R1's medical record by Registered Nurse (RN)-E for [DATE] when she alleges she responded to R1 not breathing. On [DATE] Surveyor reviewed LPN-D's statement from the investigation of [DATE] (no date, as to when the statement was taken, the statement is typed by someone else who interviewed LPN-D and is signed by LPN-D). This statement indicates: At 5:32 AM (CNA-F) came to (LPN-D) and stated (R1) appeared unresponsive. (LPN-D) states she immediately went into R1's room and the following was completed: assessed (R1) for pulse/breathing. CPR started. (RN-E) came to assist and assessed situation/observed signs of clinical death. CPR was stopped. 911 called. At approximately 5:50 AM Burlington Police Department arrived. Review of the facility investigation indicates RN-E gave a statement on [DATE] (3 days after the event) which states: On [DATE] at approximately 5:30 AM I heard a CNA yell (R1) isn't breathing. I immediately ran towards (R1's) room. I passed by (CNA-F) and told her to go get (LPN-D). I entered (R1's) room. (R1) looked yellow in color and appeared to be dead, no chest rising/breathing. I immediately checked (R1's) jugular artery for a pulse, his radial artery and femoral artery, all areas were pulseless. Writer did a sternum rub, yelled (R1's) name several times. I pulled (R1) closer towards me as the head of his bed was up at 45 degrees in an attempt to discover signs of life. I immediately noticed large, purple pooling in (R1's) skin on his back which appeared to be mottled. (R1's) feet showed signs of mottling, (R1) was cool to touch. I immediately ran out of the room, met (LPN-D) and reentered (R1's) room as I explained to (LPN-D) (R1) showed many signs of death and I wasn't going to perform CPR on a dead body. (LPN-D) and I both walked to the front desk and she called 911. (LPN-D) explained to 911 operator (R1) was found dead, no CPR was started as (R1) had several signs of death. Surveyor noted there is no documentation of such assessment at the time R1 was found unresponsive in R1's medical record. The only documentation reflecting this finding is in the facility investigation. CNA-F's statement dated [DATE] states: Around 5:00 AM -5:30 AM I was doing my rounds to empty Foley's (urinary catheters). I came to (R1's) room and saw he was not breathing and his color was not good. I immediately went to the desk to get the nurse. When I got there (RN-E) was there. I told her and called for (LPN-D). They came immediately to the room. I left and answered some call lights. On [DATE] the facility's investigation-timeline for the death of R1 was reviewed and indicates: At or about 5:30 AM CNA-F states while completing rounds she went to R1's room and he appeared unresponsive. CNA-F alerted RN-E who immediately responded and went to R1's room. RN-E assessed R1, she was unable to find a pulse, did not respond to sternal rub and she observed signs of rigor mortis and mottling to lower extremities. She then went and looked in his chart. At or about 5:32 AM LPN-D went to R1's room, she was unable to find a pulse, no signs of breathing observed, CPR started then concluded due to signs of clinical death being present and RN-E confirming clinical death. 5:45 AM police arrived. The facility's investigation did not address the inconsistencies in LPN-D and RN-E statements. LPN-D indicated she started and stopped CPR and RN-E indicated CPR was never started. RN-E also indicated she was in the room before LPN-D arrived and spoke with LPN-D when she first arrived and LPN-D indicates that RN-E was not in the room when she first arrived and she started CPR with only her being present in the room. On [DATE] at 3:24 PM LPN-D was interviewed by the Surveyor and indicated that she suctioned R1 about 3:30 AM on [DATE] and he was fine at that time after the suctioning. LPN-D indicated she was called down to R1's room by CNA-F about 5:30 AM. LPN-D indicated R1 did not have a pulse and was not breathing so she started chest compressions. LPN-D indicated she stopped compressions a short time after because rigor mortis had set in. LPN-D did not know how long she did compressions. LPN-D indicated she never did any rescue breathing and did not know if a resuscitation bag was in the room because she never looked for it. LPN-D indicated she stopped compressions before RN-E came in the room and she knew R1 was a full code before she went in the room. LPN-D indicated she did not know once she started CPR she should not stop and has since been trained that once CPR is started not to stop until someone takes over. LPN-D indicated that RN-E came in the room and told her R1 was gone and she wasn't going to do CPR. LPN-D then went and called 911. LPN-D indicated she was not CPR certified but is now enrolled in the class. LPN-D indicated she thought what happened is RN-E came in the room and went to the desk to see R1's code status and LPN-D came in the room and started CPR during that time because LPN-D states she didn't see her (RN-E) before she went in R1's room. On [DATE] at 5:15 AM RN-E was interviewed by the Surveyor and indicated CNA-F said R1 wasn't breathing and I went into his room. RN-E indicated R1 looked cold, blue and yellow and she knew what dead people look like and he was dead. RN-E then indicated she did a sternal rub with no response and saw pooling of blood on his back when she sat him up after doing the sternal rub. RN-E then indicated LPN-D came in and she told her he was gone and to call 911 and then she left the room. RN-E indicated she didn't know what LPN-D did while she was out of the room but she was the first one in R1's room and no CPR was started while she was there. RN-E indicated she would continue CPR if it was already started. RN-E indicated R1 had purple mottling, no pulse and no breathing. RN-E indicated she had been in hundreds of codes and was advanced life support certified. RN-E indicated she did not document my assessment in R1's medical record but only a statement they asked her to write. RN-E also indicated she doesn't feel she should have to perform CPR on someone just to cover herself and she knows when someone can't be revived. On [DATE] at 5:00 AM CNA-F was interviewed by the Surveyor. CNA-F indicated that LPN-D suctioned R1 about 3:30 AM and he seemed to be fine. CNA-F indicated she checked on R1 a couple times after he was suctioned and he appeared to be fine, the last time he was checked on was between 4:00 AM-4:30 AM before starting rounds. CNA-F indicated when she went in to empty R1's catheter about 5:30 AM she saw he wasn't breathing and told RN-E who went to his room and told me to get LPN-D which she did. CNA-F indicated she did not see anything after that because there were a lot of call lights on she was answering. On [DATE] at 8:00 AM Nurse Consultant (NC)-C, who conducted the investigation was interviewed and indicated she was called right after R1 passed. NC-C indicated LPN-D's statement changed several times and LPN-D said at one point she never did CPR. NC-C indicated RN-E's statement remained consistent the whole time and so she went with what RN-C said as an accurate account of R1's passing. NC-C indicated she did not report R1's death to the state agency as she felt they did everything right even though she had conflicting information. On [DATE] a police report written by Officer-G was reviewed and read: Date [DATE] time 5:44 AM. I started walking down the hallway and go into the room. I turned around and observed (LPN-D) go into room (room number). She turned the lights on and that is when I observed (R1), lying in the bed, showing obvious signs of being deceased . R1 was still, not breathing and appeared waxy in his color. (R1) had a sheet pulled up to his chest. I asked (LPN-D) when the last time someone saw (R1) alive. She told me he was checked on an hour to an hour and ½ ago. I asked her if there were any signs of life and she told me nothing. I asked her if anyone had started CPR. (LPN-D) told me she started CPR but he was gone. (LPN-D) started disconnecting R1's oxygen. (LPN-D) was asked what time R1 was found. (LPN-D) stated the CNA came to do rounds about 15 minutes ago. She said she started CPR but there were no signs of life. (LPN-D) said (R1) was a little warm but there was modeling (sic) to his back. (LPN-D) said around 5:35 AM (CNA-F) was doing rounds and said that R1 was pretty much gone at that point. (LPN-D) was asked if there was a protocol in place that states once they start CPR when they can stop. (LPN-D) said she just pretty much stopped then the police department came in (it should be noted both (LPN-D) and (CNA-F) were at the nurses station when I entered the facility). (LPN-D) was asked how many rounds of CPR she completed. She said just a couple, not many. (LPN-D) told us she went ahead and started CPR but she stopped to call 911 as there were only 2 nurses there. She said she started back up again and stopped when I arrived. I Spoke with (CNA-F) and she found (R1) white as a ghost. (CNA-F) called (LPN-D) around 5:00 AM when she found (R1). (CNA-F) said she told (RN-E) and also found (LPN-D) to inform them of (R1's) condition. She said they both came down and she continued her rounds. (CNA-F) did see both (LPN-D) and (RN-E) go into (R1's) room but did not see anyone perform CPR. I asked (CNA-F) if anyone asked her to call 911 and she told me no (LPN-D) said she started CPR and had (RN-E) take over while she called 911. I also spoke with (RN-E). I asked her what time she went into (R1's) room. She was unable to tell me the time, as she did not mark the time down. She stated she then went to look for his book because she needed to know what his code status was. She said she was unsure if he was a do not resuscitated at this time. (RN-E) said she then went into the room and was told by (LPN-D) that she had given compressions but she never actually saw her performing CPR. (RN-E) said she could tell he was super gone. (RN-E) said she was still unable to find (R1's) code status. none of the information was in the chart where it was usually at. I asked who called 911 and (RN-E) stated 'she did' I asked her where she was when (LPN-D) was calling 911 and she stated she was standing next to (LPN-D) as she was still going through documents, at the nurses station. I asked (RN-E) if she ever did CPR on (R1) and she told me no. On [DATE] the Burlington Rescue Squad report dated [DATE] was reviewed and indicated: Upon making contact with (R1) we noticed he was not breathing, he was waxy appearance, no rigor, no lung sounds, noted mottling to the back-patient was bedridden, and when 4-lead was placed on patient it was Asystole (no heartbeat). We did not perform resuscitation efforts to the patient. We were told by staff that the patient was fine about 1 hour prior, and then about 15 minutes prior they went into the room, started CPR but stopped after ,[DATE] rounds because they had no life signs. We turned the scene over to the City Police Department and cleared the scene. The report indicated they were called at 5:47 AM and arrived at 5:55 AM Lividity is the discoloration or staining of the skin that occurs after death due to accumulation of fluid blood in the dependent parts of the body. It generally starts within ,[DATE] hours and fixes after ,[DATE] hours. Rigor mortis is the stiffening of the body's voluntary and involuntary muscles. In temperate climates it begins within ,[DATE] hours after death. It appears first in involuntary muscles. Finger and toe muscles are the last to be affected. http://www.ahschools.us/cms/lib08/MN 485/Centricity/Domain/5091/PM%20changes.ppt On [DATE] a copy of RN-E's advanced cardiovascular life support training was reviewed and indicated she obtained certification on [DATE] with a renewal date of [DATE] The facility was unable to provide any CPR certification for LPN-D The above findings were shared with the Administrator and Director of Nurses on [DATE] at 12:17 PM. The facility's failure to provide CPR to R1 based upon their advanced directives created a finding of immediate jeopardy that was removed on [DATE], when the facility completed the following: 1. Completed a chart audit on all residents who were full code. 2. Updated policy on CPR and assessments on any resident who is a full code in need of CPR. Quality Assurance (QAPI) completed a meeting on the updated policy, which included the Medical Director. 3. In-servicing started on new CPR policies and procedures and upon arrival for their next assigned shift and will be tested for understanding starting [DATE]. 4. The facility will have a CPR certified staff member on every shift , this staff member will be designated on the schedule. Only CPR certified staff will initiate CPR A review will be done by the Administrator every posted schedule for the next 3 months with the results brought to QAPI. 5. CPR drills to be completed once a month for every shift for 3 months by DON or Designee with the results brought to QAPI committee for review and compliance. 6. All Licensed staff as of [DATE] have their current certification on file with the exception of one as needed nurse. This will be obtained before her next working shift. The business office manager will maintain a list of all certifications and review monthly and any exceptions will be brought to QAPI for review and compliance.

Based on observation, interview, and record review the facility did not ensure the residents (R) environment remained free from accident hazards for 2 of 18 residents sampled (R14 and R6). * R14 went outside through an alarmed door on a secured Dementia unit and fell due to the uneven terrain between the landscaping and the cement. R14 suffered a head laceration requiring 11 staples. Furthermore the outside gate of the patio was left open possibly allowing the opportunity for R14 to elope. * R6 was not assessed for safety in a broda chair before use and stood up and fell . In addition, dycem was not observed to be in R6's broda chair per the care plan. Findings include: 1.) R14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/18/17 at 10:55 a.m. the surveyor observed R14 lying on the concrete of the Dementia unit patio with the front of his head heavily bleeding. Staff called the rescue squad and attended to R14. The surveyor observed a significant difference in the height of the landscaping and the concrete. The gate to the patio was also observed to be open and was a direct route to the street. The Surveyor immediately interviewed outside contractor (OC) -N who was completing work inside the building on the dementia unit. OC-N indicated that he was coming through the gate carrying supplies and saw R14 in front of him walking on the concrete path. OC-N indicated that R14 stepped off the side of the concreate, lost his balance and fell forward. OC-N indicated that R14 was by himself outside and that no staff was visible at the time of the fall. OC-N also indicated that the gate to the patio had been open all day from approximately 8:00 a.m. On 7/18/17 at 11:30 a.m. the surveyor observed the dementia patio area where R14 fell . A 2 to 4 inch terrain difference between the concrete and the grass/landscaping was observed in the area where R14 fell on the southwest corner of the patio by one of the entrances. Several other areas of the patio were observed to have the same concern of uneven terrain most notably in the middle of the walking path and at the northeast corner by the gate. Administrator-A was in the patio area at the time of the observation and indicated that he could see the danger of the uneven terrain and instructed the maintenance director to call the landscaper and fill in the area so the terrain was even. On 7/19/17 R14's Situation, Background, Assessment and Recommendation (SBAR) for R14's fall on 7/18/17 was reviewed and read: 7/18/17 11:00 a.m. fall with laceration. R14 fell while walking outside due to uneven ground next to sidewalk. On 7/19/17 R14's fall report dated 7/18/17 at 11:18 a.m. was reviewed and read: R14 observed outside lying on sidewalk. R14 exited the door through the activity room as evidenced by door alarm sounding. R14 was witnessed by a construction worker coming from the west side of the building. As R14 walked closer to the entrance door, R14 stepped off the sidewalk onto the grass area, lost balance and fell forward causing a laceration to the right side of top of head. The area where R14 was ambulating had uneven ground when stepping off of the sidewalk which contributed to the fall. On 7/19/17 R14's progress notes dated 7/18/17 at 6:31p.m. were reviewed and read: R14 Returned from hospital emergency room at 4:10 p.m. R14 has 11 staples to the top of the head and some bloody drainage noted. Neuro checks have been negative. On 7/19/17 R14's emergency room report for 7/18/17 was reviewed and indicated imaging was done and no cervical spine fracture or evidence of intracranial hemorrhage was found. A large laceration extending to the frontal bone was verified with the CT scan. The above findings were shared with the Administrator and Director of Nurses on 7/19/17 at 3:00 p.m. Additional information was requested if available. None was provided. 2.) R6 had a fall from a broda chair in his bedroom when he attempted to get out of the chair as it was reclined. R6 has no assessment to show the need for him to be in a wheelchair or broda chair for safety or mobility. R6 was not injured in the fall. R6's was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R6 is not his own decision maker. R6's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/06/17 indicates R6 is cognitively status is moderately impaired, but that he can rarely understand and be understood. R6's vision is highly impaired and he uses corrective lenses/glasses. Wing 4, CNA (Certified Nursing Assistant) Care card, dated 5/25/17, indicates that R6 transfers with the assistance of two staff and uses a wheelchair for mobility. The CNA care card indicates that R6 ambulates with the assistance of one staff using a gaitbelt and wears glasses for vision impairment. R6's care plan, dated 1/16/17, states: R6 is at risk for falls, accidents and incidents related to incontinence, pain, impaired mobility, dementia, anxiety, major depressive disorder, hypertension, and difficulty walking. The interventions identified are: anticipate and meet R6's needs and encourage R6 to call for assistance. Dycem to be placed on wheelchair seat to help prevent falls. Follow therapy recommendations for transfers and mobility. Place R6's call light in reach while in his room. R6 is on hourly checks. R6's Physical Therapy (PT) plan of care, dated 3/13/17, states R6 was referred to PT due to a decline in functional abilities of gait due to clavicle fracture. R6's caregiver had noticed a decrease in mobility for several days prior to a hospital admission, resulting in decreased safety and an increased need for assistance. The initial assessment identified, in part: R6 is able to ambulate 300 feet or more and has full weight bearing status on both legs. R6 is able to transfer from the bed to the chair with contact guard assistance. R6 is a low fall risk. No recommendations were noted for R6 to use a wheelchair for mobility or for positioning in his room. On 7/17/17, at 9:45am, R6 was noted to be seated in a broda chair in this bedroom. The chair was reclined and R6 appeared to be watching TV. R6's call light was noted to be above the bed across the room and not in reach. Dycem was not noted to be placed in the broda chair. R6's Progress notes, completed 7/17/17, at 2:28pm, states in part that R6 was found lying on the floor in his bedroom . R6 was seen in his room 5 minutes prior to the fall sitting in the wheelchair and becoming increasingly agitated. No signs or symptoms of injury were noted. On 7/18/17, at 7am, R6 is sitting upright in a recliner in his bedroom and the call light is between the bed and the wall out of his reach. No dycem was noted to be in the recliner as stated in R6's care plan. On 7/19/17, at 8:45am, Surveyor interviewed Physical Therapist (PT) T who stated that physical therapy did not assess or recommend the use of a broda chair for R6 and that a nurse wanted to evaluate the use of it. The broda chair was only used for a short time. PT T stated that R6 is able to walk and she is not sure why he has a wheelchair. He does not use it to move about the facility. PT T stated that she usually sees R6 walking with staff in the hallway after lunch. On 7/19/17, at 9:10am, Surveyor interviewed Registered Nurse (RN) U who stated he was not sure who assigned R6 the broda chair but that it was started about last Friday. R6 always uses a wheelchair to sit in when in his room. When R6 stands up they will walk with him for a short period of a time. RN U stated that he was not sure when R6 fell if it was when he was seated in a wheelchair or the broda chair. Surveyor asked if R6 used the wheelchair to propel himself in the facility. RN U replied that R6 would not propel the wheelchair. When R6 first arrived at the facility he was weak, since physical therapy worked with him he has been much stronger. On 7/19/17, at 9:45am, Surveyor interviewed CNA Q who stated that R6's family had requested the broda chair for him and that R6 was seated in the reclined position before he fell on [DATE]. CNA Q notes that R6 only uses the wheelchair for sitting in his room. Surveyor questioned CNA Q if the facility tried any other chairs. CNA Q replied that they never tried a regular chair. The family did not like the recliner because they felt it was too low and he leaned very hard to the left. CNA Q notes that R6 needs to staff to stand up, but once he is up he will walk with just hand held assistance. On 7/19/17, at 11am, Surveyor interviewed Licensed Practicing Nurse/Unit Manager (LPN/UM) D who stated that R6 was in the broda chair when he fell on [DATE]. Surveyor asked LPN/UM D why R6 was in a broda chair and LPN/UM D replied that she had asked the same question. She was told it was tried due to a request from the family. R6 fell when he tried to stand up and the foot rest was down and he fell over. Surveyor questioned why R6 was using a wheelchair to sit in. LPN/UM replied again due to a family request, they felt he sits upright better without leaning to the left in the wheelchair. On 7/19/17, at 12:30pm, Surveyor interviewed Director of Nursing (DON) B who stated that R6's family had concerns about the recliner. The broda chair was tried after they tried several different chairs with R6. They have not found one that works for him yet. DON B notes that PT has been asked to reassess R6 for the best mode of transfer and chair positioning. The facility did not assess the broda chair for safety before placing R6 in the chair and in the reclined position. When R6 attempted to stand up he was unable causing him to accidently fall. R6 did not show the need for the use of neither the wheelchair nor broda chair as R6 is able to ambulate 300 feet or more using contact guard assistance or hand held assistance.

Based on observation, interview, and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 36 residents (R1) with a full code status. The facility failed to follow Resident (R)1's Resident Code Status. R1 identified her choice for the code status protocol as a Full Code which indicated .I understand that a Full Code Status means that if my heart stops beating, or if I stop breathing, cardiopulmonary resuscitation (attempts to restart the heart and/or breathing which may include artificial airways and mechanical ventilation) will be used. R1 was admitted to the facility on [DATE] and on [DATE] R1 was found unresponsive, pulseless, and not breathing. Cardiopulmonary resuscitation (CPR) attempts were not initiated for over seven minutes. R1 expired on [DATE]. Facility failure to initiate CPR on an unresponsive resident in a timely manner, created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on [DATE] at 12:05pm. The immediate jeopardy was removed on [DATE], however; the deficient practice continues at a scope/severity of an E (No actual harm with potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility continues to follow through on its action plan which has the potential to affect all 36 residents currently residing in the facility whose advanced directives include CPR. Findings include: The facility policy entitled, Cardio-Pulmonary Resuscitation, dated [DATE], states: Upon discovery of an unresponsive resident that is a Full Code Status: Procedure: 1. Determine unresponsiveness by shouting 'Are You Okay' and gently shake or tap on resident. 2. If no response, call for help of other staff members. 3. Instruct other staff responding to scene to obtain emergency supplies and notify [DATE] or emergency personnel. DO NOT leave resident. 4. If resident is not face-up, re-position to a face-up position while supporting head, neck, and back. 5. Determine if resident is breathing by opening airway with the head tilt-chin lift method and check for breathing using your ear and face next to the resident's nose and mouth for no more than ten seconds. 6. If resident is not breathing, give two rescue breaths using a mouth shield or ambu-bag. 7. If breaths do not go in, reposition head and neck and reattempt. If breaths still do not go in, refer to policy and procedure for [MEDICATION NAME] Maneuver. 8. Determine if unresponsive resident has a pulse or heart beat by checking carotid artery pulse or use a stethoscope to listen for heart tones. If none, then begin chest compressions. Give thirty chest compressions at the rate of one hundred per minute then give two breaths. 9. Continue the cycle of thirty chest compressions followed by two breaths until resident shows signs of life, or help arrives and takes over (emergency personnel) or physician gives order to cease. 10. Document events in medical record. On [DATE] at 10:00am, Surveyor interviewed DON B, who stated the policy and procedure titled, Cardio-Pulmonary Resuscitation (CPR) is based on the American Heart Association guidelines. Surveyor notes that in 2015 the American Heart Association updated the guidelines from a ABC (Airway/Breathing/Compression) method to a CAB (Compression/Airway/Breathing). The facility did not update its policy and procedure from ABC to CAB in 2015 as recommended by the American Heart Association. R1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R1's Preadmission screen and resident review (PASRR) Level 1 Screen, dated [DATE], indicated that R1 is not suspected of having a serious mental illness or a developmental disability. On [DATE] R1 signed her choice to be Full Code which indicated: I understand that a Full Code Status means that if my heart stops beating, or if I stop breathing, cardiopulmonary resuscitation (attempts to restart the heart and/or breathing which may include artificial airways and mechanical ventilation) will be used. On [DATE], Surveyor , reviewed the City of Burlington Incident Report with a dispatch date and time of [DATE] 20:50 (8:50pm). The report summary states, On [DATE], (R1) was found to be unresponsive and not breathing while staying at Burlington Rehab and Care. Her death appeared to be from natural causes. No further investigation will be conducted. The report contains a Narrative which states, On [DATE] at approximately 8:51pm, I officer (PO Q) .along with SGT (PO C) ., were dispatched to 677 East State Street for a patient not breathing and currently unresponsive. SGT . and I arrived on scene and immediately entered the facility with my rescue bag in hand. Upon entering and locating room (xxx), I observed several nursing staff surrounding a woman lying on her side .I observed the patients hands and they have already turned purple and she was currently warm to touch.It should be noted no cardiopulmonary resuscitation (CPR) has been provided prior to our arrival.CPR was started at 8:57 pm. by ( LPN-E) who is a licensed practical nurse. Burlington fire and Rescue arrived at 9:05 am and Medix arrived minutes later. Both began to provide medical care and CPR to the patient . Reporting Officer (PO Q). On [DATE] at 06:30am, Surveyor , observed Police Officer (PO) C's body camera and video which contained the following: On [DATE] starting at 8:52pm, PO C arrived at the Facility for a medical emergency [DATE] call for a patient not breathing and currently unresponsive. PO C's body camera and video shows PO C entering the facility, at 8:52pm,via the main entrance by unit 1 and 2 where they asked for directions to room [ROOM NUMBER]. Two staff at the nursing desk replied there is no room [ROOM NUMBER]. PO C called dispatch via his radio to confirm room number and PO C asked for directions to room (xxx). At 8:53pm, PO C's body camera show that the staff at wing 1 and 2 nurse's station informed PO C to go down the hallway and to the left. At 8:54 PO C enters the wing 4 hallway and proceeds down to room (xxx). Upon entering room (xxx), seven staff are noted to be in the room with R1 lying on the bed supine with a gown on. No emergency care (CPR) is being provided to R1 and one staff member is cleaning the floor. PO C questions the staff in R1's room asking, Do you have an Automated External Defibrillator (AED)? Licensed Practical Nurse (LPN) D replies, No, we do not have a AED, we have half an ambu-bag and the orange half board. At 8:55pm PO C states, How long has she been like this? LPN D and LPN E both replied, We came in here 5 minutes ago. PO C questioned is R1 cold? LPN D replied, No while another staff member stated, She was yelling out for help. PO C asks his partner to get the AED up and applied the AED to R1. At 8:56pm the AED states it is analyzing the heart rhythm and no shock is advised to start CPR. PO C questions who the nurse is in charge here? Was CPR started at all? Was CPR started? LPN E replied, We just got the board under her when you guys walked in to do CPR on her. Another staff member notes, We were trying to position R1 in bed when you arrived to start CPR. She was hanging out of bed and we were trying to get her repositioned in bed to do CPR when you guys showed here. At this time no staff are attempting to initiate emergency resuscitation efforts. At 8:57pm, PO C stated, Ah it's whatever your protocol is, if you want to start CPR, there is no shock advised. At 8:57pm, LPN E states, Do we have the Ambu-bag and positions his hands over the sternum of R1 and starts chest compressions. Staff reach into the crash cart and retrieve the ambu-bag. PO C exits the room and notifies County dispatch to advise rescue that R1 is unresponsive and CPR has been started. It has been seven minutes (8:50 - 8:57pm) from the time dispatch received a call from the facility that a resident was unresponsive until the time staff initiated CPR. At 8:58pm, PO C re-enters the room and questions the staff, You guys know CPR, you trained in CPR? LPN E nods his head yes PO C notes, Okay when you're ready for a switch out we'll get a switch out here. At 8:58pm, the AED instructs to stand clear to analyze the patient, no shock advised. At 9:01pm, LPN D notifies PO C that R1 had only been here 24 hours, she came in as an admit last night. I was down my hallway in a patient's room with a Certified Nursing Assistant (CNA), when we came out a guy from room .was in the hallway flagging us down. So we came down and she was half out of the bed, her legs were down, one was on the footboard and one was on the floor. (R1's) sheets were hanging off the bed, stool was everywhere, and she was lying with her arms open, so we were trying to get her in bed. PO C stated, So she was unresponsive by the time you guys got here? LPN D replied, Yes, she was unresponsive. I guess she did this earlier in the shift where she was kind a little unresponsive, but not like this. PO C replied, Okay. LPN D noted she has got a lot of co-morbidities. R1's progress note (nurses note), completed on [DATE], at 5:00pm, by LPN E, showed R1 was alert and orientated and able to make all needs known. No signs of injury noted due to fall. R1's neuros within normal limits. Moving all extremities per R1's normal. No complaints of pain were noted. R1's lungs are diminished, with no cough or shortness of breath. R1 is on oxygen at 4 liters a minute via nasal cannula .Will continue to monitor and report any significant changes. R1' progress note (Nurses note), completed on [DATE], at 10:22pm, by LPN E, showed A resident in room (yyy) was noted standing in the hallway by room (xxx) and flagged down staff and stated that (R1) asked for help. (R1's) call light was not sounding. Upon entering the room at 8:55pm, LPN E noted R1 with feet dangling off the side of the bed and unresponsive. LPN E applied a sternal rub two times. R1's radial, carotid, and apical pulses were assessed and not felt. The crash cart was obtained and [DATE] was called. CPR was initiated. Burlington Police arrived at 9:00pm and the AED was applied. The paramedics arrived at 9:05pm and initiated advanced life support. Continuous CPR was performed. Carotid and radial pulse felt at roughly 9:40pm. R1 was moved from the bed to the stretcher, pulse was reassessed and unable to be felt. CPR was re-initiated. Paramedics pronounced time of death at 9:52pm. R1's family was notified of the event and DON B was updated. The nursing progress note timeline of events does not match the events as noted on the body camera worn by PO C. CPR was not initiated until directed by PO C seven minutes after [DATE] had been called and the emergency responders were dispatched to the facility. LPN D's statement of the event on [DATE], provided from DON B on [DATE] at 12:20pm, showed LPN D was walking out of another room with a CNA around 8:45pm. As they approached the nurses desk the Resident from room (yyy) was standing in the hallway waving his arms stating the lady next to me just yelled for help. No call light was on or ringing in the hallway. The CNA and LPN D ran down the hallway in to room (xxx). A statement from the Resident from room (yyy) was recorded and provided from DON B on [DATE] at 12:00pm. The resident from room (yyy) stated he heard (R1) say help so he came out of his room. (R1's) call light was not on so he flagged LPN D who was on the wing 3. LPN D came down. Resident from room (yyy) states he was in the hallway outside of (R1's) room. On [DATE] at 12:23pm, Surveyor interviewed LPN D, who stated she was working wing 3, which is the opposite hall from wing 4 when a resident flagged her for help. LPN D walked in room (xxx) with 2 CNAs and called (R1's) name. (R1) was not responding. LPN E walked in room (xxx) and started chest compressions on R1. LPN D called a code on the overhead paging system, grabbed (R1's) chart to check status and called [DATE]. LPN F from wing 6 responded to the code. LPN F was doing the ambu-bag, LPN E was doing chest compressions. LPN D returned with the crash cart and the board was place beneath (R1). LPN E notes they were doing CPR wen [DATE] arrived, but cannot remember when the police arrived. It seemed like everyone entered at the same time both the police and the paramedics. LPN D notes she only left the room to call a code and dial [DATE]. LPN D notes it took 5 or 6 staff to get the board underneath (R1). On [DATE] at 12:46pm, Surveyor interviewed LPN E, who stated a resident next door to (R1's) room heard (R1) yelling. LPN D and LPN E were at the nursing desk and went to (R1's) room together with a CNA. They found (R1) half on the bed and half off the bed. LPN E stated he could not find a pulse and went to check (R1's) CPR status in the chart and to call [DATE]. LPN E went back to (R1's) room and started CPR. We had to get her back to bed and we did not lower her to the floor. Upon arrival only (R1's) lower extremities were on the floor. It was easier and less dangerous to get her into bed. LPN D got the crash cart and the board was placed under (R1). LPN E notes that LPN D did not start CPR due to trying to get (R1) back on the bed. When LPN E returned to the room they got (R1) in to bed and then LPN E started CPR. LPN E notes that CPR was being done when the emergency medical technicians (EMTs) arrived, but the police arrived prior to the EMTs. We were just starting CPR when the police arrived because the resident was not positioned in bed. On [DATE] at 2:22pm, Surveyor interviewed CNA G. CNA G stated she was working on the Post Meridiem (PM) shift and was looking for the charge nurse, LPN D, when the resident from room (yyy) came into the hallway and called out to us. LPN D and CNA G went into (R1's) room and found (R1) partially off the bed and incontinent of stool and urine. LPN D, CNA H, and myself (CNA G) were in the room. CNA G stated she checked and felt no pulse on (R1). CNA G told LPN D that (R1) is not breathing. When the other nurses and medics arrived I (CNA G) left (R1's) room. CNA G notes that CPR was started right away and a variety of people were doing CPR, but LPN E was the one who started doing CPR. CNA G did not remember if CPR was started before or after the police arrived. CNA G did note she was there when PO C put the AED on (R1) and that CPR was started after. On [DATE] at 2:04pm, Surveyor interviewed CNA H, who stated he and CNA G went to (R1's) room. They heard another resident state that (R1) is yelling for help. Upon entering (R1) room (R1) was found with her legs hanging off the bed. (R1) was incontinent of stool. CNA H stated that the CNAs called for LPN D and LPN E and they came into (R1's) room. They helped us try to get (R1) in bed. (R1) was not responsive. LPN D was checking (R1's) pulse. LPN E got the crash cart and started CPR until the paramedics arrived. CNA H notes that LPN D called [DATE] while LPN E gave (R1) a Dry Rub. LPN E started CPR until help came. On [DATE] 2:15pm, Surveyor interviewed LPN F, who stated she was on wing 6 and went to help LPN E. LPN F noted (R1) was on the bed and unresponsive. LPN E, LPN D, and LPN F were checking for a pulse, but could not find one. LPN E started rescue CPR. LPN F helped with the ambu-bag until the EMTs arrived. LPN F did not remember if the police arrived before the EMT staff. LPN F notes that CPR was not stopped by LPN E. On [DATE] at 1:39pm, Surveyor interviewed CNA I, who stated she was working on wing 4 on [DATE] and assigned to (R1). CNA I notes that (R1) was fine throughout the day. R1 kept trying to lay horizontal in the bed and was taking her oxygen off. R1 was laughing and talking. CNA I notes she was in another room when another resident heard (R1) call out. Another nurse and 2 CNAs went into (R1's) room. I (CNA I) finished cares on another resident and went to (R1's) room. R1 was lying horizontal in the bed. We got her in bed. (R1's) oxygen was off and we put it back on. (R1) was breathing faintly. CNA I got LPN E after (R1) was repositioned and her oxygen was back on. CNA I was questioned if CPR was started? CNA I notes that PO C put the AED on (R1). CNA I was questioned if CPR was started prior to that? CNA I notes that LPN E was doing chest compressions after PO C came and LPN E was the only one doing chest compressions. On [DATE] at 2:00pm, Surveyor interviewed PO C who stated he received a call on [DATE] at 8:50pm from the facility. PO C arrived on [DATE] at 8:53pm and 6 to 7 staff were noted in (R1's) room. One staff was cleaning up feces when PO C asked what happened. They responded that (R1) had stopped breathing. Another resident had heard (R1) calling for help. PO C notes that nothing was initiated until he arrived. PO C speculates that there was a ,[DATE] minute delay in starting CPR. PO C stated that the medical examiner determined natural causes for reason of death. PO C asked how long was (R1) down and if we could start CPR? PO C notes that the female nurse was cleaning up the resident and a male nurse was just standing there, near the head of the bed. PO C stated he had his body camera on and there is video and audio of the event. On [DATE] at 10:25am, Surveyor interviewed NHA A and DON B. Surveyor questions if (R1) had any other episode where (R1) became unresponsive on [DATE]? DON B replied, (R1) was lethargic, arousable, but lethargic. The facility notified the Medical Doctor (MD) earlier in the shift. DON B showed Surveyor a Fax from [DATE] with no time noted that stated, MD Note; if patient (R1) becomes unarousable she should be sent to the hospital. Surveyor asked DON B to explain how she expects a full code to be conducted at the facility. DON B replied when a resident is found unresponsive they call a Code Blue. The nurse should stay with the resident and they should direct others to get the crash cart and the chart. Surveyor questioned if they called Code Blue on [DATE]? DON B states, I think so, it was noted in the statements taken after the event. Surveyor questioned the policy dated [DATE] titled, Cardio-Pulmonary Resuscitation and asked if she (DON B) was aware that the American Heart Association had changed the guidelines in 2015 from a rescue pattern of ABC (Airway/Breathing/Compression) to CAB (Compression/ Airway/Breathing)? DON B replied, No, that she just pulled the policy from the computer. Surveyor informed NHA A and DON B that Surveyor watched the body camera video and audio from PO C and the video notes that R1 was assisted back into bed with staff cleaning feces up from R1 instead of providing CPR. DON B replied that she was unsure if she (R1} was responsive at that time, as apparently she (R1)was yelling right before that. Surveyor asked DON B what her expectation is when a Code Blue and [DATE] is called, are staff expected to meet emergency personnel at the door to assist them to find the resident? DON B replied she would expect staff to wait by the door to direct and assist emergency staff. Per American Heart Association 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, As recommended in the 2010 Guidelines, healthcare providers will continue to check for a pulse, limiting the time to no more than 10 seconds to avoid delay in initiation of chest compressions. Ideally, the pulse check is performed simultaneously with the check for no breathing or only gasping, to minimize delay in detection of [MEDICAL CONDITION] and initiation of CPR. The facility failure to promptly provide R1 with CPR as R1 requested just one day earlier, R1 died , with no immediate efforts having been made to try and resuscitate her. CPR efforts did not begin until seven minutes after staff found her unresponsive. This delay greatly reduced the possibility that CPR would be effective in reviving R1 which created a finding of Immediate Jeopardy starting on [DATE]. The facility removed jeopardy on [DATE], when the facility completed the following: 1. Updated policy on CPR and Emergency procedures by DON. Quality Assurance (QA) completed on updated policy. 2. Immediate in-servicing started by DON B or designee of Emergency Procedures and CPR and upon arrival for shift by DON or Designee as indicated below on: -All Licensed nursing staff will be inserviced prior to start of shift on CPR policy and procedure starting [DATE]. Education provided by DON or designee. -All facility staff will be inserviced on Emergency Procedures prior to start of shift by DON or designee starting [DATE] 3. Medical Director, notified on [DATE] at 12:35pm by NHA A. 4. CPR drills to be completed involving every shift for 48 hours, then alternating shifts and times. 3 audits per weekly for 4 weeks by DON or Designee. 5. Audits will be completed including nursing staff interview on CPR and Emergency procedures and staff responsibility during an emergent event, no less the 10 employees per week at random times varying shifts for 4 weeks.

Based on review of a facility self-report alleging neglect, complaint investigation, medical record reviews, observations and staff interview, the facility did not provide the appropriate supervision and assistive devices to prevent falls for 2 residents of 3 residents reviewed who were identified at risk for falls. (Residents #1 & #2). Additionally, appropriate supervision was not provided for 1 of 1 resident (Resident #8) reviewed with wandering behavior. * Resident #2 had a falls plan of care including the use of a wheelchair alarm and self-release Velcro seatbelt in his wheelchair. When a facility Certified Nursing Assistant (CNA) took Resident #2 to the shower room to use the toilet on 04/30/12, Resident #2 became agitated while sitting on the toilet and yelled at the CNA to get out of the shower room. The CNA left the shower room to assist another resident, and Resident #2 attempted to self-transfer and fell sustaining a fractured hip. * Resident #1 was observed without a tabs alarm in his wheelchair, a care planned intervention, and with his wheelchair next to his recliner while he was sitting in his recliner. Resident #1's plan of care includes an intervention to remove his wheelchair away from his recliner to discourage self-transfers. * Resident #8 has been identified by the facility as at risk for wandering. On the night shift of 05/14/12, 1 CNA was working on Resident #8's living unit when he exited the building. The CNA was caring for another resident when she heard the exit alarm and could not immediately respond to the alarm. The CNA's inability to immediately respond to the door alarm minimized the effectiveness of the alarmed door. Findings include: 1. Surveyor # reviewed Resident #2's closed medical record on 06/19-06/26/12. Resident #2 had been re-admitted to the facility on [DATE], after being hospitalized for [REDACTED]. Resident #2 has [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS), assessment dated [DATE], revealed Resident #2 is only able to stabilize with human assistance when moving from a seated to standing position. Review of Resident #2's plan of care/accident prevention: risk for falls dated 08/18/11, revealed fall interventions of an alarm and self-release Velcro seatbelt while in his wheelchair. Surveyor # reviewed a facility self-report investigation concerning alleged neglect of Resident #2 occurring on 04/30/12. Review of the investigation revealed on 04/30/12 at 2:10 p.m., CNA-G took Resident #2 to the shower room and assisted him onto the toilet. A summary of the investigation indicates that while on the toilet Resident #2 was very agitated and verbally belligerent to CNA-G. Resident #2 told CNA-G to get out of the shower room so CNA-G instructed Resident #2 to just sit on the toilet. CNA-G left the shower room after noticing another resident's call light was on. After CNA-G left the shower room, Resident #2 attempted to self-transfer, fell and sustained a fractured left hip. Surveyor # spoke with the Nursing Home Administrator (NHA) on 06/20/12, at approximately 9:30 a.m. The NHA indicated CNA-G that all staff had been in-serviced to not leave residents with alarms/or those that require transfer assistance unattended in the bathroom or shower room. The NHA indicated this had been the facility policy prior to Resident #2's fall on 04/30/12. 2. Surveyor # reviewed Resident #1's medical record on 06/19-06/27/12, as part of a complaint investigation. Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of Resident #1's MDS dated [DATE], revealed Resident #1 is only able to stabilize with human assistance when moving from a seated to standing position. Review of Resident #1's plan of care/accident prevention: risk for falls dated 03/01/12, revealed a fall intervention of an alarm while in his wheelchair. Resident #1's care plan indicated the resident had 8 falls from 03/13-05/08/12. Review of Resident #1's CNA Care Card dated 06/14/12, revealed the following fall prevention interventions. Bed and wheelchair alarms and remove walker/wheelchair away from bedside/recliner to discourage self-transfers. Surveyor # made the following observations of Resident #1 on 06/19/12; At 10:35 a.m., 11:10 a.m., 11:40 a.m. and 12:45 p.m., Resident #1 was observed asleep in his recliner. Resident #1 had a tabs alarm attached at these observations. Resident #1's wheelchair was observed to Resident #1's left, less than 2' from his recliner. At 1:25 p.m., Resident #1 was observed up in his wheelchair in his room. No alarm was attached to Resident #1. Resident #1's tabs alarm remained on the back of his recliner and had not been applied when Resident #1 had been transferred to his wheelchair. These observations were shared with facility administration at the daily meeting on 06/26/12, at approximately 3:00 p.m. As of 06/27/12, the facility had provided no additional information as to why Resident #1's tabs alarm had not been attached when he was up in his wheelchair or why his wheelchair was located next to his recliner. 3. Surveyor # reviewed Resident #8's medical record on 06/21-06/27/12. Resident #8 had been admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. A review of Resident #8's plan of care: behavior/mood patterns reveals problems of wandering into other residents' rooms and 5 elopements from the facility from 11/18/11-05/14/12. On 06/21/12, Surveyor # asked the Nursing Home Administrator (NHA), for the incident report regarding Resident #8's elopement on 05/14/12. Review of the incident report revealed on 05/14/12 at 4:50 a.m., Resident #8 was found outside walking back toward the alarmed emergency exit at the end of the facility's Wing #3. A statement received from Certified Nursing Assistant (CNA)-H, indicated on 05/14/12, at approximately 4:50 a.m., she located Resident #8 outside walking back toward the alarmed emergency exit at the end of Wing #3. CNA-H's statement indicates that prior to locating Resident #8, she was in another resident's room attending to that resident when she heard the emergency exit alarm on Wing 3 sounding. CNA-H's statement indicates that within less than 5 minutes she checked Resident #8's room and then located him coming back toward the exit door. Surveyor # spoke with CNA-H on 06/26/12 at approximately 7:45 a.m. At that time CNA-H indicated she was the only CNA working the night shift of 05/13-05/14/12, on Wing #3. She indicated that Resident #8 wanders a lot on the night shift. CNA-H also indicated that when Resident #8 set off the door alarm she had been in the process of assisting another resident to get dressed and could not immediately respond to the door alarm.

Based on record review, observation and staff interview the facility did not ensure that 2 of 8 residents at risk for pressure ulcers received the necessary treatment and services to prevent pressure ulcers from developing. Resident #10 and #14 have decreased mobility and are assessed to be at risk for pressure ulcer development. Resident #10 and #14's plan of care did not include the intervention for a pressure-redistribution seat cushion in their wheelchair. On 8/14/12 Resident #10 and #14 were observed in their wheelchairs without a pressure-redistribution seat cushion. Resident #10 and #14 do not have a pressure ulcer. The "Pressure Ulcer Prevention, Quick Reference Guide" (National Pressure Ulcer Advisory Panel, 2009) indicates the use of support surfaces to prevent pressure ulcers while seated includes using a pressure-redistribution seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development. Findings include: 1. On 8/14/12 Surveyor # reviewed Resident #10's medical record. The record indicates Resident #10 is [AGE] years old, was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. The admission Minimal Data Set (MDS), dated [DATE] indicates Resident #10 has a Brief Interview for Mental Status score of 9 (moderately impaired cognition), requires extensive staff assistance for bed mobility, full staff performance for transfers, is frequently incontinent of bladder and has no pressure ulcers. The Care Area Assessment (CAA) for Pressure Ulcers, dated 5/17/12, indicates Resident #10 has [MEDICATION NAME] pressure ulcer risk factors that include altered mental status, incontinence, poor nutrition, and [DIAGNOSES REDACTED]. The CAA indicates the facility will develop a plan of care for pressure ulcer prevention. The plan of care for skin integrity indicates Resident #10 has a potential for impaired skin related to incontinence. The interventions on the plan of care did not include a pressure-redistribution seat cushion for the wheelchair. On 8/14/12, at 2:30 p.m., Surveyor # observed Resident #10 sitting in his wheelchair in the hallway. Resident #10 had a string alarm attached to the back of his shirt (alerts staff if Resident #10 would attempt to stand up and self-transfer). Resident #10 did not have a pressure-redistribution seat cushion in his wheelchair. On 8/14/12, at 2:50 p.m., Surveyor # and Nurse Manager- C observed Resident #10's buttocks area. Resident #10 did not have any pressure ulcers on his buttock area. Nurse Manager- C verified Resident #10 does not have a pressure-redistribution seat cushion for the wheelchair. On 8/14/12, at 3:00 p.m., the facility provided Resident #10 with a pressure-redistribution seat cushion for the wheelchair. On 8/15/12, at 8:40 a.m., Surveyor # spoke with Nurse Consultant-HH who indicated all residents who utilize a wheelchair should have a pressure-redistribution seat cushion for the wheelchair unless they refuse it. 2. On 8/14/12 Surveyor # reviewed Resident #14's medical record. The record indicates Resident #14 is [AGE] years old, was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. The annual Minimal Data Set (MDS), dated [DATE] indicates Resident #14 has moderately impaired cognition (decisions poor; cues/supervision required), is totally dependent on staff for bed mobility and transfers, is frequently incontinent of bowel and bladder and has no pressure ulcers. The Care Area Assessment (CAA) for Pressure Ulcers, dated 8/10/12, indicates Resident #14 has [MEDICATION NAME] pressure ulcer risk factors that include altered mental status, incontinence, poor nutrition, medications ( anti-psychotics, antidepressants, and antidepressants) and [DIAGNOSES REDACTED]. The CAA indicates Resident #14 has a pressure relief mattress and pressure relief cushion for the wheelchair. Resident #14's plan of care for skin integrity was reviewed and did not include the intervention of a pressure-redistribution seat cushion for the wheelchair. On 8/14/12, at 4:00 p.m., Surveyor # observed Resident #14 sitting in his wheelchair in his room. Resident #14 had a mechanical lift sling positioned under him and a string alarm was attached to the back of his shirt (alerts staff if Resident #14 would attempt to stand up and self-transfer). Resident #14 did not have a pressure-redistribution seat cushion in his wheelchair. On 8/14/12, at 4:05 p.m., Surveyor # and Nurse Manager- C observed Resident #14 being transferred from his wheelchair into his bed using a full mechanical lift and assistance from 2 staff. Surveyor # and Nurse Manager-C observed Resident #14's buttocks area. Resident #14 did not have any pressure ulcers on his buttock area. Registered Nurse, Nurse Manager- C verified Resident #14 does not have a pressure-redistribution seat cushion for the wheelchair. On 8/14/12, at 4:15 p.m., the facility provided Resident #14 with a pressure-redistribution seat cushion for the wheelchair. On 8/15/12, at 8:40 a.m., Surveyor # spoke with Nurse Consultant-HH who indicated all residents who utilize a wheelchair should have a pressure-redistribution seat cushion for the wheelchair unless they refuse it.

Based on observations, record reviews and interviews, the facility did not ensure that 3 of 5 Residents (Residents' #7, #6 and #5,) reviewed for treatment and prevention of pressure ulcers, were provided specified pressure relief interventions to prevent the development of pressure ulcers and promote healing of existing pressure ulcers. * Resident #7 has experienced a loss of mobility over the past 6 months. Resident #7 was noted with an unstageable pressure ulcer of the right heel on 5/19/12. Although Registered Nurse (RN)-C, Nurse Manager stated Resident #7's heels were floated prior to the development of the right heel pressure ulcer, floating Resident #7's heels was not included in the care plan until 5/22/12. Resident #7 was observed 3 times on 6/20/12, with her heels not floated. The pressure ulcer on Resident #7's right heel increased in size between 6/12 and 6/19/12. * Resident #6 who is at risk to develop pressure ulcers, and whose care plan indicates her heels should be floated, was observed in bed on 6/20/12, without her heels being floated. * Resident #5, who has a pressure ulcer of the left heel, was observed in bed without his pressure relief boot in place and heels floated. Additionally, Resident #5 was observed wearing his shoes, when the care plan indicates he should not be wearing shoes because of the left heel pressure ulcer. Findings include: 1. Surveyor # reviewed Resident #7's record on 6/20 - 6/27/12. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Annual Minimum Data set (MDS) completed 5/23/12, with an Assessment Reference date of 5/16/12, Resident #7 did not have any pressure ulcers. Resident #7 is totally dependent on staff for activities of daily living, including bed mobility. The Care Area Assessment (CAA) Summary dated 5/25/12, indicates Resident #7 no longer has merry walker since 12/6/11. According to the Pressure Ulcer Care Area Assessment (CAA) dated 5/23/12, Resident #7 is at "high risk for pressure ulcers according to the Braden risk scale," and Resident #7 has a pressure ulcer of the right heel that she is getting treatment for. Resident #7 has an impaired skin integrity care plan dated 8/28/09. Interventions include turn and reposition every two hours. On 5/21/12, a Stat Guard II mattress was added to the care plan. On 5/22/12, instructions to float heels at all times, and no shoes to right foot, were added to the care plan. According to documentation in the nurses' notes and on the Weekly Non-Pressure Skin Condition Report dated 5/19/12, Resident #7 has a 3.5cm x 2 cm purplish area on the right heel. Skin prep every shift was ordered. Beginning 5/21/12, the area on the right heel was documented on the Weekly Pressure Ulcer Report. The following measurements of Resident #7's right heel are documented on the Weekly Pressure Ulcer Report form: 5/21/12--4.5cm x 4.4cm 5/30/12--5.0cm x 3.0cm 6/5/12 -- 5.0cm x 4.0cm 6/12/12-- 5.0cm x 4.0cm 6/19/12-- 6.0cm x 5.6cm On 6/20/12, Surveyor # made the following observations: At 3:00 p.m., Resident #7 was lying in bed slightly turned on her left side. There was a pillow under her right leg, which was elevating the right heel. The left foot was not on the pillow, and the left heel was resting on the mattress. At 6:00 p.m., Resident #7 was lying in bed on her back. There was a pillow under her calves, but the pillow did not provide enough elevation to prevent both heels from resting on the mattress. At 6:47 p.m., Resident #7 was in bed with the head of the bed elevated. There was a pillow under her calves. The left heel was floated, but the right heel was resting on the pillow. On 6/21/12 at 10:15 a.m., Surveyor # observed Licensed Practical Nurse (LPN) - D cleanse and apply skin prep to the right heel pressure ulcer. The right heel has a large dry black area. On 6/26/12 at 12:35 p.m., Surveyor # spoke with Registered Nurse (RN) - C, who is the Nurse Manager for Resident #7. RN-C stated Resident #7 has had a physical decline. Therapy has been attempted with no improvement. RN-C stated Resident #7 has no nutritional concerns, and has had a slight weight gain. Prior to development of the pressure ulcer, Resident #7 utilized a standard facility mattress which provides pressure reduction for up to a Stage 2 pressure ulcer. RN-C states staff routinely applies Vaseline to the heels of residents with intact skin and Resident #7's heels were being floated prior to the noted skin breakdown. During the daily meeting with Administrator and Acting Director of Nursing on 6/26/12 at 3:00 p.m., Surveyor # shared concerns related to the development of Resident #7's right heel pressure ulcer, and the observations of staff not always keeping Resident #7's heels floated. 2. Surveyor # reviewed Resident #6's medical record on 06/20-06/27/12. Resident #6 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #6 is at risk for the development of pressure ulcers. Review of resident #6's plan of care dated 06/03/12, indicates a problem-Skin/Tissue integrity impaired: potential related to [MEDICAL CONDITION]. An intervention to this problem is to "float heels when in bed." On 06/20/12 at 1:50 p.m., Surveyor # observed Resident #6 while in bed. Resident #6 was positioned on her back with a pillow under her calves. The pillow did not provide enough thickness to elevate Resident #6's heels. Both of Resident #6's heels were observed to be resting on her mattress. On 06/20/12 at 2:35 p.m., Surveyor # observed Resident #6 while in bed. Resident #6 was positioned on her back. Resident #6's left heel was observed resting on the edge of a pillow and her right heel was resting on the mattress. These observations were shared with facility administration at the daily meeting on 06/25/12 at approximately 3:00 p.m. As of 06/27/12, no further information had been provided. 3. Surveyor # reviewed Resident #5's medical record on 06/20-06/27/12. Resident #5 was re-admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE], indicates Resident #5 currently has a stage 1 or greater pressure ulcer (left heel) and is at risk for further development of pressure ulcers. A physician's telephone order dated 05/29/12, indicates float heels at all times and no shoes to left heel until blister resolved. Resident #5 also was observed with a protective boot to his left foot/heel. Surveyor # was unable to locate a physician's orders [REDACTED].#5's plan of care. Review of resident #5's plan of care dated 06/03/12, indicates a problem-Skin/Tissue integrity impaired:potential related to diabetes and pressure wound. Interventions to this problem included to float heels heels at all times and no shoes to left foot. On 06/20/12 at 1:55 p.m., 2:40 p.m. and 2:50 p.m., Surveyor # observed Resident #5 while in bed. Resident #5 was positioned on his back with the boot on his left foot/heel and his right heel resting on the mattress. On 06/20/12 at 2:55 p.m., Surveyor # observed Resident #5 in bed. At this observation Resident #5's boot had come off his left foot/heel as there was no Velcro to secure it. Resident #5's right heel was observed resting on the mattress. On 06/21/12 at 7:50 a.m., Surveyor # observed Resident #5 in the 600 Wing dining room. Resident #5 had no boot to his left foot/heel and was wearing tennis shoes. On 06/25/12 at 10:05 a.m., Surveyor # informed Registered Nurse (RN)-C that Resident #5 had been observed wearing tennis shoes at 7:50 a.m. RN-C indicated Resident #5 had therapy the morning of 06/25/12, and she had removed his shoes and applied the boot following therapy. On 06/25/12 at 8:35 a.m., Surveyor spoke with Therapy Assistant (TA)-CC. TA-CC indicated when she provides Resident #5 with services she uses a Heal Wedge Heeling shoe to keep pressure off his left heel. TA-CC stated she does not use a shoe on Resident #5's left foot when providing therapies. These observations were shared with facility administration at the daily meeting on 06/25/12 at approximately 3:00 p.m. As of 06/27/12, no further information had been provided.

Based on observations, record reviews and interviews, the facility did not ensure that 3 of 16 residents reviewed (Residents' #16, #2 and #13,) received the necessary services to attain the highest practicable physical well-being. *Resident #16, experienced right eye inflammation in late March of 2012. On 4/16/12, when little improvement was noted, the physician ordered an ophthalmology consult. There was a delay of 9 days (4/25/12) before the facility attempted to make an appointment. The appointment was made for 5/2/12, with an optometrist rather that an ophthalmologist. The resident was examined by the optometrist on 5/2, 5/9, & 6/20/12. Between 5/6 and 6/10/12, there is no evidence of a nursing assessment related to the condition of Resident #16's right eye. On 6/10/12, the optometerist was faxed related to continued redness of the right eye. Pred Forte eye drops were ordered every 4 hours for 1 week. By 6/20/12, when seen again by the the optometrist, the right eye condition had deteriorated, and the optometrist ordered the Pred Forte drops to be given every 2 hours and referred Resident #16 to the ophthalmologist. On 6/21/12, Resident #16 was examined by an ophthalmologist who noted the resident had experienced a loss of vision in the right eye and who increased the frequency of eye drops to every hour while awake. On 6/23/12, when family members visited from 10:00 a.m. until 1:15 p.m., the eye drops were only instilled one time (at 12:30 p.m.). *Resident #2 had been re-admitted to the facility on [DATE], after being hospitalized for [REDACTED]. Resident #2 received 20 staples during surgery to repair his hip. Hospital discharge instructions were to follow-up with the orthopedic clinic 1 week from Resident #2's discharge date of [DATE]. The facility did not schedule a follow-up orthopedic clinic appointment until 02/23/12, and Resident #2 was seen 02/24/12, 24 days later than the discharge instructions indicated. Resident #2's staples were removed on 2/24/12. *Review of Resident #13's Bowel Monitoring record for June 2012, revealed Resident #13 did not have a bowel movement (BM) from the night shift of 06/15/12 until the night shift of 06/19/12. The facility did not implement their bowel protocol for Resident #13. Findings include: 1. Surveyor # reviewed Resident #16's record on 6/26 & 6/27/12. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to documentation in the nurses' notes, on 3/26/12, Resident #16 was observed with a reddened right eye. Resident #16 was examined by the Evercare Nurse Practitioner, who ordered Artificial Tears to be instilled. On 3/29/12, Resident #16 was examined by a facility contracted optometrist, with the chief complaint of right eye redness without pain. The report from the optometrist indicated there was poor dilation, therefore a poor view of the internal eye structures. Resident #16 was diagnosed with [REDACTED]. Recommended treatment was to continue Dorzolamide drops and Artificial Tears, and start [MEDICATION NAME] three times daily for 5 days. Dorzolamide is for the treatment of [REDACTED]. According to documentation in the nurses' notes, there was improvement noted by 4/2/12, when nurses charted less eye redness. Nurses' notes on 4/3 & 4/4/12, indicate the right eye remains red. Resident #16 was examined by the physician on 4/5/12. The progress note does not mention right eye redness. Nursing documentation does not address the right eye again until 4/16/12, when documentation states, "right eye continued redness." In the physician's orders [REDACTED].#16's physician on 4/15/12, which states the right eye is still red with some tenderness when putting drops in the lid area. There is a scant amount of yellow exudate. The physician responded to the fax dated 4/16/12, with an order to consult ophthalmology. A corresponding physician's orders [REDACTED]." The nurses' notes on 4/16/12 at 8:00 p.m. state, "Fax back from physician, to have ophthalmology appointment made. Note left on calendar." On 4/17/12 at 2:30 a.m. and 5:00 p.m., nurses document Resident #16's right eye remains red and teary. On 4/25/12, LPN-D documents "eye appointment made at Family Vision, 11:00 a.m." The date the appointment was made for was not documented. The appointment was made for 5/2/12. On 6/27/12 at 10:30 a.m., Surveyor # asked LPN-D why the appointment was made with an optometrist when the physician ordered an ophthalmology consult. LPN-D stated she did not know why she scheduled the appointment with an optometrist rather than an ophthalmologist. Nurse Practitioner (NP)-F who was at the nurses' station while Surveyor # was speaking with LPN-D, stated that she was the NP for Resident #16, and thought it was appropriate to send Resident #16 to a community based optometrist because they can diagnose and treat eye conditions. NP-F stated there are some equipment limitations with the facility consultant optometrist. The community based optometrists can complete more thorough examinations. On 6/25/12 at 9:45 a.m., Surveyor # asked the Acting Director of Nursing who schedules ordered consults. The Acting Director of Nursing stated the nurse who transcribes the order is to make the appointment. If the order is received too late in the day, the appointment should be made the next day. The Acting Director of Nursing did not know why there was a delay of 9 days before the eye appointment was made, nor did she know why Resident #16 was sent to an optometrist rather than the ophthalmologist. According to a verbal report to Surveyor # on 6/27/12 at 9:55 a.m., from Family Vision, where Resident #16 was examined on 5/2/12, Resident #16 was diagnosed with [REDACTED]. According to Mayoclinic.com., uveitis is inflammation of the uvea, the middle layer of the eye. The uvea consists of the iris, choriod and ciliary body. The choriod is sandwiched between the retina and the white of the eye and it provides blood flow to the deep layers of the retina. Uveitis can be serious, leading to permanent vision loss. Early [DIAGNOSES REDACTED]. On 5/2/12, Pred Forte and [MEDICATION NAME] eye drops were ordered and started the evening of 5/2/12. Nursing documentation on 5/2, 5/3, and 5/4/12, describe continued redness of the right eye. On 5/5/12, nurses' notes indicate the right eye seemed less reddened. On 5/9/12, nursing documents Resident #16 went to see the eye doctor and the sclera is improved. According to a verbal report to Surveyor # on 6/27/12 at 9:55 a.m., from Family Vision, where Resident #16 was examined on 5/9/12, Resident #16 was improving. Corresponding physician's orders [REDACTED]. The Pred Forte taper was scheduled for 4 weeks, with the last drops instilled on 6/7/12. There is no documentation in the record between 5/9/12 and 6/10/12 regarding the status of the right eye. On 6/10/12, nursing documents that the NP was notified that the right eye is still red, and there is an appointment in the near future for an evaluation of the eye. On 6/11/12, nursing calls the optometrist, who is not available. An associate returns the call to the facility and Pred Forte eye drops are restarted. Nursing documents on 6/12/12, the right eye is reddened and painful. Nursing documents on 6/13/12, right eye remains red and tender, complains of pain with assessment. On 6/14/12, right eye sclera remains red with no drainage. Right eye area is tender to touch. On 6/15/12 & 6/16/12, right eye remaining red. On 6/20/12, Resident #16 was examined by the optometrist, who notes the uveitis is significantly worse and orders the Pred Forte drops to be given every 2 hours, and refers the resident to an ophthalmologist. On 6/21/12, Resident #16 is examined by the ophthalmologist, who agrees with the optometrist's findings. According to the consult dated 6/21/12, the ophthalmologist orders the Pred Forte drops to be administered every hour that Resident #16 is awake. The purpose of the increased frequency of drops is to decrease pain. The ophthalmologist indicated there would be no therapy that would improve her vision. The ophthalmologist suspects Resident #16 had a retinal vascular event which caused blurry vision. According to a family member of Resident #16, on 6/23/12, when visiting from 10:00 a.m. until 1:15 p.m., Resident #16 received the prescribed Pred Forte eye drops one time at 12:35 p.m. The family member stated when she asked about the drops, the nurse stated she was behind. Resident #16 should have received the eye drops 2 - 3 times during the family visit. On 7/2/12 at 1:20 p.m., the Administrator informed Surveyor # per telephone, that she had confirmed that the nurse on duty 6/23/12, had not given the eye drops as ordered between 10:00 a.m. and 12:35 p.m. 2. Surveyor # reviewed Resident #2's closed medical record on 06/19-06/26/12. Resident #2 had been re-admitted to the facility on [DATE], after being hospitalized for [REDACTED]. Resident #2 has [DIAGNOSES REDACTED]. Surveyor # spoke with a former employee, Registered Nurse (RN)-K on 06/20/12 at 12:45 p.m. RN-K indicated Resident #2 returned to the facility from the hospital on [DATE], after he had surgery to repair a fractured left hip. RN-K informed Surveyor # that the facility did not make a follow-up orthopedic appointment to have Resident #2's staples removed until almost a month after his re-admission. Review of Progress Notes documentation revealed on 01/19/12 at 6:30 p.m., Resident #2 stood up from his wheelchair and fell before staff could reach him. Resident #2 indicated to staff he believed his leg was broken and he was sent to the emergency room where it was determined he had sustained a fracture of his left hip. According to the hospital discharge summary dated 01/24/12, Resident #2 had surgery to repair the hip on 01/19/12. Under the follow-up section of the discharge summary, instructions were to follow-up with the orthopedic clinic in one week. Progress Note documentation indicates Resident #2 received 20 staples as a result of the hip surgery. Progress notes made no mention of an orthopedic clinic follow-up until 02/23/12 at 12:30 p.m. The entry indicated, "Call place to orthopedic MD for follow-up 02/24/12 at 2:00 p.m." On 06/26/12 at approximately 1:15 p.m., Surveyor # spoke to a representative from Resident #2's orthopedic clinic. The representative indicated Resident #2's staples were removed at the clinic by a Nurse Practitioner without problem, on 02/24/12. When asked, the representative indicated Resident #2 had not been seen at the clinic between 01/24-02/24/12. Surveyor # spoke with the Nursing Home Administrator (NHA), on 06/26/12 at approximately 1:30 p.m. The NHA was asked whether she could provide information as to why there had been a 24 day delay for a follow-up orthopedic appointment for Resident #2. As of 06/27/12, no information had been provided. 3. Surveyor # reviewed Resident #13's medical record on 06/25-06/27/12. Resident #13 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of Resident #13's Bowel Monitoring record for June 2012, revealed Resident #13 did not have a bowel movement (BM) from the night shift of 06/15/12 until the night shift of 06/19/12. On 06/25/12 at approximately 1:30 p.m., Surveyor # asked the Nursing Home Administrator (NHA) for the facility's bowel monitoring protocol. Review of the bowel protocol (not dated) revealed the following: Day 2 with no BM, give prune juice Day 3 with no BM, give Milk of Magnesia (MOM)/laxative Day 4 with no BM, notify MD and family Review of Resident #13's as needed (prn) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Progress Note documentation provided no evidence Resident #13's MD or family were contacted on day 4 without a bowel movement. This information was shared with facility administration at the daily meeting on 06/25/12.