Every finding on record at Chi Franciscan Villa

Based on interviews, observations, record reviews, and facility policy review, the facility 1.) failed to attach wheelchair footrests during transport for one of six residents (Resident (R) 46) who was transported by Certified Nurse Aide (CNA) 1 which resulted in the resident's right foot being dragged under her wheelchair, requiring hospitalization, further medical treatment and harm. 2.) The facility also failed to reassess the safety of R4's slide board transfers after implementing an air mattress with inflated bilateral bolster which altered the transfer surface and had the potential to cause a fall and injury. This failure had the potential to increase the risk of accidents with the potential for injury. A total of 32 residents were included in the sample. Findings include: 1. Review of R46's admission Record, located under the Profile tab in the electronic medical record (EMR), indicated that the facility admitted the resident on 09/16/24 with a diagnosis of muscle weakness. Review of R46's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/26 and located under the MDS tab of the EMR, indicated the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. The assessment indicated that the resident used a wheelchair for mobility and required staff assistance. The assessment also indicated that the resident was dependent on staff for transfers from bed to her wheelchair. Review of R46's Care Plan, dated 09/18/24 and located under the Care Plan tab indicated that the resident had a self-care performance deficit related to limited mobility and was dependent on staff for all transfers. The care plan did not include interventions to address the resident's refusals to use wheelchair footrests during transport despite a history of right knee dislocation. Review of R46's Nurse Practitioner (NP) Prog (Progress) Note dated 06/02/25 and located under the Prog Notes tab of the EMR, revealed that the resident had a history of right knee dislocations. Review of R46's 72-Hour Follow Up, dated 05/15/26 following the resident's most recent hospitalization and located under the Prog (Progress) Note tab in the EMR, indicated that the resident had a history of refusing to wear a right knee brace. The documentation indicated that the resident expressed pain. The NP was onsite and assessed the resident immediately and ordered an x-ray. Review of R46's Nurse's Note, dated 05/16/26 and located under the Prog Note tab in the EMR, indicated that the resident's x-ray results were pending. Review of R46's Nurse's Note, dated 05/17/26 and located under the Prog Note tab in the EMR, indicated that the NP was notified by the facility of the resident's positive x-ray results of a right knee dislocation. The NP ordered that the resident was to be sent to the emergency room immediately. The resident was admitted to the hospital on this same date for dislocated/malalignment of the femoral component of right knee arthroplasty. A review was conducted of the hospital records titled, History & Physical, dated 05/17/26 which indicated . Patient presents with knee pain. 2 days ago, patient was being pushed in a wheelchair when her right leg got caught and pulled under the wheelchair. She heard a crack and developed knee pain right away. The pain has been constant since onset but waxing and waning in severity. It is worse with bending the knee, better if she keeps it in a certain position. The pain is sharp and 10/10 at its worst, 1-2/10 at best. She had an x-ray at her facility that revealed that her knee was dislocated. No numbness or tingling. Leg has been warm and well-perfused.At baseline she is wheelchair bound and uses a Hoyer for transfers.ED (Emergency Department) attempted a reduction under anesthesia but unfortunately it was unsuccessful.Ortho consulted. Low energy mechanism, right total knee arthroplasty dislocation, failed emergency department reduction attempts. Review of R46's Post Hospital ER (emergency room)/OBS (observation)/Outpatient, dated 05/19/26 and located under the Misc tab in the EMR, indicated that the NP assessed the resident after her recent hospitalization. It was noted that the resident had acute pain from an incident on 05/15/26 in which CNA 1 transported the resident, while in her wheelchair and without her footrests attached. The note continued that the resident's right foot then dragged and twisted under her wheelchair. On 05/16/26 the x-ray revealed that the resident's right knee was dislocated and on this same date was sent to the hospital for a possible right knee manual reduction. During an interview on 05/26/26 at 1:41 PM, R46 confirmed that an unknown staff member pushed her in her wheelchair without the footrests attached. The resident stated that she lifted her legs during transport and then her right leg fell and dragged under her wheelchair. The resident stated that she had the incorrect footrests to be attached to her wheelchair. The resident stated she was taken to the hospital to have her knee put back into place. During an interview on 05/27/26 at 3:58 PM, CNA1 confirmed she was the staff member who transported R46 in her wheelchair without attaching her footrests. CNA1 stated that the resident refused to use her footrests but wanted to attend an activity program. CNA1 stated she reminded the resident that she needed to use the footrests, but again the resident refused and claimed that the footrests were not hers. CNA1 stated that the resident could bend her right knee but not too much since her legs always caused her pain. CNA1 stated she had seen other staff transfer the resident in this manner prior to her assisting her. CNA1 stated that the resident began to cry and she got a nurse to assist with the incident. During an interview on 05/28/26 at 9:37 AM, the Director of Rehabilitation (DOR) confirmed that the NP asked her to assess R46 for a knee brace in the past. The DOR presented an email to confirm this request was completed on 12/19/25. The DOR stated she ordered the knee brace, but the resident refused to wear it. The DOR stated that the resident's right leg only bent to 45 degrees. The DOR stated that the skilled therapy department assessed the resident for multiple wheelchairs and the goal was for the resident to self-propel. The DOR stated she was unsure how the resident got her right leg caught under her wheelchair. At 9:57 AM, the DOR entered R46's room and confirmed that the resident had the correct wheelchair and footrests. The DOR reminded the resident that the footrests were to be attached to her wheelchair during transport. During an interview on 05/28/26 at 10:46 AM, Registered Nurse (RN) 2 stated that if a resident refused to use footrests to their wheelchair the staff member was to inform the nurse. RN2 stated residents should not be transported without the use of footrests. During an interview on 05/28/26 at 12:32 PM, the Director of Nursing (DON) stated that when R46 refuses to use footrests, the DON suggested telling R46, to just use the footrests until she was in activities and then remove the footrests, so she was comfortable. The DON stated that R46's right knee was chronically dislocated. 2. Review of R4's admission Record, located under the Profile tab in the EMR, indicated that the facility initially admitted the resident on 11/06/24 with a left leg amputation. Review of R4's annual MDS, with an ARD of 04/16/26 and located under the MDS tab in the EMR, indicated that the resident had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. The assessment also indicated that the resident required supervision/touching from staff to transfer. The resident sustained no falls during this assessment period. Review of R4's Care Plan, dated 02/03/25 and located under the Care Plan tab in the EMR, indicated that the resident had skin impairments and used an air mattress. Review of R4's Care Plan, dated 10/17/25 and located under the Care Plan tab in the EMR, indicated the resident had a right above the knee amputation and was at risk of increased falls. The approaches were to have one staff member assist him with transfers, via a slide board. During an interview on 05/26/26 at 3:26 PM, R4 stated that he had an air mattress recently placed on his bed and he hated it. The resident stated that the inflatable bi-lateral bolsters got in his way to complete a slide board transfer getting in and out of bed. The resident stated he had the air mattress for the past two weeks. When in bed, the resident stated he felt pinned in and it was like laying in a trough. During an interview on 05/28/26 at 7:50 AM, R4 stated he transferred from his bed to his wheelchair using a slide board. The air mattress was observed during this interview, and it had two bi-lateral bolsters which were inflated. The resident stated he used the slide board to transfer from his bed to the wheelchair and the slide board would not be level to get into the wheelchair since the inflated bolsters caused an uneven transfer instead of the slide board being flat. The resident stated that a CNA was present, but he still felt like he might fall due to the air mattress. During an interview on 05/28/26 at 7:57 AM, the DOR stated the use of the air mattress for R4 was a nursing decision. The DOR stated that she was not aware that the resident was placed on an air mattress. The DOR also stated that the resident was previously assessed for the use of a slide board transfer and referred to the Occupational Therapist (OT). During an interview on 05/28/26 at 8:06 AM, the OT stated that she had been working with R4 with the slide board for transfers to and from his wheelchair to a commode. The OT stated she had not been working with the resident on transfers to and from the bed, with the inflatable air mattress and his wheelchair. During an interview on 05/28/26 at 8:10 AM, the DOR stated that R4 would need to be evaluated on the use of the slide board with the bolstered air mattress to ensure that the slide board was still an appropriate device to use while the air mattress was on his bed. During an interview on 05/28/26 at 12:32 PM, the DON stated that the air mattress comes with inflatable bolsters, and the bolsters could be deflated. The DON stated the current air mattress was in place to address R4's pressure ulcers which had gotten better. The DON stated that the resident did voice to her that he was concerned about falling with the current air mattress and the use of his slide board. Review of a facility policy titled, Accidents and Incidents - Investigating and Reporting, dated 07/02/25 indicated . Accident' refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.

Based on observation, interview, and facility document review, the facility failed to ensure garbage was properly contained which would affect 86 census residents and staff in the facility. This had the potential to attract pests. Findings include: During an initial tour of the kitchen on 05/26/26 at 9:20 AM, Cook2 accompanied the surveyor and went outside of the facility where there was one dumpster. The dumpster was open and contained three quarters of trash. Cook2 stated that there was typically a pole to pull the dumpster lid down but was unable to locate this device during the observation. Cook2 stated it was important to keep the dumpster lid closed to prevent pests, such as racoons, from entering the dumpster. During an interview on 05/28/26 at 1:38 PM, the Dietary Manager (DM) stated that the dumpsters were to remain closed, so pests did not enter. Review of a facility policy titled, Disposal of Garbage and Refuse, dated 05/27/26 indicated .The facility shall properly dispose of kitchen garbage and refuse.Refuse containers and dumpsters kept outside the facility and designed and constructed to have tightly fitting lids, doors, and covers. Containers and dumpsters shall be kept covered when not being loaded.

Based on observation, interviews, and policy reviews, the facility failed to follow proper sanitation methods for the prevention of foodborne illnesses when staff did not wear hair restraints while working in the kitchen. The facility failed to ensure the kitchen was maintained in a sanitary condition. Specifically, the facility failed to label, date, and store food properly. Finally, the facility failed to ensure [NAME] 2's personal drink was not left in the kitchen refrigerator. This failure increased the risk of foodborne illness and had the potential to affect 82 of 84 residents who ate food from the kitchen. Findings include: During an initial tour of the kitchen and interview on 05/26/26 9:20 AM, the following was noted: -Cook2 was observed preparing chicken for lunch meal without wearing a beard restraint.-Cook3 was in the food prep area, and he did not have a beard restraint on. [NAME] 2 confirmed that he did not have a beard restraint on and that he typically did. -The first refrigerator on the right side of the kitchen contained a transparent plastic container of chopped tomatoes. There was a plastic cover over this container with two dates, 05/09/26 and 05/25/26. Cook2 did not know what the used by date was. -A second transparent container of chopped cucumbers with two dates, 05/11/26 and 05/24/26 was observed. -The second refrigerator contained metal containers of the following: four containers of pureed beef dated 05/21/26; pureed chicken dated 05/16/26; breakfast sausage dated 05/16/26, and thickened gravy dated 05/17/26. Finally, a bottle of Gatorade was observed and Cook2 verified that it was his drink and it should not be stored in the kitchen refrigerator since there was a refrigerator for staff to use. During an interview on 05/28/26 at 1:38 PM, the Dietary Manager (DM) stated that staff were supposed to wear beard restraints since it was an infection control issue. The DM stated that her expectation was for staff to routinely check on the food stored in the refrigerators and toss out the food after the used by date. The DM stated Cook2's drink should have been stored in the employee refrigerator and not in the kitchen refrigerator. Review of the Food Code.US Food & Drug, dated 2017 indicated, .An employee shall eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed food; clean equipment. other items needing protection cannot result. Review of a facility policy titled, Storage of Food Guidelines, dated 05/12/26 failed to contain evidence that pureed beef and chicken should be disposed of after one day. In addition, the policy failed to identify when to label and date fresh food items. Review of a facility policy titled, Hair Restraints, dated 01/14/26 indicated, .Hair shall be restrained to prevent physical contamination of food.The following are acceptable as hair restraints.Hairnets'.Beard restraints.

Based on observations, record review, interviews, and facility policy review, the facility failed to: 1.) ensure proper personal protective equipment (PPE), was donned (put on) by Certified Nurse Aide (CNA) 6 prior to entering into (Resident (R) 33's room who was under contact precaution; 2.) failed to post proper Transmission Based Precautions (TBP) signage for neutropenic isolation for R58; and 3.) failed to ensure Housekeeping Aide (HA)1 transported soiled linens without placing these items in a plastic bag. This increased the likelihood that infectious organisms could be transmitted from residents to staff, other residents, or the environment. Findings include: 1. Review of R33's admission Record, located under the Profile tab electronic medical record (EMR), indicated that the facility admitted the resident on 04/24/26. Review of R33's Physician Orders, dated 04/27/26 and located under the Orders tab in the EMR, revealed the resident was placed on contact isolation due to multi-drug-resistant organisms (MDRO). During a room tray observation on 05/26/26 at 12:13 PM, CNA6 entered R33's room without putting on a gown. CNA6 did don a mask and gloves. An interview was conducted immediately after this observation and CNA6 stated she normally put on a gown, and did not, prior to entering a resident's room that was on contact isolation and stated the PPE was to protect her and other residents from possible transmission. During an interview on 05/28/26 at 12:32 PM, the Director of Nursing (DON) stated it was her expectation that staff don a gown and gloves prior to entering a room that was under contact isolation. 2. Review of R58's admission Record, located under the Profile tab in the EMR, indicated that the facility admitted the resident on 04/04/25. Review of R58's Physician Orders, dated 01/16/26 and located under the Orders tab in the EMR, indicated to place the resident on reverse isolation (neutropenic) due to her chemotherapy treatment. Review of R58's Medication Administration Records (MAR), located under the Orders tab in the EMR, revealed from 03/26 through 05/26/26 staff documented that the resident was under reverse isolation per shift. An observation was made on 05/26/26 at 10:25 AM and a sign was posted which was for enhance barrier precautions (EBP). During an interview on 05/28/26 at 10:24 AM, Registered Nurse (RN) 2 stated that reverse isolation was placed on R58 since she was immunocompromised due to her cancer diagnosis and receiving chemotherapy. RN2 confirmed that R58 had EBP posted outside of the resident's room. During an interview on 05/29/26 at 11:32 AM, the DON stated that R58 was not in reverse isolation, and this order was not identified. The DON stated that the facility could not provide that level of care for the resident. 3. Review of R39's admission Record, located under the Profile tab of the EMR, revealed R 39 was admitted to the facility on [DATE] with diagnosis of dementia, hyperlipidemia, and anxiety disorder. Review of R39's quarterly MDS, with an ARD of 04/10/26 and located in the EMR under the MDS tab, revealed a BIMS score of zero out of 15, which indicated severely impaired cognition. During an observation on 05/26/26 at 11:48 AM, Housekeeping (HA) 1 was observed walking from R39's room with gloves on and R39's unbagged soiled clothing. During an interview on 05/26/26 at 11:52 AM, HA1 stated, The proper way to transport soiled residents' clothes should be in a bag. Review of a facility policy titled, Isolation-Categories of Transmission-Based Precautions, dated 05/22/25 indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.Contact precautions may be implemented for residents known or suspected to be infection with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Review of a facility policy titled, Neutropenic Precautions, dated 05/28/26 .It is the policy of this facility to ensure that residents that require neutropenic precautions are protected from the risk of infection based on current standards of practice.People that receive or have received chemotherapy or have other medical conditions that result in the decrease of the number of white blood cells are at risk for developing neutropenia. Neutropenic precautions are a mechanism to help protect the neutropenic person from the increased risk of infection.The nurse will obtain and verify the physician's order for neutropenic precautions and place signage outside the resident's door informing staff, residents, and visitors of the precautions.

Based on interview, record review, facility policy review, document review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents (Residents (R) 73 and R76) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for residents to contract pneumonia. Findings include: 1. Review of R73's admission Record, located under the Profile tab in the electronic medical record (EMR), indicated that the facility admitted the resident on 07/29/25. Review of R73's Immunization, located under the Immun (Immunization) tab of the EMR, indicated that R73 received the Pneumovax 23 (PPSV23) vaccine on 04/29/11. The resident received the Prevnar 13 (PCV13) vaccine on 10/05/16. Finally, the resident received her annual influenza vaccine on 10/04/24. There was no evidence that showed the resident was offered, consented, or declined the 2025 influenza vaccine. Review of a document titled, Personal Immunization History, provided by the facility, indicated that R73 received PPSV23 on 04/29/11 and the PCV13 on 10/05/16. According to this document the resident was up to date on their pneumococcal vaccinations. 2. Review of R76's admission Record, located under the Profile tab in the EMR, indicated that the facility admitted the resident on 08/05/21. Review of R76's Immunization, located under the Immun tab of the EMR, indicated that R76 received the PCV13 on 04/05/17. The clinical record indicated that the resident received the influenza vaccine on 10/02/24. There was no evidence that showed the resident was offered, consented, or declined the 2025 influenza vaccine. Review of a document titled, Personal Immunization History, provided by the facility, indicated that R76 received the PPSV23 on 10/28/08 and the PCV13 on 04/05/17. According to this document the resident was up to date on their pneumococcal vaccinations. During an interview conducted on 05/29/26 at 9:59 AM, the Director of Nursing (DON) confirmed that R73's and R76's pneumococcal vaccines were not up to date after reviewing the CDC guidelines. The DON stated there was no documented evidence that R73 and R76 were offered an influenza vaccine and either accepted it or declined the vaccination. The DON stated that there were no influenza outbreaks during this time. Review of the CDC website titled, PneumoRecs VaxAdvisor App (Application) for Vaccine Providers, dated 02/25/26, indicated . Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 or PCV21 is administered, their pneumococcal vaccinations are complete. Review of a facility policy titled, Pneumococcal Vaccination (Series), dated 05/12/26 indicated . It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Review of a facility policy titled, Influenza Vaccination, dated 05/12/26 indicated .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against influenza disease in accordance with national standards of practice. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine.

Based on clinical record reviews and staff interviews, the facility failed to ensure the clinical records were complete for two of five residents (Resident (R) 73 and R76) reviewed for vaccination status out of a total sample of 32 residents. This had the potential for the residents not to receive accurate care. (Cross Reference F883) Findings include: 1. Review of R73's admission Record, located under the Profile tab in electronic medical record (EMR), indicated that the facility admitted the resident on 07/29/25. A review was conducted of R73's clinical record and there was no evidence that the resident was offered, received, or declined the 2025 influenza vaccine. 2. Review of R76's admission Record, located under the Profile tab in the EMR, indicated that the facility admitted the resident on 08/05/21. A review was conducted of R76's clinical record and there was no evidence that the resident was offered, received, or declined the 2025 influenza vaccine. Review of a document titled, Status, provided by the facility, indicated Registered Nurse (RN) 4 was hired on 06/11/25 as Staff Development and turned in his resignation on 01/04/26. Review of a document titled, Staff Development, job description dated 06/11/25, provided by the facility, indicated that Staff Development was to maintain staff vaccination records. There was no evidence in the job description that Staff Development was to maintain the clinical records for residents' vaccination status. There was no evidence in his employee record which would indicate he was adequately trained on the responsibilities of infection prevention and management of educating residents of the risks verses benefits of receiving the 2025 influenza vaccine. During an interview on 05/28/26 at 12:32 PM, the Director of Nursing (DON) stated that RN4 destroyed the 2025 consents/records for the 2025 influenza vaccines. The DON stated there were no records to verify if any resident was offered the 2025 influenza. During an interview conducted on 05/28/26 at 2:04 PM, the Administrator stated that RN4 destroyed all the records associated with the 2025 influenza vaccination status. A telephone call was placed on 05/28/26 at 4:05 PM and a message was left for RN4. No return call was received prior to the end of the survey. During an interview on 05/29/26 at 8:43 AM, the Health Information Manager (HIM) stated that typically the Infection Preventionist (IP) was responsible for all the resident vaccinations. The IP would gather the data of the residents' immunization and place that information in the EMR. RN4 should have entered the influenza information in each of the residents' EMR and confirmed that this was not done. During an interview on 05/29/26 at 9:59 AM, the DON stated since she was the Infection Preventionist (IP) at the time that RN4 was hired and she delegated all the resident vaccination responsibilities to him. The DON stated the protection of resident records was a part of RN4's competency and responsibilities as an RN. The DON stated she believed that RN4 offered and gave the influenza vaccines to the residents since she made the order from the pharmacy and the influenza vaccines, contained in boxes, went down in count. The DON stated that there were no influenza outbreaks at this time. Review of a facility policy titled, Retention of Medical Records, dated 05/12/26 indicated, . Medical records of discharged residents will be retained for a period of 7 years from the date of service. Where state law or practices require longer retention of records than those shown,state law or practice is controlling.

Based on review of the facility policy, resident-specific meal service documents, and menu records, the facility failed to provide meals consistent with neutropenic precautions for one out of one resident (Resident (R) 58), out of a survey sample of 32, by serving fresh fruits and vegetables despite the resident's need to avoid those foods. The facility's failure to provide meals consistent with neutropenic isolation precautions placed the resident at increased risk for exposure to foodborne pathogens. (Cross Reference F880) Findings include: Review of R58's admission Record located under the Profile tab in electronic medical record (EMR), indicated the facility admitted the resident on 04/05/25. Review of R58's Physician Orders, dated 01/16/25 and located under the Orders tab in the EMR, indicated the physician ordered the resident to be placed on reverse (neutropenic) isolation since the resident received chemotherapy. Review of a document referred to as a Meal Ticket, provided by the facility, for R58 failed to indicate that the resident was not to be served fresh fruit and vegetables. Review of a document titled, Week at a Glance Week 1, provided by the facility, indicated that the resident was served a broccoli salad on Monday 4th for dinner. On Wednesday 6th of the month the resident was served coleslaw and watermelon for dinner. On Saturday 9th the resident was served sliced apples with dinner. Review of a document titled, Week at A Glance Week 2, provided by the facility, indicated that R58 was served tomato wedges on Monday 11th with dinner. For Wednesday13th the resident was served fresh fruit with dinner. For Thursday 14th the resident was served creamy cucumber salad for dinner. For Saturday 16th she was served sliced orange with dinner. Review of a document titled, Week at A Glance Week 3, provided by the facility, indicated that R58 was served tomato wedges with dinner on Monday 18th. On Tuesday 19th the resident was served grapes with lunch and for dinner the resident was served a cucumber/tomato salad. On Wednesday 20th the resident was served lettuce/tomato/onion with dinner. Review of a document titled, Week at A Glance Week 4, provided by the facility, indicated R58 cucumber salad was served on Wednesday 27th with dinner. During an interview on 05/28/26 at 1:38 PM, the Dietary Manager stated she was not alerted that R58 was on neutropenic isolation, therefore, could not receive fresh fruit and vegetables. Review of a facility polity titled, Nutritional Management, dated 09/16/25 indicated .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.Care plan implementation.Interventions will be individualized to address the specific needs of the resident.Disease specific interventions.

Based on observation, interviews, and policy review, the facility failed to ensure an opened vial of Tuberculin (TB) Purified Protein Derivative was labeled when opened with an expiration date in one of two medication rooms reviewed for storage and labeling. This deficient practice had the potential for inaccurate TB testing due to the vial potentially being expired and ineffective. Findings include: An observation on [DATE] at 11:40 AM, the refrigerator in the med room on the Heritage North Hallway, contained a vial of TB derivative was stored in a box on the shelf in the door. The vial was opened without a date to reflect when the vial was opened. The manufacturer expiration date was 09/27. During an interview on [DATE] at 11:40 AM, Licensed Practical Nurse (LPN) 1 verified the opened vial of TB derivative should have been dated when opened and marked for expiration 28 days after being opened, and it was not labeled. During an interview on [DATE] at 11:52 AM, Registered Nurse (RN) 1, confirmed when a vial of medication or biological (TB) was opened it should be labeled with the date opened and the expiration date should be 28 days later. During an interview on [DATE] at 12:04 PM, the Director of Nursing (DON) confirmed when a biological TB vial was first used/opened, it should be labeled with the date opened and the date to expire 28 days later. Review of the facility policy titled, Labeling of Medication Containers, revised [DATE], revealed . Labels for stock medications include all necessary information, such as:a. the name and strength of the drug; b. the lot and control number; c. the expiration date when applicable .

Based on observations, interviews, and facility policy review, the facility failed to provide appropriate tube feeding management for one resident (Resident (R) 10) reviewed for tube feedings out of a total sample of 32 residents. This failure had the potential for the resident and others receiving liquid nourishment via tube feedings to receive outdated nourishment and created the risk for infection. Findings include: Review of R10's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R10 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, and atrial fibrillation. Review of R10's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] and under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS), score of zero out of 15, which indicated severely impaired cognition. Review of R10's Care Plan, focus initiated on [DATE] and located under the Care Plan tab in the EMR, revealed that R10 received nutritional formula via tube feeding. Interventions included to ensure R10's head of bed was at least at 30 degrees, and to monitor for aspiration and nausea/vomiting. Observation on [DATE] revealed R10's tube feeding formula and water flush bag were not dated and labeled. During an interview on [DATE] at 11:20 AM, Registered Nurse (RN) 2 stated, My process with tube feeding is to disconnect R10 from the pump. I think the order is for noon. When I re-connect R10 to the pump, I check for placement, prime pump, and ensure that her head of bed is at 40 degrees. I make sure the formula is not expired and the formula is labeled with the resident's name and it is dated. Review of the facility's policy titled, dated 05/26, . The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings On item # 3, Check the enteral nutrition label against the order before administration. Check the following information: sub-item a. Resident name, identification, and room number. b. type of formula, c. date and time formula was prepared, and g. rate of administration.

Based on observations, interviews, and facility policy review, the facility failed to ensure appropriate Activities of Daily Living (ADLs) to maintain appropriate hygiene for two residents (Resident (R) 81 and R25) reviewed for ADLs out of a total sample of 32 residents. This failure had the potential for the residents to have unmet hygiene needs and affect resident care. Findings include: Review of R81's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed Resident (R) 81 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, chronic respiratory failure, and major depressive disorder. Review of R81's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/26, and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that her cognitive function was intact. The MDS indicated R81 required partial to moderate assistance for oral care. Review of R81's Care Plan, focus initiated on 11/19/25 and located under the Care Plan tab of the EMR, revealed that R81 had the potential for dental problems related to poor oral hygiene, decayed teeth at gumline, and a tooth fractured at the gumline. Interventions in place included monitor for oral problems needing attention. Observations on 05/26/26, 05/27/26, 05/28/26, and 05/29/26, revealed R81 had debris on her teeth. During an interview on 05/27/26 at 1:50 PM R81 stated, The staff doesn't offer me to brush my teeth. If I don't ask them, they don't offer it. During an interview on 05/27/26 at 11:00 AM, Certified Nurse Aide (CNA) 3 stated, I usually check the resident roster to see which patients I am assigned to. I bring ice water in, get them washed, cleaned, and changed, wipe their face, brush their teeth, and if the resident is combative, I always bring someone in with me. During an interview on 05/27/26 at 11:47 AM, the Director of Nursing (DON) stated, The expectation is that oral care is done morning and night at least. When a resident is care planned for oral care, the staff needs to get everything set up, ask them if they are ready to have their teeth brushed and to make sure that the resident can stay as independent as they can. 2. Review of R25's admission Record, located in the Profile tab of the EMR revealed Resident (R) 25 was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), and vascular dementia. Review of R25's quarterly MDS, with an ARD of 03/18/26, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated that her cognitive function was severely impaired. The MDS indicated R25 required set-up assistance from one person for personal hygiene. Review of R25's Care Plan, initiated on 11/06/25 and located in the Care Plan tab of the EMR, revealed R35 had a self-care performance deficit and was dependent on staff for ADL care related to impaired balance, limited mobility, incontinence, dementia, rheumatoid arthritis, and decreased stamina. Approaches initiated on 11/06/25 revealed that R25 required assistance by one staff member to wash her face and hands and to brush her hair, as needed. Observations on 05/26/26, 05/27/26, 05/28/26, and on 05/29/26, revealed R25 was observed with chin hair. During an interview on 05/27/26 at 11:00 AM, Certified Nurse Aide (CNA) 5 stated, I start resident care with assisting residents with their hygiene such as setting up supplies like wipes for incontinent care, helping set up with breakfast, brush their hair, help with dressing, and with cleaning their dentures. During an interview on 05/28/26 at 12:31 PM, R25 stated, If they can do it, I would like them to take it off. R25 was referring to her chin hair. Review of the facility policy titled, Activities of Daily Living (ADLs), dated 10/25, on page one of two, indicated, . The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: item A. bathing, dressing, grooming, and oral care.

Based on interviews, record reviews, and policy review, the facility failed to ensure injuries and injuries of unknown origin were reported timely for two of three residents (Resident (R) 21 and R46 out of a total sample of 32 residents. This deficient practice had the potential for harm from unrecognized abuse by not identifying injuries of unknown origin. (Cross reference F689) Findings include: 1. Review of R21's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed an admission date of 04/16/26 with medical diagnoses that included unspecified dementia and adult failure to thrive. Review of R21's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 05/21/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severely impaired cognition. During an interview on 05/26/26 at 11:25 AM, Family Member (FM) 1 expressed concern about the big red sore on R21's breast that was observed earlier that morning while R21 was being dressed for the day. FM1 stated they asked (R21) what happened, and R21 was unable to explain what occurred. During an interview on 05/27/26 at 10:27 AM, the Occupational Therapist (OT) confirmed noticing a red line across the center of R21's breast and bruising near the nipple while she was helping dress R21. The OT confirmed she requested Registered Nurse (RN) 2 to look at the red mark. RN2 checked the red area and told the OT to notify Licensed Practical Nurse (LPN) 2 who was assigned to care for R21. During an interview on 05/27/26 at 12:09 PM, RN1 stated she spoke with LPN2, who had worked the unit for R21 the day before, and confirmed being told to assess R21 by the OT and verified she forgot to assess when notified. During an interview on 05/27/26 at 3:12 PM, RN1 assessed the red area on R21's breast and informed the Director of Nursing (DON) about the injury of unknown origin. During an interview on 05/28/26 at 12:06 PM, the DON confirmed being told about R21's injury and began a report for an injury of unknown origin in the internal system for the facility. During an interview on 05/28/26 at 12:42 PM, LPN2 verified she was told about the possible injury for R21 by the OT on 05/26/25 and that RN2 assessed R21. LPN2 stated she thought RN2 documented the assessment but RN2 did not document what was assessed. LPN2 confirmed she did not assess R21 for the injury and did not report it. During an interview on 05/28/26 at 3:51 PM, RN2 confirmed being called to R21's room on 05/26/26 to assess the injury and did not document the assessment or tell anyone else since R21 was not assigned to be his resident that day. During an interview on 05/29/26 at 9:09 AM, the Administrator confirmed he had not filed a report about the injury of unknown origin due to beginning an investigation after being notified. The Administrator stated the cause of R21's injury was identified as being caused by a gait belt being placed around R21's waist, and R21's breast was caught under the belt. The Administrator confirmed the report was filed three days after the incident was originally reported. Review of the facility document titled, Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, revealed a date of discovery 05/26/26, date reported 05/29/26 at 10:38 AM. 2. Review of R46's admission Record, located under the Profile tab in the EMR, indicated that the facility admitted the resident on 09/16/24 with a diagnosis of muscle weakness. Review of R46's quarterly MDS, with an ARD of 04/05/26 and located under the MDS tab in the EMR, indicated the resident had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. The assessment indicated that the resident used a wheelchair for mobility and required staff assistance and indicated that the resident was dependent on staff for transfers from the bed to her wheelchair. Review of R46's Care Plan, dated 09/18/24 and located under the Care Plan tab in the EMR, indicated that the resident had a self-care performance deficit related to limited mobility and was dependent on staff for all transfers. The care plan indicated that the resident often refused to wear her right leg brace. Review of R46's 72-Hour Follow Up, dated 05/15/26 and located under the Prog note tab in the EMR, indicated that the resident had a history of wearing a right knee brace. The documentation indicated that the resident expressed pain. The Nurse Practitioner (NP) was onsite and assessed the resident immediately and ordered an x-ray. Review of R46's Nurse's Note, dated 05/16/26 and located under the Prog note tab in the EMR, indicated that the resident's x-ray results were pending. Review of R46's Nurse's Note, dated 05/17/26 and located under the Prog note in the EMR, indicated that the NP was notified by the facility of the resident's positive x-ray results of a right knee dislocation. The NP gave an order for R46 to be sent to the emergency room immediately. R46 was admitted to the hospital on this same date for dislocated/malalignment of the femoral component of right knee arthroplasty. A request was made by the facility to provide R46's hospital records from 05/17/26 and they did not provide them prior to survey exit. Review of R46's Post Hospital ER/OBS/Outpatient, dated 05/19/26 and located under the Misc tab in the EMR indicated, indicated that the NP assessed the resident after her recent hospitalization. It was noted that the resident had acute pain from an incident in which Certified Nurse Aide (CNA) 1 pushed the resident, while in her wheelchair and without her footrests attached on 05/15/26. The note continued and indicated that the resident's foot was dragged and her right knee twisted. On 05/16/26 the x-ray indicated that the resident's right knee was dislocated and on this same date was sent to the hospital for a possible right knee manual reduction. R46 was referred to orthopedics in which the physician attempted to undergo a closed knee reduction which was unsuccessful. The resident was sent to another orthopedic doctor, and she underwent a closed knee reduction on 05/17/26 and this procedure was successful. The resident was readmitted back to the facility. During an interview on 05/26/26 at 1:41 PM, R46 stated that her leg rests to her wheelchair were missing, and she had asked an unknown staff member (CNA1) to push her to activities. The resident confirmed that no leg rests were attached to her wheelchair at the time the staff member pushed her. R46 stated she was lifting her leg, and it was pulled under her wheelchair and dragged. Review of a document titled, Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 05/26/26 at 5:45 PM, provided by the facility, indicated that the Administrator reported to the State Survey Agency (SSA) an allegation of Reportable incident that was not misconduct. The report to the SSA outlined the incident dated 05/15/26 and the injury that R46 sustained by her right leg being dragged under her wheelchair by a staff member. During an interview on 05/29/26 at 9:11 AM, the Administrator stated that the incident involving R46 and CNA1 should have been reported to the SSA immediately and confirmed that it was not done. Review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised 05/01/24, revealed . It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.Injuries of unknown source include circumstances when both the following conditions are met; i. The source of the injury was not observed by any person or could not be explained by the resident.The Director of Nursing Services, Administrator, or designee will: a. Notify the appropriate agencies immediately as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion.

Based on observation, interview and record review, the facility did not ensure 2 (R6 and R5) of 4 received adequate supervision and assistance devices to prevent and be free of accidents. R6 did not have a low bed in place and experienced a fall that resulted in sutures and a closed face fracture. R5 was not provided with supervision per R5's care plan to ensure safety while eating and to prevent choking. Findings include: 1.) R6 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, Adult Failure to Thrive, Right Orbital Fracture and Cognitive Communication Deficit. R6's admission MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 5, indicating R6 is severely cognitively impaired. Section E0900 Wandering documents wandering behavior occurred 1 to 3 days during the assessment period. Section GG (Functional Abilities and Goals) documents that R6 require supervision or touching assistance to sit to stand and requires partial/moderate assistance for chair to bed transfers. R6's Falls CAA (Care Area Assessment) dated 1/29/26 documents under the Care Plans Consideration section: Resident is at risk for falls r/t (related to) impaired mobility and cognition. She is receiving pt (physical therapy)/ot (occupational therapy)/sp (speech therapy) services. She currently requires partial to moderate assist with transfers. She is frequently incontinent of b/b (bowel and bladder), staff to check and change, provide peri care after each incontinence episode. Skin is intact, although she is at risk for impairments r/t (related to) incontinence. Preventive measures in place such as pressure reducing mattress and w/c (wheel chair) cushion, weekly skin checks and prn (as needed). Denies pain. Continues on anti anxiety, antidepressant medication r/t behaviors secondary to Alzheimer's. Staff to monitor for abnormal behaviors and s/s of depression. Proceed to care plans and update prn (as needed). R6's Falls Risk assessment dated [DATE] documents a score of 10, indicating that R6 is at risk for falls. R6's Falls care plan dated 1/27/26 documents the following interventions: Bed in lowest position. R6's nursing note dated 2/7/26 documents: Note Text: resident is being monitored for restless, combative behaviors and wandering into other resident rooms. Resident did display and combative behaviors while wandering. She is easily redirected and cooperative. resident walks in hallway to back to room. No c/o (complains of) pain or discomfort during shift. No concerns at this time. R6's nursing note dated 2/7/26 documents: Note Text: Patient is found walking down the hallway with her walker and blood on her head, right side of her face, nose and mouth. Writer and CNA [name] assisted this patient back to bed. Patients bed is noted to be above waist high in the air and blood on the floor next to her doorway and her glasses. Patient was just seen in her bed laying down with her bed low to the ground approximately 20-30 minutes prior to her fall. Patient stated she had raised the bed up high and did not realize that she did this. Bed remote is noted to be next to patient on her side rail. Patient states her head does hurt but nothing else at this time and rates it a 2/10. Writer and CNA cleaned blood from patient and it is noted patient has about 1-1.5 inch laceration to her right eyebrow and a small laceration to her lower lip. Patient stated she did have her glasses on when she fell. Patient is alert and oriented per baseline and ROM (range of motion) WNL (within normal limits), no rotating or shortening noted. VSS (vital signs stable) at this time. Bell Ambulance called for transport of this patient to the ER (emergency room). R6's Fall Protocol Checklist dated 2/7/26 documents that R6 was seen around 20-30 minutes prior to the fall. The report documents that R6 appears to have rolled out of bed and that R6 had a bed at waist high level. Under the Summary Statement of Fall section it documents: Resident found walking in hallway with walker and blood on face/mouth. Previously 20 min/30 min resting in bed in lowest position. Resident stated she raised bed up high and didn't realize she did this. Bed remote found next to resident's side rail (enabler bar). Reported 2/10 head pain, laceration to right eyebrow and lower lip glasses on at time of the fall. Assessment completed. 911 called. Under the Witness Statement section it documents: I had helped resident to bed and her bed was in the lowest position. She later was walking in hallway with blood on her face. I assisted her back to her room and her bed was high. I didn't know R6' reaction to when I asked her how her bed got up so high. Nurse helped me assist back to room and stayed with resident until 911 arrived. R6's nursing note dated 2/8/26 documents: Narrative Text: 0317 Resident return from ER per stretcher, assisted back to bed by EMS (Emergency Medical Services). Res (resident) still sleeping quietly, respiration calm, non labored, skin warm and dry to touch, normal in color. New order of ABT (antibiotic) received from ER (emergency room) for acute bacterial infection of sinuses, Res. discharge diagnosis of closed fracture of right orbital floor, closed fracture of right maxillary sinus. Received also res. with 5 stitches to right eyebrow. Bruise to right periorbital, right cheek and upper lip. R6's hospital After Visit Summary dated 2/8/26 documents: Diagnoses- Closed Fracture of Right Orbital Floor, Facial Laceration-Sutures. R6's nursing note dated 2/8/26 documents: Late Entry: Note Text: IDT (interdisciplinary team) FALL REVIEW- 2/07/2026 The IDT met to review the fall that occurred on February 7, 2026. The resident has a documented medical history including Alzheimer's, adult failure to thrive, anxiety, mild cognitive impairment, diverticulitis, restlessness, agitation, muscle weakness, and cognitive communication deficit. Per the incident report, staff responded to the resident's need for assistance. Resident was found walking down the hall towards the nurses station. Resident was using her walker appropriately at this time and wearing proper footwear at the time of the fall. The resident was immediately assessed and obvious facial trauma was present. Ambulance was called and staff stayed beside with resident until she was transferred to the hospital. Resident reported facial pain rating of 2/10 during the time of the assessment. Resident was assisted back into her bed by nurse and CNA (Certified Nursing Assistant). Range of motion was within normal limits, and neuro checks were initiated as a precautionary measure. The IDT determined that the resident likely attempted to use the bed control not understanding what she was doing and had the bed in the highest position, did not use call light and rolled out of bed. As a result, the facility has moved the resident's room closer to the nursing station for observation, bed in lowest position, and enabler bars to promote independence. The resident's primary care provider and family have been notified of the incident and the new interventions. Family is in agreement and has no questions at this time. The facility's self-report to the state agency submitted on 2/13/26 documents: Staff responded to the residents' need for assistance. The resident was found walking down the hall towards the nurses station. The resident was using her walker appropriately at this time and wearing proper footwear at the time of the fall. The resident was immediately assessed and obvious facial trauma was present. An ambulance was called and staff stayed beside the resident until she was transferred to the hospital.The IDT determined that the resident likely attempted to use the bed control not understanding what she was doing and had the bed in the highest position, did not use call light and rolled out of the bed. The result of the fall with injury was a closed right orbital fracture and closed right maxillary sinus fracture. Surveyor noted that the facility's self report and fall investigation did not address why R6 did not have adequate supervision to prevent R6's fall on 2/7/26, despite documentation stating that R6 was experiencing behaviors prior to her fall. Surveyor also noted that the facility's fall investigation documented that R6's fall interventions of a low bed was not in place at the time of R6's fall. On 2/17/26 at 12:23 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above findings. Surveyor asked DON-B if R6 was provided with supervision prior to R6 falling. DON-B stated that she would provide additional information. On 2/17/26 at 9:47 AM, Surveyor spoke with LPN-L regarding the note she documented regarding R6's behaviors prior to R6's fall on 2/7/26. LPN-L informed Surveyor that R6 was experiencing behaviors including restlessness and getting out of bed frequently prior to R6's fall. LPN-L informed Surveyor that LPN-L was not present at the time of R6's fall. On 2/17/26 at 9:52 AM, Surveyor informed DON-B of the above findings. Surveyor informed DON-B of concerns that R6 was provided supervision prior to R6's fall on 2/7/26 despite experiencing R6 experiencing behaviors prior to R6's fall. Surveyor informed DON-B that R6's fall intervention of a low bed was not in place prior to R6's fall. No additional information was provided as to why R6 did not have fall interventions in place and supervision on 2/7/26 when R6 experienced a fall. 2.) The facility's policy titled Meal Supervision and Assistance dated 2/18/26 documents (in part): The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: A. Identifying hazard(s) and risk(s). B. Evaluating and analyzing hazard(s) and risk(s). C. Implementing interventions to reduce hazard(s) and risk(s). D. Monitoring for effectiveness and modifying interventions when necessary. Risk refers to any external factor, facility characteristic (e.g. staffing or physical environment) or characteristics of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Compliance Guidelines: The facility will develop and implement an individualized care plan to address the residents needs and goals and to monitor the results of the planned interventions such as adequate supervision during mealtime. R5 was admitted to the facility on [DATE] and has diagnoses that include chronic respiratory failure, tracheostomy (trach) status, laryngeal hypoplasia, epilepsy, anxiety disorder, obesity, functional quadriplegia, Type 2 diabetes mellitus and dysphagia. R5's Speech Therapy Recommendations dated 11/4/25 document: Diet texture – mechanical soft. Dining assist – supervision. Swallowing guidelines – clear throat/cough when gurgly. Slow rate, small bites. PMSV (Passy Muir Speaking Valve) to be worn with all PO (by mouth) intake. R5's Care Plan documents: Alteration in nutrition/hydration r/t (related to) hx (history) pneumonia, DM (Diabetes Mellitus) II, obesity, quadriplegia, dysphagia as evidenced by needs for therapeutic diet, needs for mechanically altered diet, supervision with meals, swallowing recommendation – dated 1/6/26. Approaches – Swallowing recommendation: Oral care BID (twice daily); Passy Muir speaking valve must be worn during all PO (by mouth) intake. Needs supervision with meals. R5's Kardex dated 2/17/26 documents: Eating – I require partial to moderate assist with eating. Swallowing recommendation: Oral care BID; Passy Muir speaking valve must be worn during all PO intake. Needs supervision with meals. On 2/16/26 at 12:20 PM, Surveyor and Unit Manager-I entered R5's room to view supplies. Surveyor observed R5 had her lunch plate on her stomach/lap in bed, was eating independently and had consumed at least 50% of her meal. Unit Manager-I stated, We need to put the cap on you and proceeded to obtain a purple cap from the counter across from R5's bed and placed it on the end/opening of her trach. After viewing supplies with Unit Manager-I, she put a gown on and stated, I'm staying with her because she needs supervision when eating. On 2/17/26 at 12:10 PM, Surveyor observed R5 lying in bed with her head of bed elevated between 30-45 degrees. R5 appeared to be asleep, and her lunch tray was on the bedside table in front of her. Surveyor noted the purple PMSV valve was not on her trach and no other staff entered R5's room for another 27 minutes. On 2/17/26 at 12:37 PM, Surveyor observed 2 staff members gown and enter R5's room. Surveyor heard 1 staff member say she would sit with R5 while she eats. On 2/18/26 Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were advised of the above findings. No additional information was provided.

Based on observations, interviews and record review the facility did not ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 1 of 2 (R4) residents reviewed for pressure injuries. R4 developed a facility acquired stage 3 pressure injury on her left buttock and an unstageable Deep Tissue Injury (DTI) on her right lateral ankle. Surveyors had observations of care plan interventions not in place and R4's feet were observed not to be offloaded during survey. Findings include:R4 admitted to the facility on [DATE] and has diagnoses that include anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder and anxiety.The facility did not provide a pressure injury policy and procedure. Surveyor was provided a form titled Pressure Injuries Overview dated last approved 5/22/25. The form only documented the general definitions and staging of pressure injuries.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) documented a staff assessed score of 99, indicating that R4 is comatose. The MDS documents that R4 has impairment to both sides of R4's upper and lower extremities and is dependent on staff for her mobility needs of rolling left and right. Section M (Skin Conditions) documents that R4 is at risk for development of pressure injuries. R4's Pressure Injury CAA (Care Area Assessment) documents under the Care Plan Considerations section: Resident was admitted from hospital with dx (diagnosis): acute resp failure with hypoxia . She is at risk for skin impairment, preventive measures in place such as pressure reducing mattress and w/c cushion, weekly skin checks and prn (as needed). R4's CNA (Certified Nursing Assistant) Kardex dated 2/17/26 documents: Bed mobility - I require 2 staff members to reposition and turn in bed. Reposition every 2 hours as tolerated. I am totally dependent. I require bilateral heel boots to offload pressure to heels.R4's care plan documents: I have potential/actual impairment to skin integrity r/t (related to) bedbound, trach and PEG (Percutaneous Endoscopic Gastrostomy) tube placement.Approaches: I have an air mattress to assist with wound healing/prevention. Please make sure it is set to my weight for maximum benefits - initiated 1/16/25.I require bilateral heel boots to off load pressure to heels - created on 7/25/25, revised 2/13/26.R4 has a history of pressure injuries and is followed by [NAME] wound physician.R4's [NAME] wound physician notes dated 1/23/26 documents: Unstageable DTI of the right, lateral ankle undetermined thickness 0.6 x 0.5 x not measurable cm (centimeters). Unstageable DTI with intact skin. Purple/maroon discoloration. Duration >1 day. Approach: Close monitoring, off-loading.R4's [NAME] wound physician notes dated 1/30/26 documents: Stage 3 pressure wound of the left buttock full thickness 1.5 x 0.7 x 0.1 cm. Granulation tissue 100%. Light serous exudate. Duration >1 day; Unstageable DTI to right lateral ankle, 0.6 x 0.4 x Not Measurable cm. Intact skin, purple/maroon discoloration. On 2/13/26, [NAME] wound physician notes documented: Unstageable DTI of the right lateral ankle undetermined thickness 0.6 x 0.3 x not measurable cm. Intact with purple/maroon discoloration. Stage 3 pressure injury wound of the left buttock full thickness 0.9 x 0.7 x 0.1 cm. Granulation tissue 100%. Light sero-sanguinous exudate.Surveyor noted that the facility did not document a root cause for the development of R4's stage 3 left buttock pressure injury and noted that R4's care plan was not updated to include any interventions to address the potential root cause for the development of R4's left buttock pressure injury. On 2/16/26 at 9:20 AM, Surveyor observed R4 lying in bed on her back. Surveyor observed R4 was not wearing pressure relieving boots and her feet were not offloaded. R4's feet were resting on a pillow with each foot lying on the lateral side on the pillow.On 2/16/26 at 12:00 PM, Surveyor observed R4 to be in the same position, on her back. R4 was not wearing pressure relieving boots and her feet were not offloaded. Each foot was resting on the lateral side directly on the pillow. On 2/17/26 at 7:19 AM, Surveyor observed R4 laying in bed, not wearing pressure relieving boots and R4's resting directly on the mattress and not offloaded. On 2/17/26 at 10:46 AM, Surveyor observed R4 laying in bed, not wearing pressure relieving boots and R4's resting directly on the mattress and not offloaded. On 2/17/26 at 11:00 AM, Surveyor observed R4 laying in bed, not wearing pressure relieving boots and R4's resting directly on the mattress and not offloaded. On 2/18/26 at 9:01 AM, Surveyor observed a pillow under R4's legs to float her heels. Surveyor noted the pillow was flattened, and although her heels were not resting on the mattress, both feet were resting on each lateral side on the pillow. R4 was not wearing pressure relieving boots.On 12/18/26 at 11:56 AM, Surveyor informed Nursing Home Administrator (NHA)-A and DON (Director of Nursing)-B about the above findings. Surveyor asked DON-B how the facility addressed the potential root cause of the development of R4's facility acquired stage 3 pressure injury. DON-B stated that the facility believes the root cause of R4's facility acquired stage 3 pressure injury was due to R4's incontinence product, as the edge of the incontinence product lies directly over the pressure injury. Surveyor informed DON-B that R4 is fully dependent on staff for repositioning and that R4's care plan did not include any interventions to address the development of R4's facility acquired stage 3 pressure injury. DON-B informed Surveyor that she would review and address it. DON-B informed Surveyor that DON-B would also review the heel boots that R4 is supposed to be wearing, as R4's family had brought in some heel boots for R4 to wear.No additional information was provided as to why R4 developed a DTI and a stage 3 pressure injury and why R4's interventions to prevent the development of pressure injuries were observed to not be in place.

Based on interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident potentially affecting 86 of 86 residents in the Facility. * The Facility had documented low staffing ratios in the month of October. Findings include: Due to a complaint received alleging October 2025 the facility was constantly understaffed Surveyor reviewed the PBJ (Payroll Based Journal) report for July 1 to September 30, 2025, and the facility triggered for one star staffing and excessively low weekend staffing. Surveyor reviewed PBJ report for October 1 to December 31, 2025, provided by the facility, and the facility again triggered for low weekend staffing. On 02/17/26, at 8:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H and was told staffing is no different here than anywhere else, they are short because of the call ins. When asked about doing transfers with the mechanical lift CNA-H stated they have to get someone to help, and the nurses will step in. On 02/17/26, at 8:29 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G and was told staffing is ok, it is the call ins that make shifts short. When asked if residents suffer when short CNA-G replied of course. On 02/17/26, at 8:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated that staffing is pretty good except for the call ins. If a CNA calls in the nurses have to help. On 02/17/26, at 8:42 AM, Surveyor interviewed Certified Medication Assistant (CMA)-F who stated that call ins are a problem, staff have to work as a team and help each other. They get behind but in the end get the work done. When asked about the impact on residents CMA-F responded they try their best to not affect residents. On 2/17/26, at 9:05 AM, Surveyor interviewed Scheduler-K who stated that on first shift they schedule 8 CNA, second shift 8 CNA, and third shift 5 CNA. For first shift there are 4 nurses/medication technicians, second shift is 5 and third shift is 2. Surveyor reviewed the October schedules and Daily Staffing postings. Of the 31 days in October, 21 days did not meet the number of CNA the facility deems appropriate for a shift. All four weekends were less than the number as well. Nurses and Certified Medication Assistants were short of the facility deemed numbers 6 times. Four of these were weekends the CNA numbers were also short. Surveyor noted that if a CNA relies on nurses for help and the nurses are short as well, this impacts resident care. On 2/17/26, at 9:10 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that in October and November there were staffing challenges. They are now in a better spot as they have brought on four nurses and six CNA, it is the most staff they have had in 12-15 months. When asked how they met the resident needs in October and November NHA-A replied that nurse managers were here every weekend providing cares. On 2/18/26, at 10:48 AM, Surveyor informed Director of Nursing (DON)-B of concern related to low staffing, especially October per the review. The facility did not provide any additional information as to low staffing concerns. On 2/17/26, at 8:10 AM, Surveyor observed a call light activated (on) outside of R9's room. Surveyor noted the call light remained on for a period of 16 minutes until a staff member entered R9's room at 8:26 AM. Surveyor observed multiple staff members pass by R9's room [ROOM NUMBER] times, while R9's call light was activated. The light was then turned off at 8:26 AM, and the staff member left the room a short time later. On 2/17/26, at 9:54 AM, Surveyor observed a call light activated outside of R8's room. Surveyor observed Certified Nursing Assistant (CNA)-D go into R8's room and overheard R8 stating R8 needed to go to the bathroom. CNA-D told R8 to wait, stating she would be right back and turned off R8's call light. Surveyor observed R8 turn the call light on at 10:04 AM. Surveyor observed a staff member walk by R8's room and the staff member told R8 they would be right in. Surveyor observed a different staff member enter R8's room at 10:09 AM, the light was then turned off, and the staff member left the room a short time later. On 2/18/26, at 10:02 AM, Surveyor notified Nursing Home Administrator (NHA)-A of concern mentioned above. NHA-A acknowledged these concerns. No additional information was provided as to why there was a delay in the call lights being answered by staff and why there was sufficient staff observe to answer call lights in a timely manner.

Based on record review and interview, the facility did not establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights, ensuring that all written grievance decisions include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, and any corrective action taken or to be taken by the facility as a result of the grievance for 1 of 2 (R4) residents reviewed for grievances.R4's family filed a grievance on 8/14/25. There was no evidence of follow-up or resolution of the grievance with R4's family.Findings include:R4 admitted to the facility on [DATE] and has diagnoses that include anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder and anxiety.R4's Brief Interview for Mental Status (BIMS) documented a staff assessed score of 99. Resident comatose.The facility policy titled Resident and Family Grievances dated last approved 2/11/26 documents (in part):It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. 1. The administrator has been designated as the Grievance Official with the social services representative as backup designee.2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; and issuing written grievance decisions to the resident.4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay.10. Procedure:b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form.i. Take any immediate action needed to prevent further potential violations of any resident right.d. The Grievance official will take steps to resolve the grievance and record information about the grievance and those actions, on the grievance form.ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the form to the grievance official. Prompt effort include the acknowledgement of the complaint/grievance and actively working toward a resolution of that complaint/grievance.g. In accordance with the resident's right to obtain a written decision, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: The date received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance and the date the written decision was issued.While reviewing the facility grievance log, Surveyor identified a grievance filed by R4's family (Guardian) on 8/14/25. The facility provided Surveyor a copy of the grievance which documented:Date: 8/14/25 - Family voiced concerns re (regarding): Cares, not being turned as frequently as she should be, feces on sheet and resident not being checked on as often as they would like and they think the trach is infected. Follow up/Resolution: SW (Social Worker) and DON (Director of Nursing) met with (Guardian). At this time, they wanted resident to be checked at Froedtert hospital to be sure her trach was not infected. Resolution: Was the concern/grievance resolved? X next to Yes, describe. Family satisfied with plan. Signed by DON on 8/14/25.On 2/16/26 at 3:00 PM, Surveyor asked DON-B if she had any information as to what the follow up or resolution of the grievance filed on 8/14/25 was. DON-B stated, That was the old DON, I don't know. I can't find any other information or documentation related to the grievance.On 2/17/26 at 9:30 AM, Surveyor spoke with R4's Guardian who reported she still has the same concerns: R4 is not turned and repositioned, does not get checked on often, is never wearing her boots and is getting bed sores. R4's Guardian reported there was no follow up or plan after the grievance was filed in August, No-one addressed or changed anything.On 2/18/26 Nursing Home Administrator (NHA)-A and DON-B were notified of concern regarding grievances. No additional information was provided.

Based on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 (R1) of 2 residents reviewed for quality of care. R1 pulled out their catheter prior to a fall on 11/30/25. The catheter was reinserted and hematuria was noted. R1 was on an antiplatelet and an anticoagulant. There is lack of documentation that R1 was being monitored for bleeding due to being on blood thinning medications. R1 was sent to the hospital later for hematuria.Findings include:R1 was admitted to the facility on [DATE] with pertinent diagnoses that include Alzheimer's disease (a progressive, neurodegenerative brain disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), delirium (an acute, fluctuating disturbance in attention, awareness, and cognition that develops rapidly (hours to days), often caused by underlying medical conditions, infections, or medication side effects), and chronic kidney disease stage 3B (kidneys are moderately damaged, filtering at 30-59% capacity).R1's Admission/Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 11/30/25, documents no Brief Interview for Mental Status (BIMS) being completed. R1 is coded as rarely/never understood and rarely/never understands others. The MDS documents that R1 was assessed to have behaviors of verbal behavioral symptoms directed toward others that occurred 1-3 days of the look back period. R1 was assessed to have other behavioral symptoms not directed towards others 1-3 days of the look back period. Per the MDS, R1 was taking both an anticoagulant and an antiplatelet.R1's physician order dated 11/27/25 documents Clopidogrel Bisulfate Oral Tablet 75 MG. Give 1 tablet by mouth in the morning for antiplatelet.R1's physician order dated 11/26/25 documents Warfarin Sodium Oral Tablet 5 MG. Give 1 tablet by mouth in the evening for anticoagulant.Surveyor noted there was no baseline care plan created for monitoring R1's use of an anticoagulant or antiplatelet. R1 had hematuria and was transferred to the hospital.Surveyor reviewed the Fall Protocol Checklist dated 11/30/25, with time of fall 23:30 (11:30pm). It is documented that R1 got up from bed, pulled out catheter, walk out the door and lost his balance and fell on his buttock outside his room door. R1's progress note, written by Registered Nurse (RN)-J dated 12/1/2025, at 12:44am, documents: 0030 (12:30am) Resident got up from bed, pulled off indwelling catheter, got out the room fell outside the door, staff found resident on the floor outside resident door, writer found resident with staff standing already with aggression towards staff. Writer able to calm down resident and assisted res. (resident) to bathroom per his request. Noted abrasion to left forearm and left lower back during head to toe assessment. Bleeding also noted from penis probably from trauma of dislodgement of catheter. Writer able to replaced catheter in 1 attempt, initial drainage of blood clots but thinning out after clots. C/o (complaints of) bladder pain, prn tylenol given.Surveyor noted a discrepancy regarding time of the fall. The Fall Protocol Checklist documents 11:30pm (11/30/25) and the progress note documents 12:30am (12/1/25).R1's medication administration note, dated 12/1/2025, at 8:43am, documents: Document Residents pain level. Resident is in pain from dislodged foley catheter. Resident has hematuria in foley line and bag. Foley is still in place but appears to be out partially. Patient is complaining of discomfort at his penis and has dried blood around site. [Name] Ambulance called for transport to hospital for further evaluation.R1's progress note, dated 12/1/2025, at 10:00am, documents: Resident was sent out to [hospital name] for complaint of hematuria. Resident has an indwelling foley catheter inserted. Resident was found with dried blood around his penis, groin, and right leg. Foley securement device had foley tubing secured but the point that is normally secured was further down, appears resident pulled on foley and dislodged catheter. Spoke with Unit Manager (UM)-I and reported he had hematuria noted in foley yesterday (11/30) and was being monitored. Resident had blood throughout foley tubing and into foley bag. Spoke with NP (Nurse Practitioner) on the phone and was instructed to send resident out to hospital for further evaluation. [Name] Ambulance arrived around 09:45am. On 2/17/26, at 11:30am, Surveyor interviewed Registered Nurse (RN)-J regarding R1 pulling out catheter. Surveyor asked if R1 was having any bleeding around the catheter or in the urine before pulling out the catheter prior to R1's fall. Per RN-J there was no bleeding prior to R1 pulling out catheter. R1 did continue with hematuria after the catheter was reinserted.On 2/17/26, at 1:00pm, Surveyor interviewed Director of Nursing (DON)-B and asked how R1 was being monitored due to being on blood thinners. DON-B stated DON-B would review R1's medical record and let Surveyor know. On 2/17/26, at 2:15pm, DON-B stated that the facility has 14 days to set up a care plan. Surveyor asked due to the kind of medications R1 was on if there would be an expectation for monitoring and DON-B replied yes, they would expect monitoring. DON-B will provide the lab orders for PT/INR related to Warfarin. And would expect staff to monitor for bleeding and bruising due to the medications. On 2/18/26, at 8:55am, Surveyor interviewed Unit Manager (UM)-I and UM-I stated remembering the blood in R1's catheter. R1 was being monitored on the 24 hour board, UM-I will look for documentation and get back to Surveyor.Surveyor noted no documentation was provided by UM-I. Surveyor noted R1 was a new admit and would have been being monitored on 24 hour board for this.On 2/18/26, at 9:03am, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A regarding the concern that R1 had a change of condition and there is a lack of documentation regarding assessments and monitoring between time of R1's fall and when R1 went out to the hospital.On 2/18/26, at 10:48am, Surveyor interviewed DON-B after the hospital records were provided and Surveyor stated there remains the concern that for approximately eight hours that R1 was in the facility after pulling out catheter and there is limited documentation of assessment and monitoring of the hematuria and R1 was then sent to the hospital for hematuria. No additional information was provided regarding the lack of assessments and monitoring.

Based on interview and record review, the facility did not ensure 1 (R3) of 2 residents reviewed for Activities of Daily Living (ADL) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene.R3 is scheduled for showers twice a week and did not receive showers on 7/26/25, 8/9/25, 8/13/25, 8/23/25, 8/27/25, 8/30/25, 9/6/25, 9/10/25, 9/17/25, 9/20/25, 10/4/25, 10/8/25, 10/11/25, and 10/15/25.Findings include:The facility's policy titled Activities of Daily Living (ADLs), Supporting, dated 3/6/22, last approved 5/22/25, documents the following:Residents will be provided with care, treatment and services as appropriate to maintain or improve their own ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).R3 was admitted to the facility on [DATE]. R3's diagnoses include dysphagia (a language disorder caused by brain damage), cerebral infarction (death of brain tissue), Chronic Obstructive Pulmonary Disease (COPD) (long term lung disease), Congestive Heart Failure (CHF) (weakened heart muscle), and muscle weakness. R3's Quarterly Minimum Data Set (MDS) completed on 1/24/26, documents that R3 is independent with eating and rolling left to right. The MDS documents: R3 requires supervision with toileting hygiene, showering, bathing, dressing, transfers, and walking 10 feet using a walker; R3 is always continent of bowel and bladder; R3 was documented as having a Brief Interview for Mental Status (BIMS) score of 15, indicating that R3 is cognitively intact.R3's Annual MDS completed on 10/24/25, documents the following Care Area Assessment (CAA):Functional Abilities CAA: R3 requires supervision or touching assistance with transfers. R3 is continent of bowel and bladder. R3 is able to ambulate with a walker with supervision.R3's care plan, dated 10/18/24, documents:R3 has an ADL self-care performance deficit related to fatigue and impaired balance (created on 10/18/24, revised on 10/16/25).Interventions include:Transfer: stand and pivot transfer with two wheeled walker, contact guard assistance and one person (created on 10/18/24, revised on 2/2/26).Hygiene/Dressing: R3 requires upper body set up and lower body moderate assistance (created on 10/18/24, revised on 2/2/26).Bathing: R3 requires supervision or touching assistance by one staff to provide a bath as necessary (created on 10/18/24, revised on 1/28/26).On 2/16/26, at 9:29 AM, Surveyor interviewed R3 who stated R3 does not get a shower daily. R3 was unable to recall when R3's last shower was. On 2/17/26, at 9:52 AM, Surveyor observed R3 sitting in a recliner dressed in personal clothes. Surveyor observed R3's personal clothes to be soiled with food stains down the front of R3's shirt and pants.Surveyor reviewed R3's Electronic Medical Record (EMR) which documents R3 is to receive a shower twice weekly. Surveyor notes R3 did not receive showers on 7/26/25, 8/9/25, 8/13/25, 8/23/25, 8/27/25, 8/30/25, 9/6/25, 9/10/25, 9/17/25, 9/20/25, 10/4/25, 10/8/25, 10/11/25, and 10/15/25.On 2/18/26, at 8:20 AM, Surveyor interviewed Director of Nursing (DON)-B who stated the Certified Nursing Assistant (CNA) is to complete a shower sheet when a resident receives a shower. DON-B stated the CNA is to document any refusals on the shower sheet. Surveyor asked where the shower sheets are kept, and DON-B stated the facility keeps the handwritten shower sheets for approximately one month. Surveyor requested shower sheets for R3.On 2/18/26, at 10:49 AM, DON-B notified Surveyor the facility does not have shower sheets for R3. Surveyor notified DON-B of concerns with R3 not receiving a documented shower for the dates listed above. DON-B acknowledged these concerns. No additional information was provided.

Based on observation, record review and interviews, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 9 (R5) residents reviewed. R5 has been sent to the hospital repeatedly for behavior of pulling out her own tracheostomy tube. A care plan with interventions for this behavior was not developed or implemented. In addition, tracheostomy care and treatment are not included in the Facility Assessment.Findings include:R5 admitted to the facility on [DATE] and has diagnoses that include chronic respiratory failure, tracheostomy (trach) status, laryngeal hypoplasia, epilepsy, anxiety disorder, obesity, functional quadriplegia, dysphagia and type 2 diabetes mellitus.The facility policy titled Care Plan Revisions Upon Status Change dated 5/22/25 documents (in part):The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.The MDS (Minimum Data Set) Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions.R5's care plan documents: The resident has a tracheostomy r/t (related to) impaired breathing mechanics she is at risk for sob (shortness of breath) - revised 11/24/25. Approaches include: Ensure that trach ties are secured at all times - initiated 10/27/25. Tube Out Procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If unable to breathe spontaneously, elevate HOB (head of bed) 45 degrees and stay with resident. Obtain medical help immediately - initiated 10/27/25.The resident uses anti-anxiety medications r/t anxiety disorder. I pull out my trach often - initiated 10/27/25. Approaches: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/record occurrence of for target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression toward staff/others, etc. and document per facility protocol.R4's History and Physical (H&P) dated 6/10/25 documents (in part):Past medical history significant for chronic encephalopathy, recurrent UTI (urinary tract infection), sepsis, chronic respiratory failure status post chronic indwelling tracheostomy, dysphagia, history of posterior glottic stenosis status post lysis and Decadron injection. Patient has been weaned off the ventilator but due to super morbid obesity chronic respiratory failure sleep apnea the patient requires indwelling tracheostomy but remains in chronic encephalopathic state with delirium keeps pulling out tubes and tracheostomy at the nursing home.Surveyor noted that despite R5's H&P documenting repeated episodes of pulling out her tracheostomy tube, a care plan and interventions for this behavior were not created or implemented.Review of R5's progress notes documented that she has pulled out her trach tube at least 28 times since admission. Facility staff have been able to reinsert the tube at times, however when unable, 911 is called and R5 is sent to the emergency room (ER). Surveyor noted 911 has been called at least 18 times since admission due to R5's removal of her tracheostomy tube.On 2/16/26 at 2:25 PM, Surveyor spoke with Director of Nursing (DON)-B. DON-B reported R5 pulls out her trach tube daily, sometimes multiple times a day. Surveyor asked DON-B what interventions (besides Ativan), the facility has implemented for this behavior. DON-B reported her Ativan has been increased and the hospital uses wrist restraints, which can't be used in the facility. DON-B reported she thought the facility asked her son for a psych consultation, but he refused.DON-B was unable to provide evidence that a psychiatric consult was ordered and/or refused by R5's son. Surveyor advised DON-B of concern that R5 does not have a care plan or interventions for her repeated behavior of removing the trach tube. DON-B reported R5's room is close to the nurses' station, which allows for more frequent checks. Surveyor found no evidence that the facility implemented any interventions, aside from increasing the Ativan, for R5's repeated behavior of removing her trach tube. No additional information was provided.

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, the facility did not report 1 of 1 allegations of misappropriation to the State Survey Agency during the required timeframe.R1's spouse reported to the facility on [DATE] that R1's wedding ring was missing. The wife contacted the police department 12/3/25. This was delayed in being reported to the State Survey Agency until 12/9/25.Findings include:The Facility Policy titled Abuse, Neglect, and Exploitation, effective 5/22/25, documents (in part):IV. Identification of Abuse, Neglect and Exploitation.B. Possible indicators of abuse include, but are not limited to4. Resident reports of theft of property, or missing property.R1 was admitted to the facility on [DATE] with pertinent diagnoses that include Alzheimer's disease (a progressive, neurodegenerative brain disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), delirium (an acute, fluctuating disturbance in attention, awareness, and cognition that develops rapidly (hours to days), often caused by underlying medical conditions, infections, or medication side effects), and chronic kidney disease stage 3B (kidneys are moderately damaged, filtering at 30-59% capacity).R1's Admission/Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 11/30/25, documents no Brief Interview for Mental Status (BIMS) being completed. R1 is coded as rarely/never understood and rarely/never understands others. The MDS documents that R1 was assessed to have behaviors of verbal behavioral symptoms directed toward others that occurred 1-3 days of the look back period. R1 was assessed to have other behavioral symptoms not directed towards others 1-3 days of the look back period.R1's wife called the facility on 12/2/25 and reported that R1's wedding ring was missing. The wedding ring was not with R1's belongings. Facility staff who took the call completed a Resident/Family Concern/Grievance Report form.R1's wife visited the South Milwaukee Police Department on 12/3/25 and reported that she contacted facility and spoke with admission Director who stated they did not have the ring. She believes she last saw the ring on R1's finger on Sunday, November 30th. She described the ring as a white gold men's wedding ring with diamonds.On 2/17/26, at 1:00pm, Surveyor interviewed Nursing Home Administrator (NHA)-A about R1's wife filing a grievance on 12/2/25 that R1's wedding ring was missing. R1's wife then reported this to the police on 12/3/25. Surveyor stated that the facility was informed twice that R1's wedding ring was missing and asked why R1's missing ring was not reported to the State Survey Agency. NHA-A replied that R1's wife never indicated it was stolen, just misplaced.On 2/17/26, at 3:07pm, Surveyor informed NHA-A of the concern related to R1's wife reporting the wedding ring missing and this qualifies as misappropriation and should have been reported on 12/2/25 to the State Survey Agency.On 2/18/26, at 10:48am, Surveyor spoke with Director of Nursing (DON)-B and stated that there is a concern that R1's missing wedding ring was not reported to the State Survey Agency in a timely manner.No additional information was provided regarding R1's allegation of misappropriation of the missing wedding ring's delay in being reported to the State Survey Agency.

Based on observation, interview and record review the facility did not ensure that 1 (R7) of 7 residents reviewed was treated with respect and dignity.On 2/17/26, at 9:58 AM, Surveyor observed R7 being wheeled down the hallway in a shower chair to the shower room wearing a hospital gown with R7's left hip and side of buttocks exposed.Findings include:The facility's policy titled, Dignity, not dated, documents the following:Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times.Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.R7 was admitted to the facility on [DATE], with diagnoses that include Congestive Heart Failure (weakened heart muscle), lymphedema (chronic buildup of fluid in the arms or legs causing swelling), morbid obesity, Peripheral Vascular Disease (PVD) (circulation disorder), and history of falls. R7's Quarterly Minimum Data Set (MDS) dated [DATE], documents R7 requires partial/moderate assistance with showering and supervision from staff with tub/shower transfers. R7 requires set up assistance with ambulating 10 feet. R7 was documented as having a Brief Interview of Mental Status (BIMS) score of 14, indicating R7 is cognitively intact.R7's care plan dated 6/4/25 documents:R7 has an Activities of Daily Living (ADL) self-care performance deficit related to pain, increased weakness, decreased mobility, Obstructive Sleep Apnea (OSA), and lack of motivation (dated 6/6/25, last revised 10/16/25).Interventions include:Ambulation: 5 feet with 4 wheeled walker and minimal assist with one person (created on 6/6/25, last revised 10/16/25).Transfer: Assist R7 with one person and a 4 wheeled walker. R7 requires partial to moderate assistance (dated 6/6/25, last revised 10/16/25).Dressing: R7 requires supervision or touching assistance for upper body dressing. R7 requires substantial to maximal assistance by one staff member for lower body dressing (dated 6/6/25, last revised 10/16/25).Bathing: R7 requires partial to moderate assistance on staff to provide a bath as necessary (dated 6/6/25, last revised 10/16/25).Bathing: Provide R7 with a sponge bath when a full bath or shower cannot be tolerated (dated 6/6/25, last revised 10/16/25).On 2/17/26, at 9:58 AM, Surveyor observed Certified Nursing Assistant (CNA)-C wheeling R7 down the South hallway, past the main entrance, and halfway down the North hallway to the shower room. Surveyor observed R7 wearing a hospital gown, sitting in a shower chair with R7's left hip and the side of R7's buttocks exposed.On 2/17/26, at 10:24 AM, Surveyor interviewed R7 who states she was not happy that R7's skin was exposed while being wheeled down the North and South hallway, past the main entrance to get a shower. R7 stated that R7 did not know skin was exposed and R7 states R7 is not an exhibitionist.On 2/17/26, at 3:14 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of dignity concerns listed above. NHA-A and DON-B acknowledged concerns. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that residents remained free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 2 (R1 and R2) of 3 residents reviewed for accidents. *R1 rolled out of bed while receiving cares on 10/15/2025 that resulted in a closed displaced intertrochanteric fracture of the right femur. *R2 did not have reminder signs placed in R2's room or trip hazards removed from R2's room per care plan, and did not have an accurate fall risk assessment completed on 10/9/2025. Findings include: The facility policy titled Falls and Fall Risk, Managing last approved 5/2025 documents: Based of previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors:1. Environmental factors that contribute to the risk of falls include: .d. Obstacles in the foot path.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 factors of falls for each resident at risk or with a history of falls.7. In conjunction with the attending physician, staff will identify and implement relevant interventions . to try to minimize serious consequences of falling.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. 1.) R1 was admitted to the facility on [DATE] and has diagnoses that include cerebral palsy, hemiplegia affecting the left nondominant side, neuralgia, major depressive disorder, and mild cognitive impairment. R1's annual minimum data set (MDS) dated [DATE] indicated R1 has intact cognition with e Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R1 having an impairment to the left upper extremity and impairments to right and left lower extremities and required total assist of 1 staff member for toileting hygiene, and maximal assistance with 1 staff member for personal hygiene and dressing. The MDS also documented that R1 was transferred using a Hoyer lift with assist of two staff. R1 is incontinent of bowel and bladder and wears a protective brief and is able to make R1's needs known. R1's activities of daily living (ADL) self-care performance deficit related to confusion, hemiplegia, impaired balance, limited mobility, limited rang of motion, left hand contracture, incontinence, . and cerebral palsy care plan last revised on 9/10/2025 documents the following interventions:- Toilet use: [R1] is totally dependent on assist of one for incontinence care. [R1} does not use the toilet, uses a bed pan.- Personal hygiene: [R1] requires total assistance of 1 staff member for all personal hygiene care. On 10/15/2025, at 11:30am, R1's progress notes written by director of nursing (DON)-B documented: While receiving daily ADL cares, certified nursing assistant (CNA)-C attempted to turn (R1). (R1) right contracted leg moved faster than expected and (R1) rolled out of bed and hit R1's right hip and shoulder on the floor. 911 call initiated and R1 sent out to hospital. On 10/15/2025, at 16:13 (4:13pm), in the progress notes, DON-B documented call made to hospital for status update on R1. Hospital informed DON-B R1 has a right femur fracture. On 10/21/2025, at 22:08 (10:08pm), in the progress notes, nursing documented R1 readmitted to facility . Diagnosis: displaced intertrochanteric fracture of the right femur which occurred on 10/15/2025 from fall at facility. On 11/13/2025 Surveyor reviewed the facility self-report that was completed for R1's fall on 10/15/2025 that resulted in a displaced intertrochanteric fracture of the right femur. CNA-C documented while doing cares on R1, R1 rolled to the left side and fell onto the floor. CNA-C denied R1 hitting head on the floor. On 11/13/2025, at 11:20am, Surveyor observed R1 lying in bed watching TV. R1 stated R1 had a fall out of bed couple weeks ago and broke R1's right leg. Surveyor asked R1 what happened. R1 stated staff was changing and getting dressed and was rolled out of the bed. Surveyor asked R1 if R1 helps hold self up when staff is helping change R1. R1 stated that R1 did not help because R1's left hand is contracted and not strong enough to help. Surveyor observed R1's bed in the middle of the wall with the right and left side of the bed open. R1 stated that 1 staff used to help R1, but now 2 staff come in and help R1 during cares. On 11/13/2025, at 11:40am, Surveyor interviewed CNA-D who stated if a resident is assist of one with repositioning or ADL care, staff are taught to always roll a resident towards you and never away. CNA-D stated if a resident needed to be turned away such as with incontinence cares, then staff is to ask another staff member for help, so the resident does not roll and fall onto the floor. On 11/13/2025, at 12:59pm, Surveyor interviewed CNA-C who stated CNA-C was doing cares on R1 on 10/15/2025. CNA-C turned R1 away from CNA-C so CNA-C could perform incontinent cares on R1. CNA-C turned R1 onto R1's left side and R1's right leg continued to go over and R1 rolled out of bed and fell onto the floor. Surveyor asked what skills training staff get when repositioning or performing cares on a resident that is assist of one. CNA-C stated that staff should make sure the resident is in the middle of the bed and to roll the resident towards you, not away from you. Surveyor asked if CNA-C asked other staff to assist with R1's cares. CNA-C did not ask other staff members for assistance because R2 was an assist of 1 staff at that time. CNA-C stated CNA-C was not sure how to perform incontinence care on R1 if R1 was not rolled away from CNA-C. On 11/13/2025, at 2:45 pm, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who stated all staff receive training upon hire, quarterly, and as needed on proper and safe techniques. Surveyor asked what staff is trained to do while doing cares for a resident that is assist of 1 staff member. DON-B stated staff are taught to never roll a resident away from them unless there is another person on the other side or some kind of barrier such as a wall. DON-B stated staff are told to get assistance of another staff member to assist with repositioning or cares if the resident needs to be turned away from the staff member even if they are an assist of 1. Surveyor shared the above findings with NHA-A and DON-B regarding CNA-C not following facility guidance rolling R1 away from CNA-C during cares and as a result R1 rolled out of the bed resulting in a right femur fracture. No additional information was provided. 2.) R2 was admitted to the facility on [DATE] with diagnoses including epilepsy (brain condition that causes recurring seizures), malignant neoplasm of unspecified female breast (breast cancer), chronic pain syndrome, and mild intermittent asthma. R2's Falls Care Area Assessment (CAA) dated 4/7/25 documents . resident has no known recent falls . will monitor resident for safety . using antidepressant and narcotics . is incontinent of bowel and bladder . R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents R2 has a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documents R2 requires supervision for rolling and bed mobility, and R2 is dependent for sit to stand, bed to chair, and toilet transfers. R2's falls care plan with initiation date 10/23/25 and revision date 10/29/25 documents the following interventions: .-Put the following intervention in place: educated resident on importance of waiting for assistance. Placed reminder signs in room.-Remove trip hazards from my room. R2's Fall Risk Evaluation dated 10/9/25 documents a score of 3.0. Surveyor noted under section AS_3. Medications question 1 documents medications: respond based on the following types of medications: anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics and question 2 for medication documents no response. R2's Medication Administration Record (MAR) documents the following medications were administered to R2 between 10/1/25 and 10/9/25: -Oxycodone, www.drugs.com documents this medication's drug class as a narcotic.-Ativan, www.drugs.com documents this medication's drug class as a benzodiazepine. -Lacosamide, www.drugs.com documents this medication's drug class as an anticonvulsant/antiseizure.-Lasix, www.drugs.com documents this medication's drug class as a diuretic. -Levetiracetam, www.drugs.com documents this medication's drug class as an anticonvulsant/antiseizure.-Diphenhydramine, www.drugs.com documents this medication's drug class as an antihistamine.-Hydroxyzine, www.drugs.com documents this medication's drug class as an antihistamine.Surveyor noted question 2 for medication should have been marked as c. Takes 3-4 of these medications (or medication classes) currently and/or within last 7 days. R2's Fall Risk Evaluation dated 10/23/25 documents a score of 14.0, indicating R2 is at risk for falls. A nurse's progress note in R2's electronic health record (EHR) dated 10/23/25 documents on 10-23-25 . writer heard loud banging noise coming from resident's room. Writer responded and observed resident sitting upright on buttocks on the floor in front of . w/c (wheelchair) and next to commode. attempting to self transfer/self toilet and fell to the floor. On 11/13/25, at 11:03 AM, Surveyor interviewed R2 in R2's room. R2 stated R2 had a fall about 2 weeks ago when trying to get onto the commode from the wheelchair. Surveyor observed R2 sitting on the edge of the bed with R2's feet resting on a folded-up sheet on the floor. R2 stated R2's family brought in a door mat and placed the folded-up sheet on top of it to prevent R2 from falling. Surveyor did not observe any signage posted in R2's room reminding R2 to wait for assistance. R2 stated no signs were ever put up in R2's room. On 11/13/25, at 11:33 AM, Surveyor interviewed certified nursing assistant (CNA)-D regarding trip hazards. CNA-D stated online training the facility provides touches on trip hazards. Surveyor asked if the folded-up sheet in R2's room would be considered a trip hazard, and CNA-D replied CNA-D would consider that a trip hazard, but R2 specifically requested it to be there because R2's legs are currently leaking and R2 does not want the floor to get wet. Surveyor asked what the process is if a resident makes a request that is not considered safe, and CNA-D replied CNA-D was not sure, but the nurse on duty would know the process. On 11/13/25, at 11:50 AM, Surveyor interviewed Unit Manager-F regarding the process if a resident makes a request that is not considered safe. Unit Manager-F stated staff would try to have a conversation with the resident and educate them on safe practices. Unit Manager-F stated a risk versus benefits could be completed, and the resident's care plan could be updated to include the request. Surveyor asked Unit Manager-F if a folded-up sheet on the floor would be considered a trip hazard, and Unit Manager-F replied yes, that is a trip hazard. Unit Manager-F was not aware the folded-up sheet was in R2's room and stated Unit Manager-F would educate R2 and remove the sheet. Surveyor reviewed R2's EHR and did not locate any risk versus benefits or care plan revisions regarding the folded-up sheet in R2's room. On 11/13/25, at 2:45 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A regarding fall risk evaluations. DON-B stated a fall risk evaluation would be completed when triggered by the MDS coordinator, after a fall, or if there is a change in condition. DON-B stated the fall risk evaluation is typically completed by the nurse on the floor or the MDS coordinator. Surveyor shared concern with DON-B and NHA-A that Surveyor observed R2's feet resting on a folded-up blanket and that Surveyor did not observe any signage in R2's room reminding R2 to wait for assistance per R2's care plan. DON-B agreed that the folded-up blanket would be a trip hazard, and staff has talked with R2's family in the past regarding trip hazards, but DON-B would follow up. On 11/13/25, at 3:08 PM, Surveyor interviewed MDS coordinator-G via phone call. MDS coordinator-G stated fall risk evaluations are completed by MDS coordinator-G only on a quarterly basis when it gets triggered in the EHR that a quarterly MDS assessment is due. MDS coordinator-G confirmed that MDS coordinator-G completed the fall risk evaluation for R2 dated 10/9/25. Surveyor asked why there was no response for question 2 under the medications section on this assessment. MDS coordinator-G responded MDS coordinator-G must have accidentally clicked to the next page, and the fall risk evaluation was not completed correctly. MDS coordinator-G stated question 2 under the medications section should have been marked as c. Takes 3-4 of these medications (or medication classes) currently and/or within last 7 days which would have resulted in a higher fall risk score. On 11/13/25, at 3:34 PM, Surveyor shared concern with NHA-A and DON-B that the fall risk evaluation for R2 dated 10/9/25 was not completed accurately. No additional information was provided as to why R2's fall interventions were not in place to prevent future falls or why an accurate fall risk evaluation was not completed for R2.

Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed for elopement (R16.)Facility elopement assessment upon R16's admission indicated R16 was an elopement risk. The facility did not pick up on this conclusion and did not put measures in place to prevent elopement. On 06/09/2025, R16 eloped from the facility, fell on the railroad tracks approximately 0.4 miles from the facility, and was brought to R16's family members house/R16's former home by persons who found R16. The facility was not aware of R16's elopement until R16's family member notified the facility that R16 had eloped to R16's family members house and sustained a fall. R16's family member brought R16 to the Emergency Room, where R16 was diagnosed with abrasions to R16's forehead, right knee, and right hand.The failure to provide adequate supervision to prevent R16 from eloping from the facility created a finding of Immediate Jeopardy that began on 06/09/2025. The Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B) were notified of the immediate jeopardy on 07/15/2025 at 1:35 PM. The immediate jeopardy was removed and corrected on 06/12/2025. The deficiency is being cited as past noncompliance.Findings include:The facility's policy titled Elopements and Wandering Residents, dated 03/21/2025, documents i 3. The Facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering . b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements.R16 was admitted to the facility on [DATE] with diagnoses of Dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and falls.R16's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS documents that R16 requires supervision or touching assistance to walk 10 feet, requires supervision or touching assistance to walk 50 feet with two turns, and requires supervision or touching assistance to walk 10 feet on uneven surface.R16's Activities of Daily Living care plan noted an intervention of AMBULATION: 50 feet with 2 wheeled walker and CGA. (Contact Guard Assist)R16's admission elopement assessment, dated 05/05/2025, documents, Any 3 or more risk factors indicate the resident is at risk for elopement. Surveyor noted the following three areas were marked for R16: Does the resident ambulate independently, with or without the use of an assistive device? (i.e. walker, cane or wheelchair). 3. Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, Intellectual/Developmental Disability, Delusions, Hallucinations, Anxiety disorder, depression, bipolar, and/or Schizophrenia?. 2. Cognitively impaired with poor decision-making skills (i.e. disorientation, cognitive deficits, disorganized thinking? Surveyor noted the acknowledgment section documents R16 is not an elopement risk but was checked for 3 risk factors.Surveyor reviewed the Facility Reported Incident (FRI), dated 06/09/2025, which documents R16 was sitting outside the facility enjoying the sun and decided R16 wanted to visit R16's daughter's house which is 0.7 miles away from the facility. The facility's self-report documents that R16 was found 0.4 miles away from the facility by a passerby on the sidewalk after falling on the railroad tracks. R16's family member notified the facility that R16 was with the family member and R16 was ok. R16 was taken to the emergency room by R16's family member with no concerns found from the fall.Surveyor noted that on 06/09/2025, the official temperature was 66 degrees Fahrenheit around 2 PM when R16 eloped from the facility. Surveyor noted that the speed limit in front of the building is 30 miles per hour (mph) and changes to 25 mph where R16 was found.On 07/14/2025, at 11:38 AM, Surveyor interviewed NHA-A regarding R16's elopement. NHA-A indicated that marking 3 sections on the elopement assessment would indicate an elopement risk. NHA-A indicated that R16 had never actually eloped and would not be considered an elopement risk. NHA-A explained that R16 just wanted to go to R16's daughter's house but while R16 was walking across the railroad tracks, NHA-A believes R16's walker got stuck in the ruts in the railroad track and fell. NHA-A was unsure of how long R16 was gone from the facility and said would get back to Surveyor with that information. NHA-A indicated the facility has revised the elopement assessment since R16's elopement, reeducated staff on signing residents in and out, asking nursing staff if unsure of a resident's status, and residents who require supervision going outside.On 07/14/2025, at 1:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding R16's elopement. ADON-C indicated that based on R16's admission elopement assessment, R16 should have been considered an elopement risk. ADON-C informed Surveyor that the Nurse Practitioner (NP) should have been notified of the elopement risk and that further assessments would have been needed and checks on R16 to ensure safety. ADON-C explained that R16's family member encouraged R16 to be able to go outside, but ADON-C indicated R16 would go outside to the activity patio not to the front of the building with no supervision.On 07/14/2025, at 1:56 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated that based on R16's admission elopement assessment, R16 should have been an elopement risk, and a Wanderguard should have been implemented and discussed with R16's Power of Attorney (POA). DON-B indicated that DON-B and ADON-C are responsible for reviewing the elopement assessments and expect staff to notify DON-B or ADON-C of any residents at risk for elopement.On 07/14/2025, at 3:27 PM, Surveyor interviewed Receptionist-E. Receptionist-E informed Surveyor that on the day R16 eloped from the facility, Receptionist-E was transitioning shifts with Receptionist-F. R16 asked to go wait outside for R16's family member to take R16 for an appointment. Receptionist-E informed Surveyor that transition of shifts occurred around 2PM, and both Receptionists were present. Receptionist-E looked through the wander list and did not see R16 on the list. Receptionist-E had to leave for an appointment and indicated that Receptionist-F took over from there.On 07/14/2025, at 3:41 PM, Surveyor interviewed Receptionist-F. Receptionist-F indicated that R16 eloped during the shift's transition period, around 2PM. R16 came through the secured double doors to the reception area, without setting off the door alarm and asked to go outside to wait for R16's family member to pick R16 up for an appointment. Receptionist-F indicated that R16 was not on the wander list and R16 was allowed to go wait outside. About 30 minutes later, Receptionist-F received a phone call from R16's family member, indicating R16 was with R16's family member. They had not been aware R16 was missing until the phone call from R16's family member. R16's family member informed Receptionist-F that R16 was going to be taken to the emergency room by R16's family member for evaluation of an unwitnessed fall. Receptionist-F indicated that training and reeducation was provided by the facility on how reception is to inquire with nurses prior to allowing residents outside.R16's Hospital After Visit Summary (AVS), dated 06/09/2025 documents diagnoses that include: abrasions (a superficial injury to the skin that results from rubbing or scraping against a rough surface) to R16's forehead, right knee, and right hand.R16 was readmitted back into the facility on [DATE].Surveyor noted that the only path of travel that R16 could have taken using the sidewalk would be to travel North, then turn right (heading East), toward the railroad tracks. Surveyor noted there is only one sidewalk on the avenue where the train tracks are located. After reviewing the path that R16 took to her relative's house, Surveyor noted that R16 had to cross a two-lane road, at an uncontrolled intersection, to walk on a sidewalk. Otherwise, R16 would have had to walk in the street towards the railroad tracks.The failure to provide adequate supervision to prevent R16 from eloping from the facility created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy that began on 06/09/2025. The Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B) were notified of the immediate jeopardy on 07/15/2025 at 1:35 PM. The immediate jeopardy was removed and corrected on 06/12/2025 when the facility completed the following:* Residents that do not have an activated power of attorney will be signed out of the facility in order to track residents going in and out of the facility.* Residents that have an activated power of attorney are only to be outside of the facility, with staff supervision, or under the supervision of their power of attorney.* Education to staff on residents signing in and out and activated residents being supervised when outside of the facility at all times.* All residents in the facility were re-evaluated for elopement risk on 6/9-6/11 (New evaluation that was implemented 6/9/25)* Tested wander system for effectiveness and alarm audibility. All magnetic lock doors were checked on 6/9/25 and 6/12/25 for functionality.* The resident that was affected added to the wander log and wander guard placed on resident upon arrival back to facility, education to resident and family on wander guard and elopements.* Immediate staff educated on new wander risk residents elopement risk residents were added to binder.

Based on observation, interview, and record review, the facility did not ensure that residents remain free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents for 2 (R10 and R41) of 9 residents reviewed for accidents. * R10 had a fall on 12/5/2024 that was not thoroughly investigated. R10 had a fall on 12/12/2024 that resulted in a left subdural hemorrhage and laceration to left upper forehead requiring 3 (three) sutures. * R41 had a fall on 10/21/2024 that was not thoroughly investigated. Findings include: The facility policy titled Accidents and Incidents - Investigating and Reporting revised July 2017 documents: Policy Statement: All accidents or incidents involving residents, . occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: . 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: . c. The circumstances surrounding the accident or incident. e. The name(s) of witnesses and their accounts of the accident or incident. m. Other pertinent data as necessary or required . 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. 1.) R10 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus, Polyneuropathy, Cognitive Communication deficit, muscle weakness, depression, and anxiety disorder. R10's Annual Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating that R10 has moderately impaired cognition. The MDS documents that R10 needs total assistance with 2 staff members for personal and toileting hygiene. R10 requires a Hoyer lift with 2 staff members for transfers to and from bed into wheelchair, R10 is able to self-propel self once in wheelchair. R10 experienced delusional and verbal behaviors and would yell out R10's needs instead of using the call light at times. The MDS also documents that R10's upper extremities were impaired due to contractures. R10 was assessed to be a high risk for falls with a fall risk score of 20. R10's at risk for injury care plan created on 3/3/2022 related to falls documents that due deconditioning, incontinence, history of falling, and cognitive communication deficit R10 is at risk for falls. Under the Interventions section it documents: - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - Ensure I am wearing appropriate footwear when out of bed. - Make sure that my floor/path is clutter free and properly lighted. - Keep my bed in low position when I am in it to prevent me from rolling out and being injured. - Wedge cushion in wheelchair (initiated 2/5/2024) - Encourage me to be in common areas when I am awake. (initiated 12/19/2024) - Encourage me/family/caregivers about safety reminders and what to do if a fall occurs. - When being transported by staff, to have foot pedals on wheelchair (initiated 12/20/2024) R10 has a psychosocial well-being problem related to anxiety care plan that was initiated on 3/25/2024 with the following interventions: . - I (R10) need assistance/supervision/support with identification of potential solutions to present problems. R10's progress note dated 12/5/2024, at 21:49 (9:49 PM) documents: . (R10) noted sitting on the floor, leaning against the bathroom door with the wheelchair behind R10. Hoyer sling still in place in wheelchair. R10 stated R10 slid out of the wheelchair. (R10) was screaming out before fall. Surveyor reviewed the fall investigation packet for R10's fall on 12/5/2024. Nursing documented that R10 fell at 18:15 (6:15 PM) and was screaming out to go to bed prior to R10's fall. Surveyor noted that there are no individual staff statements indicating when R10 was last checked on, toileted, or if staff addressed R10 calling out wanting to go to bed. Surveyor noted the intervention documented in the summary statement/root cause of the fall was to offer R10 to go to bed after dinner. R10's care plan was not revised with that intervention. R10's care plan was revised with the following intervention: - Routine scheduling every 2 hour checks to ensure (R10) is sitting correctly in the wheelchair. (R10) tends to slide forward to propel chair with feet. (initiated 12/6/2024) R10's progress note dated 12/12/2024 at 19:34 (7:34 PM) documents: At 1700 (5:00 PM) nursing was notified by certified nursing assistant (CNA) that R10 fell out of the wheelchair, hitting face first on the floor and R10 was bleeding. CNA stated was pushing R10 to R10's bedroom when R10 put feet down on the floor and then fell out of wheelchair. Nursing documented R10 was face down on the floor, left side of face on floor and facing to the right with blood pooling around R10's head. R10 was alert, oriented, and responsive at R10's baseline. Nursing documented first aid provided, 911 called and R10 was transported to the hospital for further evaluations. R10's progress note dated 12/12/2024 at 22:07 (10:07 PM) documents that R10 was admitted to the hospital with a diagnosis of subdural hematoma. On 12/17/2024, R10 was readmitted into the facility with a diagnosis of: Left subdural hematoma and laceration to the left side of forehead with 3 sutures intact. Surveyor reviewed the facility self-report that was completed for R10's fall on 12/12/2024 that resulted in a laceration to R10's left forehead requiring 3 sutures and a subdural hemorrhage. Surveyor noted that R10's fall on 12/12/2024 was documented to have happened around 5:00 PM and R10 was yelling out in wheelchair prior to the fall. The investigation does not indicate if R10 was offered to lay down or if staff asked R10 or if staff checked to see if R10 was sitting correctly in wheelchair before assisting R10 to R10's room in the wheelchair. The investigation did not confirm that R10's feet and position in the wheelchair were secured before pushing the wheelchair. Surveyor noted that there were staff signatures for education that was provided, but the investigation did not include what type of education was provided to staff members. On 2/17/2025 at 9:55 AM, Surveyor observed R13 self-propelling down the hallway when a staff member came up to R13 and assisted R13 the rest of the way down the hallway. The staff member did not put foot pedals on R13's wheelchair before pushing R13's wheelchair forward. On 2/17/2025 at 11:23 AM, Surveyor observed CNA-H pushing R38 down the hallway in a wheelchair without the foot pedals on R38's wheelchair. On 2/18/2025 at 11:41 AM, Surveyor asked to see the education provided to staff after R10's fall on 12/12/2024. Nursing Home Administrator (NHA)-A stated that staff were educated to put foot pedals on wheelchairs before pushing a resident in a wheelchair. NHA-A stated education started on 12/12/2024 and into the weekend and it was completed on Monday, 12/15/2024 for all staff. NHA-A stated that when staff came on for shift they were educated, and some staff were called at home. NHA-A stated that audits are done visually and verbally on a daily basis. On 2/18/2022 at 12:22 PM, Surveyor interviewed CNA-G who stated on 12/12/2024, CNA-G was assisting another resident back to their room when CNA-G noted R10 yelling out. CNA-G told R10 CNA-G would be back to assist with R10 after taking another resident to their room. CNA-G stated when returned to R10 it was noted that R10's wheelchair was caught on a wheel of a Hoyer lift. CNA-G unhooked R10 and took R10 to R10's room. CNA-G gave R10 the call light and stated R10's CNA would be in to help in a little bit. CNA-G did not see R10 again until CNA-G was told a resident had fallen. When CNA-G went to the area to help she noticed it was R10 that had fallen. CNA-G stated she put R10 in R10's bedroom about 30 minutes prior to R10 falling. CNA-G did not offer to lay R10 down because R10 was not on CNA-G's assignment that night and figured the CNA assigned to R10 would have helped R10 for bed. CNA-G stated that once R10 was in the bedroom R10 seemed content when CNA-G left. On 2/18/2025 at 3:24 PM, Surveyor interviewed CNA-F regarding R10's 12/12/2024 fall. CNA-F stated that CNA-F was in another resident's room assisting with cares when CNA-F heard yelling in the hallway. CNA-F finished cares and went out into the hallway and noted R10 against the wall in R10's wheelchair yelling. CNA-F went up to R10 and told R10 that CNA-F was going to take R10 to her bedroom. CNA-F stated that when CNA-F got R10 turned around to go to R10's bedroom, R10 put both feet down and went to propel forward but instead R10's feet caught on the floor and R10 fell out of the wheelchair face first. CNA-F stated CNA-F did not tell R10 to scoot back or hold her feet up and did not put foot pedals on the wheelchair to take R10 back to her bedroom. CNA-F stated it looked as though R10 was going to propel herself at the same time CNA-F was pushing forward and R10 just fell out of wheelchair, landing head first on the floor. CNA-F stated R10 typically will yell out if R10 wants something instead of using the call light and once R10 is helped R10 is usually content. On 2/18/2024 at 4:00 PM, Surveyor requested staff statements for R10's fall on 12/5/2024. NHA-A stated would look into it to see if staff statements were obtained. NHA-A stated staff do a fall huddle after each fall and statements would be collected at that time from the nurse gathering information for the fall investigation packet. Surveyor stated that the fall investigation previously provided did include a summary statement from staff involved in the huddle, but it was not documented in the statement when R10 was last checked on, or if staff addressed R10 yelling out wanting to go to bed. NHA-A stated NHA-A would look into it. Surveyor also shared with NHA-A concerns that R10's intervention initiated on 12/5/2024 of offering to be put to bed was never transferred or revised on R10's care plan and that on 12/12/2024, R10 had a fall that resulted in a head laceration and subdural hemorrhage. Surveyor shared concern that R10 was yelling out around that dinner time and staff did not offer to put R10 to bed or make sure R10 was sitting correctly in wheelchair before pushing R10 in the wheelchair. Surveyor also shared concerns that surveyors made current observations of staff pushing residents in wheelchairs without foot pedals on the wheelchairs. NHA-A stated would look into the information needed and would initiate audits again regarding foot pedals. NHA-A stated each wheelchair should have foot pedals in a bag on the back of the wheelchair if the resident is not currently using them. NHA-A stated the pedals are in the bag so they are readily available in the event foot pedals are needed. On 2/19/2025 at 7:13 AM, Surveyor observed CNA-R pushing R1 down the hallway without foot pedals on R1's wheelchair. On 2/20/2025 at 11:35 AM, Registered Nurse Unit Manager (RNUM)-I provided a copy of R10's December 2024 Medication Administration Record (MAR) and showed Surveyor that R10's 1800 (6:00 PM) medications were signed out on 12/5/2024 and stated that R10 fell at 6:15 PM. Surveyor asked if there was a time stamp of what exact time the medications were given to R10 and as there was no statement indicating what staff did for R10 while R10 was yelling to go to bed. RNUM-I stated that no individual staff statements could be found for R10's fall on 12/5/2024 and that RNUM-I could not confirm exactly what time R10's 1800 medication was given or if staff addressed R10 yelling out. On 2/20/2025 at 1:18 PM, Surveyor shared concerns with NHA-A that R10's fall on 12/5/2024 was not thoroughly investigated and did not include when R10 was last checked on/toileted or offered to lay down. Surveyor informed NHA-A that for R10's fall on 12/12/2024 staff did not indicate if R10 was offered to lay down per her 12/5/2024 fall interventions or if R10 was placed in the wheelchair properly by staff before staff pushed R10 back to R10's bedroom without foot pedals. Surveyor informed NHA-A that R10 ended up falling onto the floor resulting in a left forehead laceration requiring 3 sutures and subdural hemorrhage. Surveyor also shared surveyors' current observations of residents being pushed in their wheelchairs by staff without foot pedals on the wheelchairs. No additional information was provided as to why the facility did not ensure that R10 remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents. 2.) R41 was admitted to the facility on [DATE] with a diagnoses that include Hemiplegia and hemiparesis following a stroke affecting the right dominant side, Type 2 Diabetes with angiopathy, chronic kidney disease, Dementia with agitation, below the knee amputations and obstructive uropathy requiring a foley catheter. R41's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating that R41 has severely impaired cognition. The MDS documents that R41 needs extensive assistance with 2 people toileting and personal hygiene, repositioning. R41 did not always use the call light and would yell out when needing assistance. R41 was assessed on 9/30/2024 as being a high fall risk with a score of 16. R41's bowel incontinence care plan was initiated on 10/5/2020 with the following intervention: . - I (R41) use disposable briefs. Change me every 2-3 hours and as needed (PRN). R41's risk for injury related to falls due to confusion, deconditioning, incontinence, and bilateral above the knee amputation . care plan initiated on 10/7/2020 documents the following interventions: . - I need activities that minimize potential for falls while providing diversion and distraction. - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - Encourage me to be in common areas while awake (initiated 3/12/2021) R41's progress note dated 10/21/2024, at 11:38 AM documents a 72 hour fall follow up progress note documenting certified nursing assistant (CNA) found (R41) lying perpendicular in low bed with mat on the floor. R41's upper half of body was on pillow and floor mat and R41's lower half of body was on R41's bed. Surveyor reviewed R41's fall investigation for R41's fall on 10/21/2024. Nursing documented that R41 was observed on the floor around 10:04 am and R41 was restless, confused, yelling, and was incontinent of bowel. Nursing documented in the summary statement/root cause that (R41) manipulates self when restless and that the bed was low with fall mat next to bed. Surveyor noted there are no staff statements indicating when R41 was last toileted or if R41 was incontinent prior to the fall or at the time of fall and if anyone addressed why R41 was yelling. On 2/18/2024, at 4:00 PM, Surveyor requested staff statements for R41's fall on 10/21/2024. NHA-A stated would look into it to see if staff statements were obtained. NHA-A stated staff do a fall huddle after each fall and statements would be collected at that time from the nurse gathering information for the fall investigation packet. Surveyor stated that the fall investigation did include a summary statement from staff involved in the huddle, but it was not documented in the statement when R41 was last checked on, or if staff addressed R41 yelling out wanting to go to bed. NHA-A stated NHA-A would look into it. On 2/20/2025, at 11:35 AM, Registered Nurse Unit Manager (RNUM)-I provided a copy of R41's October 2024 medication administration record (MAR) and showed Surveyor that R41's 0800 (8:00 AM) medications were signed out on 10/21/2024 and stated that R41 fell around 10:00 AM. Surveyor asked if there was a time stamp of what exact time the medications were given to R41 and there still was no statement indicating what staff did for R41 while R41 was yelling out. RNUM-I stated that no individual staff statements could be found for R41's fall on 10/21/2024 and that RNUM-I could not confirm exactly what time R41's 0800 medication was given or if staff addressed R41 yelling out. On 2/20/2025, at 1:18 PM, Surveyor shared concerns with NHA-A that R41's fall investigation on 10/21/2024 was not thorough and did not include when R41 was last checked on or assessed as to why R41 was yelling out. No additional information was provided as to why the facility did not ensure that R41 remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents.

Based on observation, interview, record review, the facility did not ensure that 1 of 4 residents (R1) was free from verbal and mental abuse. Certified Nurse Aide (CNA) D intentionally moved R1's call light out of his reach and closed his door, thereby taking away R1's ability to summon assistance in the event of an emergency or need. CNA D reported her actions to RN E (Registered Nurse); however, RN E did not report the incident to the Administrator. This allowed CNA D to work 3 shifts at the facility following the incident before she was suspended. The facility's failure to ensure residents were free from abuse created a finding of immediate jeopardy that began on 10/19/24. Surveyor notified the Nursing Home Administrator (NHA) of the immediate jeopardy on 11/8/24 at 11:10 a.m. The immediate jeopardy was removed on 11/8/24, however continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, dated 10/22/24, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will have written procedures that include: reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required 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 . Review of the facility's policy titled, Compliance With Reporting Allegations of Abuse/Neglect/Misappropriation, revised 07/2021, revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes .When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident .Remove the accused employee from resident care areas .Notify the Director of Nursing and Administrator .Notify the attending physician, resident's family/legal representative, and Medical Director .Complete an incident report and initiate an investigation .Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident .Suspend the accused employee pending completion of the investigation . R1 was readmitted to the facility on [DATE] with diagnoses that included traumatic spinal cord dysfunction and quadriplegia. R1's Care Plan dated 02/01/23 stated, .Be sure puff call light is in reach . Review of R1's annual Minimum Data Set (MDS), dated [DATE], revealed R1 is cognitively intact. The MDS recorded R1 had functional limitations in range of motion on the upper and lower extremities bilaterally and was dependent on staff for all activities of daily living. Review of the facility's investigative file for the incident between R1 and CNA D revealed the following: A statement from LPN F (Licensed Practical Nurse) dated 10/24/24 stated, Resident stated that CNA D was mean to him, he asked her to change him, and she refused, and they started arguing, she then got mad at him removed his call light which he blows into, turned out the lights on him and shut the door. He also stated that she wouldn't even change him the next day because she didn't like him and that he could starve to death. A statement from DON B (Director of Nursing) stated, 10/24/24 LPN G reported to me that (R1) had reported to her that CNA D had taken his mouthpiece call light system out of his mouth to where he couldn't reach it then turned lights out and closed his door after having an argument. I went to see R1 to discuss his allegation. R1 stated that CNA D had taken his mouthpiece out of his mouth and moved it out his reach then left his room closing his door. Stated she had worked on Sunday, Monday and Wednesday. Stated this happened on Wednesday pm shift after having an argument with her. He also stated that she came into his room about 4:00 pm and he told her he had 'pooped' and needed changed but she left the room and never came back. R1 also stated that she said to him 'I don't need you, you need me.' I asked R1 who replaced your mouthpiece? He stated the nurse RN H replace it and opened his door .He is able to speak but no movement and uses mouthpiece for contacting staff for his needs . A statement from RN E notes, 10/25/24 Re: Incident involving R1. Resident put his call light on, and CNA D went to answer it. A couple minutes later, I, RN, came down the hall, and noted resident's door closed, which was strange. I thought maybe he was getting cares. However, when I got to the nurses' station, I noted the CNA sitting there. I asked her why was R1's door closed, and she replied that she shut it, and took away his call light. She stated they had some words, both of them calling each other names. She stated she got angry, took away the call light and slammed the door closed. I told her that she can not [sic] do that, and that I gave him back his call light and opened the door. I told the CNA not to go back into the resident's room, that she would need to switch him with another CNA. After giving the resident back his call light and opening up his door; the resident stated he feels better and now safer. An undated statement from CNA notes, Hello [Administrator], On Sunday October 20th, I went to answer [R1]'s light. He [unknown] been upset already. I asked him if he needed something he started complaining about his [unknown] so I told him I would go get the nurse then he started yelling at me getting real disrespectful calling me fat bitches multiple times and threatened to slap me. I told him I'm not gonna be too many fat bitches and for him to go ahead and slap me. He then threatened to have someone come up to the job to fight me. So I told him go ahead. After that I left out his room. On Monday October 21 I didn't have much going on with him except he accused me of doing something to his food so he didn't want it. On Wednesday October 23rd I didn't have much going on with him. I told the other aide that worked with me that she would have to take him cause of our interaction. I thought she agreed to. At the end of shift the nurse did come ask all of us who had him. I told her I thought the other aide did but she said no so I said I'll go in his room only if someone else comes in there with me because I didn't want him saying I tried to do something to him. The nurse said no I don't want you going in there cause he won't let you touch him and so he doesn't say anything else to you so I didn't. Also, another aide did go in his room answer his light told him she would go get someone for him. He's just overall a hard person to deal with especially when things don't go his way. [unknown] of the other aides and nurses don't like to go in his room because he's too much . A statement from CNA I, dated 10/31/24, stated, On 10/23/24 I was standing outside R1's room talking to CNA D. I saw his light come on so I answered it. He told me that he needed to be changed and he had been waiting. I told him I was going to pass it to his aide. CNA D was standing outside the door. She was shaking her head no. I came out asked her why she not doing him [sic]. She told me because he called her a fat bitch and that he was going to slap her. And she can refuse to do him. I replied no you can't refused [sic] to do him, but he can refuse you as his aide. She told me I didn't know what I was talking about . Review of CNA D's Individual Timecard revealed she worked on 10/20/24, 10/21/24, and 10/23/24. The surveyor was unable to determine which hallway she had worked on. During an interview on 11/07/24 at 5:00 PM, RN E stated that on 10/19/24, she had stepped away from the unit and on returning to the unit about 9:20 PM, she noticed R1's door was closed which was not normal. She stated CNA D was observed seated at the nurses' desk, and when asked why the door was closed, CNA D stated R1 and she had words with each other, calling one another names about 9:00 PM. RN E stated CNA D reported that R1 called her a fat ass bitch. RN E stated CNA D further stated she had removed R1's puff activated call light from his reach and slammed his door shut. RN E stated she told CNA D what she did was not appropriate, and she went to his room. RN E stated she opened his door and returned his call light to him and asked if he was OK or scared of anyone including CNA D, and that R1 told her he was not afraid of anyone. RN E stated the problem started on Saturday 10/19/24, not on a weeknight. RN E stated she removed CNA D from R1's care around 9:20 PM, and that CNA D sat at the nurse's station until she clocked out at 9:58 PM on 10/19/24. RN E reported R1 was without his puff call light for 20 to 30 minutes. RN E confirmed she did not report the incident to the NHA A (Nursing Home Administrator). She stated she felt that she had handled the situation, and she was unaware she could call the Administrator, no matter what time it was. RN E stated she was unaware CNA D should have been suspended following the incident. During an interview on 11/07/24 at 9:45 AM, NHA A stated he felt RN E had addressed the issue; however, he had two concerns. He stated he was concerned that he was not notified immediately, and that CNA D was not sent home but only removed from R1's care. NHA A stated he and the DON had provided education to RN E related to abuse, reporting allegations of abuse to the Administrator immediately, and the facility's policy and procedure related to adhering to federal guidelines for reporting allegations of abuse. NHA A stated he had informed RN E that he was available, no matter the time of the day. During an interview on 11/08/24 at 5:50 PM, DON B confirmed she expected staff to notify her of any issues or concerns with residents. She stated her expectation was to be notified of allegations of abuse immediately. DON B confirmed she provided education to RN E related to abuse and reporting allegations of abuse to her or NHA A immediately. During an interview on 11/08/24 at 5:59 PM, R1 stated he was unable to provide the exact date of the incident. He stated he and CNA D had some words, and he called her a name. He stated she called him a name as well but could not remember what it was. He stated he was not afraid of any staff and was alright. The Surveyor attempted to reach CNA D on 11/07/24 and 11/08/24. Messages were left, but no return phone call was received. CNA D left R1 alone in the dark and without R1's communication, thus depriving R1, a resident who is dependent on staff for all activities of daily living, of the ability to communicate his needs to staff. CNA D was allowed to continue to work on the same unit on two additional shifts, creating opportunity to further retaliate against R1. The failure to ensure residents were free from abuse or the ongoing threat of abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 11/8/24 when the following was completed: RN E was given a verbal education on abuse policy, reporting compliance, and to always contact the Administrator if there are any allegations of abuse on 10/25/2024 CNA D was removed from resident care on 10/24/2024 prior to the start of shift. All nursing staff will be re-education on abuse, neglect and misappropriation policy education; abuse reporting and compliance policy; resident call light accessibility. Administrator or designee to orient all new staff on the abuse reporting policy and how to contact those individuals 24/7. Director of Nursing or designee to provide education on abuse reporting policy monthly at staff meetings.

Based on observation, interview, and record review, the facility failed to ensure that 1 (R255) of 1 resident reviewed for elopement was provided with safety measures, interventions, and assessments to prevent elopement and ensure safety. The facility also did not ensure 3 (R70, R53, and R255) of 4 residents reviewed for safety and supervision received an environment free of accident hazards, adequate supervision, and assistive devices to prevent accidents. ~ R255 was found outside the facility on 5/7/23 with multiple abrasions to his body and face. R255 stated he was going to the gas station to buy beer. R255's Power of Attorney (POA) was contacted and still wanted R255 to be able to go outside independently if he chose to. The facility did not assess R255 at this time to determine his level of safety awareness and his ability to safely be outside alone and did not put any added supervision or interventions in place to keep him safe. This was despite the encounter on 5/7/23 finding R255 in the facility parking lot with injuries. The facility did document an Elopement Assessment that put him at risk for elopement. On 6/2/23, R255 was again found outside the facility attempting to go the gas station for beer. Again, the facility did not assess R255 regarding safety awareness and his ability to safely be outside alone and did not put in any added supervision or interventions to keep him safe. On 6/5/23, R255 was found in the middle of the street with traffic stopped in both directions. The street has a speed limit of 40 miles per hour and is Highway 32 in Milwaukee County. The facility's failure to assess, supervise, and intervene on previous elopements of R255 created a finding of Immediate Jeopardy (IJ) that began on 5/7/23. Surveyor notified Nursing Home Administrator (NHA)-A and Associate Executive Director (AED)-C of the IJ on 12/4/23 at 1:47 PM. The immediate jeopardy was removed on 6/6/23. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) related to the following examples involving R70, R53, and an additional example regarding R255. ~ R70 did not have a thorough investigation or root cause analysis done for a fall that occurred on 9/1/2023. ~ R53 did not have a fall investigation initiated for falls that occurred on 10/1/2023 and 11/28/2023 until Surveyor asked for the fall investigations on 11/29/2023. ~ R255 had a history of sexual abuse with female residents. R255 was found entering other residents' rooms and touching their personal belongings. R255 was put on 1 hour checks for sexual expressions. On 9/7/23, R255 was found touching another female resident's breast in the common area noting increased supervision was not effective. Findings include: Surveyor reviewed facility's Elopements and Wandering Residents policy with a revised date of 8/12/2022, which documented: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 5. Procedure for Locating Missing Resident a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). b. The designated facility staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office. d. DON or designee shall notify the physician and family member or legal representative. e. Police will be given a description and information about the resident; include any photos. f. All parties will be notified of the outcome once the resident is located. g. Appropriate reporting requirements to the State Survey agency shall be conducted. 6. Procedure Post-Elopement a. A nurse will perform a physical assessment, document, and report findings to physician. b. Any new physician orders will be implemented and communicated to the family/authorized representative. c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults. d. The resident and family/authorized representative will be included in the plan of care. e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. f. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. g. Documentation in the medical record will include: findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. R255 was admitted to the facility 6/24/21 with diagnoses that included Alzheimer's Dementia, Dementia with Behaviors, and Major Depressive Disorder. Surveyor reviewed R255's MDS (Minimum Data Set) with an assessment reference date of 7/31/23. Documented under Cognition was a BIMS (brief interview mental status) score of 07 which indicated severely impaired cognition. Surveyor reviewed R255's Progress Notes. Documented on 5/7/23 at 4:28 PM was, [POA]-A was notified that resident was found outside the facility. Skin assessment was performed when resident was brought back to facility and abrasions were noted at right knee, right side of right eye, nose and chin. Minimal bleeding noted. Documented on 5/7/23 at 7:18 PM was, Resident is alert and oriented. Is able to propel self. [POA-O] is in agreement to him going outside independently. [POA-O] request facility provide nonalcoholic beer. Will discuss in [interdisciplinary team (IDT)] in am and follow up with primary physician and [POA-O]. It was noted R255 was attempting to go to the gas station for beer. Surveyor reviewed R255's Electronic Medical Record (EMR). There were no Care Plan Interventions or Safety Assessments after R255 left the building on 5/7/23 except an Elopement Assessment that documented R255 at risk for elopement. Although POA-O wanted R255 to be able to go outside independently, the facility is responsible for R255's safety; the facility did not assess R255 safety awareness or his ability to be safely outside without supervision. On 12/4/23 at 10:36 AM, Surveyor interviewed Social Services Director (SSD)-K. Surveyor asked if R255 was ever provided nonalcoholic beer as R255's POA suggested. SSD-K stated she was not made aware of the request but she would have followed up on it because there is nonalcoholic beer available at the facility. On 6/1/23, an MD order was put in R255's chart that documented, Monitor location, activities, and sexual expression [every (Q)] hour. Chart in [EMR]. Every hour for sexual expression. Documented in R255's Progress Notes on 6/2/23 at 3:30 PM was, at [3:15 PM] observed resident outside in parking lot. he was in his [wheelchair (w/c)]. approached resident. asked him where he was going. he pointed at the nearest gas station. indicating he wants a beer. redirected resident back into facility . R255's EMR showed there were no Care Plan, Interventions, or Safety Assessments after R255 left the building on 6/2/23. Documented in R255's progress notes on 6/5/23 at 4:00 PM was, Resident noted in middle of street in front of building trying to cross to the other side. Resident not using cross walk and had traffic stopped in both directions. Writer started to approach and called the nursing supervisor. Documented on 6/5/23 at 6:24 PM was, Writer immediately responded to phone call from staff nurse and was able to redirect resident out of the street and back into the facility. Writer was unable to determine what resident was attempting to do or why due to him being mainly Serbian speaking. Resident does have [activated POA-O]. In the past [POA-O] has wanted [R255] to be able to sit outside front entrance without restriction. Writer called [POA-O] to discuss the above event, resident's poor safety awareness/decision making, possible outcomes of the above event as well as intervention strategies. [POA-O] in agreement that resident's actions demonstrate poor decision making ability as well as poor safety awareness. Discussed use of wander guard to alert staff of resident's attempts to exit facility so that he could be redirected. [POA-O] informed that resident would no longer be able to sit outside by himself but that she would be able to take him out during her visits and that resident would still be able to use activity patio with staff supervision. [POA-O] states that she understands this and is in agreement with placement of wander guard for resident safety . Surveyor observed the street in front of the facility and noted no traffic lights or stop signs, and the speed limit is 40 miles per hour. Surveyor also noted the street is Highway 32. Surveyor reviewed R255's Elopement Assessment from 6/5/23 that documented R255 at risk for elopement. Surveyor reviewed R255's Comprehensive Care Plan that was initiated 6/6/23 after the third elopement from the facility. Documented was: Focus: I am an elopement risk/wanderer [as evidenced by (AEB)] Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Significantly intrudes on the privacy or activities. Goal: My safety will be maintained through the review date. Interventions: - Monitor location hourly and [as needed (PRN)]. Document wandering behavior and attempted diversional interventions. - WANDER ALERT: Assure Wanderguard is located on my left ankle and functional Q (each) night shift. Expires 6/8/24. - Redirect me away from exit doors. Talk to me in a calm, reassuring manner. On 12/04/23 at 10:22 AM, Surveyor interviewed Receptionist-V. Surveyor asked if she remembered R255 being on 1 hour checks. Receptionist-V stated she did not remember ever being informed of that regarding R255. Surveyor asked when the desk is staffed. Receptionist-V stated 8:00 AM to 8:00 PM. Surveyor asked how she knows what residents wander and are at risk for elopement. Receptionist-V showed Surveyor a binder with face sheets, lists, and pictures. Surveyor asked what she does if these residents try to leave the facility alone? Receptionist-V stated, redirect them and let staff know. Surveyor asked if R255 was ever on this list. Receptionist-V stated yes, after he received a Wanderguard. Surveyor noted the Wanderguard was placed 6/5/23 on the 3rd elopement from the facility. On 11/29/23 at 10:02 AM and 11:11 AM, Surveyor interviewed Assistant Executive Director (AED)-C. Surveyor asked why, after the 5/7/23 elopement, there were no safety assessments and why R255 was allowed to go outside independently again without supervision for safety. AED-C stated POA-O still wanted R255 to have the freedom to go outside, go to the gas station. Surveyor asked if there was an incident report or safety assessment. AED-C stated no. Surveyor asked what is the process to make sure a resident is safe to be out of the facility independently? AED-C stated the facility would assess to make sure they are safe and know their surroundings. Surveyor asked why this was not done for R255? AED-C stated that was his first time leaving the building and they did not feel he was an elopement risk. On 11/29/23 at 1:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and AED-C. Surveyor asked about the Elopement Assessment completed 5/7/23. NHA-A stated the Interdisciplinary Team (IDT) met and stated he was not a risk for elopement so they did not add any elopement interventions at that time. AED-C stated he had money in his pocket and knew where he was going so he had a purpose so they did not consider it an elopement. Surveyor noted the Elopement Assessment assessed him at risk and R255 eloped again on 6/2/23 for the same reason. AED-C stated he was on increased monitoring. Surveyor noted the monitoring was for sexual expressions. NHA-A stated R255 was monitored for all sorts of things including behaviors, sexual expressions, where he went throughout the building. Surveyor noted that the 1 hour checks did not start until 6/1/23. Surveyor asked what was done after the 6/2/23 elopement? AED-C stated POA-O was updated and she still wanted him to be able to go outside independently. Surveyor asked why he wasn't assessed for safety at this time? AED-C stated he would look into that. Surveyor asked what changed on 6/5/23 that led the facility to add a care plan and Wanderguard on that date? NHA-A stated when we found him (R255) in the middle of the street (Highway 32) and we brought him back in, he was not making sense. AED-C stated POA-O was updated was agreeable for him to wear a Wanderguard. AED-C stated at this point he (R255) needed to be more secure for safety. On 12/4/23 at 8:19 AM, Surveyor interviewed NHA-A. NHA stated after a timeline was developed NHA-A noted there were no interventions put in place after R255 eloped from the facility on 5/7/23. NHA-A stated the 1 hour checks did include location in the facility but did not start until 6/1/23 and R255 did not receive the Wanderguard until after he was in the middle of the street on 6/5/23. NHA-A was unaware why, after the 5/7/23 incident and elopement the interventions were not addressed. The facility's failure to assess R255 for safety awareness and establish an individualized plan of care to ensure R255's safety created a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy, The jeopardy began on 5/7/23 when R255 went beyond the entry area of the facility and attempted to elope from the property and he was noted to have injuries that were not evaluated to determine a root cause for the elopement and injuries. The immediacy was removed on 6/6/23 when the facility established an individualized plan of care to ensure the safety of R255, a system was established to monitor the safety of R255, and staff were trained on the interventions. The deficient practice continues at a scope/severity level of D (No Actual Harm/Isolated) for the followingl examples including additional concerns for R255. 2. R255 was admitted to the facility 6/24/21 with diagnoses that included Alzheimer's, Dementia, Dementia with Behaviors and Major Depressive Disorder. Surveyor reviewed R255's MDS (Minimum Data Set) with an assessment reference date of 7/31/23. Documented under Cognition was a BIMS (brief interview mental status) score of 07 which indicated severely impaired cognition. Surveyor reviewed R255's Comprehensive Care Plan initiated 8/11/22. Documented was: Focus: I have a behavior problem [related to (r/t) approaching/touching females without consent. Goal: I will not touch female [residents] without consent. Interventions: - Anticipate and meet my needs. - If reasonable, discuss my behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to me, Utilize family and interpreter as needed. - Increased supervision with staff interaction for inappropriate contact with others - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Med reviews prn - Referral to psych services and follow up prn Review of R255's Progress Notes revealed the following: Documented on 3/2/23 at 10:07 PM was, Nurse witnessed resident went to one of the lady's room and escort him out of the room right away. Not sure what was the reason. Advise him not to go to any other rooms. No other behavior noted. Documented on 3/7/23 at 5:53 AM was, Resident noted entering other resident room this shift, easily redirected to go back to his room. Slept well, no other behavior problem noted. Documented on 3/8/23 at 2:32 PM was, Resident for monitoring for behaviors. Writer caught resident in one of resident's room in their closet, looking and holding their clothes, pants. Instructed/pointed to resident to leave room. Documented on 4/8/23 at 5:33 AM was, Writer noted resident trying to enter other resident room, easily redirected to go back to his own room. No other behavior issues noted or reported. Documented on 4/25/23 at 3:27 PM by Social Services Director (SSD)-K was, Resident moved from room [room number] to [room number] for safety. POA and resident are in agreement with room change. On 12/4/23 at 10:36 AM, Surveyor interviewed SSD-K. Surveyor asked why R255 changed rooms. SSD-K stated R255 was moved to an all-male hallway due to his history of touching female residents. A Comprehensive Care Plan was added for R255 on 4/26/23. Documented was: Focus: I have a behavior of entering other resident rooms without being invited and rummaging through their belongings. Goal: I will not enter other resident rooms without being invited. Interventions: - Encourage activities of interest (Serbian podcasts, TV). - Provide reminders, direction and assistance. - Redirect resident to own room. On 6/1/23, an MD order was put in R255's chart that documented, Monitor location, activities, and sexual expression [every (Q)] hour. Chart in Electronic Medical Record [EMR]. Every hour for sexual expression. Documented in R255's Progress Notes on 9/7/23 at 2:19 PM was .[R255] was in the common room and [Certified Nursing Assistant (CNA)] was watching a female resident when she saw [R255] approaching the resident. CNA went around the nurses' station to see what [R255] was doing. When she came around the nursing station corner she saw [R255] with his hand on a female resident's breast squeezing . On 12/4/23 at 8:19 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. After a timeline was developed, NHA-A stated there was no additional supervision put in place for R255 between the 1 hour checks on 6/1/23 and the incident on 9/7/23. NHA-A stated on 9/7/23, one to one supervision was put in place for R255 until discharge from the facility on 10/16/23. No additional explanation was provided to explain how R255 was able to touch another resident despite a known history of seeking out female residents. 47094 Examples 3 and 4. Falls: The facility policy, entitled Falls - Clinical Protocol, revised March 2018, states: Assessment and Recognition . 2. In addition, the nurse shall assess and document/report the following: a. Vital signs b. Recent injury, especially fracture or head injury c. Musculoskeletal function . d. Change in condition or level of consciousness e. Neurological status f. Pain g. Frequency and number of falls since last physician visit h. Precipitating factors- details of how fall occurred. i. All current medications, especially those associated with dizziness or lethargy. j. all active diagnoses 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. 5. The staff will evaluate, and document falls that occur while the individual is in the facility. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position. b. Those that occur while upright and attempting to ambulate. c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, or if a fall may have significant medical cause . or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops until a reason is identified for its continuation. 3.) R70 was admitted to the facility on [DATE] and has diagnoses that include rheumatoid arthritis, fibromyalgia, severe dementia with psychotic disturbance, agitation, mood disturbance, and other behavior disturbance, type 2 diabetes, post-traumatic stress disorder, major depressive disorder, and unspecified psychosis. R70's admission minimum data set (MDS) dated [DATE] indicated R70 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 and assessed R70 as needing extensive assistance with 2 staff members for bed mobility, transferring, and toileting. R70 was assessed as needing extensive assist with one staff member with dressing, hygiene, and bathing, and one staff member assist walking with a walker. R70 was occasionally incontinent of urine and wore an adult brief. R70's admission falls risk score assessment dated [DATE] indicated R70 was at moderate risk for falls with a score of 15. R70's Risk for injury related to falls due to deconditioning, incontinence, weakness, impaired mobility, and gait care plan was initiated on 6/29/2023 with the following interventions: - Physical therapy (PT), Occupational therapy (OT), Speech therapy (ST) to evaluate and treat as indicated. - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - Make sure that my floor/path is clutter free and properly lighted. - Anti-rollback brakes to wheelchair (initiated 8/29/2023) - Anti-tippers to front of wheelchair R70's visual/ bedside Kardex reports has the following interventions in place: SAFETY: - All staff to remain watchful of me and alert to my safety - Anti-rollback brakes to wheelchair - Anti-tippers to front of wheelchair - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer - Encourage me to use bell to call for assistance - Ensure I have unobstructed path to the bathroom - Floor mat next to bed - Make sure that my floor/path is clutter free and properly lighted - Provide me with an environment with adequate lighting, free of glares as much as possible On 9/1/2023 at 4:43 PM in the progress notes, nursing charted R70 had unwitnessed fall around 2:45 PM. R70 alert and responsive. R70 was found lying on R70's left side on the floor. R70 stated R70 hit head and complained of left hip and knee pain. Nursing charted there was no active bleeding or visible injuries. Nursing notified the Nurse Practitioner (NP) and received orders to send R70 to the emergency room for evaluation. On 9/1/2023 at 11:20 PM in the progress notes, nursing charted R70 returned to the facility around 11:15 PM with no new orders. On 9/6/2023 at 9:43 AM in the progress notes, nursing charted R70 was discussed with the interdisciplinary team (IDT) regarding fall on 9/1/2023. R70 transferred self in room and fell on to left side, complained about hitting head and left hip pain. Immediate intervention: R70 sent to the emergency room for evaluation. Interventions: fall mat, NP and Power of Attorney (POA) in agreement with plan of care. Care plan updated. Surveyor reviewed the fall investigation for R70's fall on 9/1/2023. Surveyor noted that the investigation did not include staff interviews to determine what interventions were in place at the time of the fall, what R70 was doing prior to the fall, or when R70 was last checked on prior to R70's fall on 9/1/2023. There was no root cause analysis done to determine why R70 fell . Surveyor also noted that the immediate intervention was to send R70 to the emergency room to be evaluated, but the fall mat was not initiated until 9/6/2023. On 11/29/2023 at 3:46 PM, Surveyor informed Director of Nursing (DON)-B of Surveyor's concern that R70 did not have a thorough investigation completed for the fall on 9/1/2023. DON-B expressed understanding and would see if DON-B could find any other information regarding R70's fall on 9/1/2023. On 11/30/2023 at 10:48 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-N who stated when a resident falls, LPN-N will gather vital signs and notify a Registered Nurse (RN) on duty right away to assess the resident. LPN-N stated that a fall sheet is filled out and given to the quality assurance coordinator (QAC)-F. LPN-N stated that the information from the fall gets put into IRIS in the computer and a fall report is generated. On 12/4/2023 at 9:00 AM, DON-B provided Surveyor a sheet with a summary statement and root cause for R70's fall on 9/1/2023; the sheet was written and signed on 12/1/2023. Surveyor shared concerns that the information still did not provide information regarding why R70 had a fall and what R70 was doing prior to the fall, what interventions were in place, and interviews with staff to help determine when R70 was last checked on or observed by staff. DON-B expressed understanding. No further information provided at this time. 4.) R53 was admitted to the facility on [DATE] with diagnoses that include Dementia with severe agitation, adult failure to thrive, panic disorder, type 2 diabetes, insomnia, and anxiety disorder. R53's Minimum Data Set (MDS) dated [DATE] indicated R53 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 4 and the facility assessed R53 as needing extensive assist with one staff member for bed mobility, dressing, and eating, and being total dependence with one staff member for toileting, hygiene, and bathing. R53 is on Hospice and required a Hoyer lift transfer with two staff members into a Broda wheelchair. R53 was incontinent of bowel and bladder and wears an adult brief. R53's falls risk assessment score dated 7/2/2023 indicated R53 was a high risk for falls with a score of 21 and R53's most recent falls risk assessment dated [DATE] indicated R53 was still a high fall risk with a score of 20. R53's risk for injury related to falls due to confusion, deconditioning, gait/balance problems, incontinence, and unaware of safety needs care plan was initiated on 3/1/2022 with the following interventions in place: - (R53) has behaviors of placing self on floor - (R53) has behaviors of scooting/crawling on floor - Encourage me frequently to ask for assistance or use call bell for any assistance - Encourage me to be in common areas when I am awake. - Please check and change or toilet me often to prevent me from self-transferring or self-toileting to prevent falls or injuries. - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - I need activities that minimize the potential for falls while providing diversion and distraction. - I need to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate as needed for continued appropriateness. - Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated. - Ensure that I am wearing appropriate footwear when out of bed. - Make sure that my floor/path is clutter free and properly lighted. - Keep my bed in low position when I am in it to prevent me from rolling out and being injured. - (R53) was moved closer to nurses' station (initiated 3/2/2022) - Provide frequent reminders to ask for assistance, rather than attempting to provide self-care (initiated 5/17/2022) - Safety mat next to bed to prevent injury (initiated 6/4/2022) - Insure Broda chair is reclined to prevent falling forward (initiated 6/14/2022) - Check every two hours while in bed (initiated 10/10/2022) - Frequent rounding while in bed (initiated 10/5/2023) - Bed moved against left side of wall. Fall mat to be placed on right side of bed (initiated 10/30/2023) R53's visual/bedside Kardex reports has the following interventions in place: Safety: - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - Bed moved against left side of wall. Fall mat to be placed on right side of bed. - Encourage me to use bell to call for assistance. - Ensure that I am wearing appropriate footwear when out of bed. - Frequent rounding while in bed. - Insure Broda chair is reclined to prevent falling forward - Keep my bed in low position when I am in it to prevent me from rolling out and being injured. - Make sure that my floor/path is clutter free and properly lighted. - Please check and change or toilet me often to prevent me from self-transferring or self-toileting to prevent falls or injuries. - Provide frequent reminders to ask for assistance, rather than attempting to provide self-care. - Resident was moved closer to the nurse's station. - Safety mat next to bed to prevent injury. Surveyor noted that there is no mention of R53's behaviors of placing self on floor or R53's behaviors of scooting/crawling on floor on the Kardex that staff use, specifically the certified nursing assistants (CNAs) to use as a quick reference for the care of R53. On 10/1/2023 at 10:58 AM in the progress notes, nursing charted nursing was brought to R53's room and R53 was observed sitting on buttocks with back to bed sitting on mat and was bleeding on the left side above R53's eye. RN called to assess R53, Hospice and (power of attorney) POA also informed, and Hospice will be out to assess R53. R53 has skin tear measuring 1.0 CM X 0.1 CM, cleaned with [TRUNCATED]

Based on record review and staff interviews, the facility failed to provide care and treatment in accordance with professional standards of practice for 1 out of 1 residents (R1) who experienced a fall resulting in a significant head injury. * On [DATE] at approximately 1:30 PM, Certified Nursing Assistant (CNA)-E was turning and repositioning R1 in order to provide incontinence care to R1 while he was in bed. R1 rolled from the bed to the floor, hitting his head on the metal frame of the bed side table. R1 was noted to have a contusion with bleeding to the forehead. CNA-E sought the assistance of another CNA and together the two CNAs used a Hoyer lift to put R1 back into bed prior to a Registered Nurse (RN) assessing R1 for injury. Once in bed, R1 was assessed by the nurse. The Nurse Practitioner-F (NP) gave orders to send R1 to the emergency room by calling 911. Instead of calling 911, Licensed Practical Nurse (LPN)-H called for a private ambulance company to transport R1 to the emergency room . It was noted that the fall occurred at approximately 1:30 PM, and R1 was not transported to the emergency room until 2:15 PM. R1 was noted to be on a blood thinner and was excessively bleeding from the contusion on R1's forehead. On [DATE], R1 was admitted into the hospital with a subdural hematoma. R1 received staples and sutures to the forehead and was admitted into the Intensive Care Unit (ICU). R1 was discharged from the hospital and readmitted into the facility on [DATE]. The hospital discharge instructions included for R1 to have follow up, within 2 weeks, with a CT scan of the head that the hospital had scheduled for [DATE]. Once the CT scan was obtained, R1 was to be seen by Neurosurgery which the hospital scheduled for [DATE]. Facility staff noted it would be difficult to obtain transportation for the CT scan on [DATE] at the time indicated for R1. The facility proceeded to change the appointment for the CT scan without notifying the Neurosurgical clinic to discuss if it would be alright for R1 to have the CT scan after the 2-week timeframe already established in the hospital discharge. In addition, R1 attends Dialysis 3 times weekly. R1 returned to dialysis for treatment after his discharge from the hospital and readmission into the facility. The facility did not communicate to the dialysis center the significance of R1's head injury and his sustaining a subdural hematoma. On [DATE], the dialysis center staff noted R1 had a less than 1 minute seizure like activity and tried to call the facility to communicate this information. The facility did not respond to this phone call and the dialysis center then communicated the seizure activity on the paper communication sent with R1 back to the facility. The facility did not review the dialysis center's written communication regarding R1's seizure activity and therefore was not aware of R1 having a seizure at dialysis. The facility was not able to monitor and follow-up with R1's primary physician regarding R1's seizure activity. On [DATE], R1 became unresponsive and 911 was called. R1 was admitted into the hospital with an extensive brain bleed, seizure, and plural effusion. R1 was placed on comfort care and passed away on [DATE]. The facility's failure to provide the necessary care and treatment for R1 by not ensuring an RN assessment was completed following R1's fall with an active bleeding head injury and prior to transferring R1 back to bed, calling a private ambulance versus calling 911 therefore delaying treatment, the failure of the facility to consult with the physician of the delay in R1 having a CT scan of his head within 2 weeks of hospital discharge (per hospital instructions) and follow-up with neurosurgery, the failure to communicate to the Dialysis Center about R1's subdural hematoma, and the failed communication between dialysis and the facility regarding R1's seizure-like activity on [DATE] created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator-A and Assistant Executive Director-C of the immediate jeopardy on [DATE] at 12:45 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of D as the facility continues to implement and monitor its action plan. Findings include: Surveyor reviewed the facility's Head Injury policy which was revised ,d+[DATE]. The policy indicated in part: Policy: It is the policy of this facility to report head injuries to physician and implement interventions to prevent further injury. Policy Explanation and Compliance Guidelines (includes): 1.) Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: e.) any injuries to head, neck, eyes or face, including lacerations, abrasions, or bruising. 2.) Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. Surveyor's review of Long Term Care Facility Outpatient Dialysis Services Coordination Agreement dated [DATE] includes in part; B.) Obligations of Long-Term Care Facility and/or Owner 1.) ESRD (end-stage renal disease) Residents Information. The Long-Term Care Facility shall ensure that all appropriate medical and administrative information accompanies all ESRD Residents at the time of referral to the ESRD Dialysis Unit. This information shall include, but is not limited to, where appropriate, the following: e.) Treatment presently being provided to ESRD Residents, including medications. 2.) Interchange of Information. The Long-Term Care Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents, including a contact person at the Long-Term Care Facility whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents. R1 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, other nontraumatic intracerebral hemorrhage, epilepsy, type 2 diabetes mellitus with diabetic chronic kidney disease, aphasia, heart disease, end stage renal disease, peripheral vascular disease, and vascular dementia. R1's Fall Risk assessment, dated [DATE], assessed R1 as a high risk for falls. R1's Quarterly MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview of Mental Status) of 5 indicating R1 is severely cognitively impaired. R1 has an activated POA (Power of Attorney). R1's functional status for bed mobility, transfers, dressing, and toilet use are all assessed as extensive assist with two + person physical assist. R1's physician orders include Plavix Oral tablet 75mg (milligrams) once daily and Aspirin oral tablet 81mg once daily for anticoagulants and Vimpat tablet 150mg - give 0.5 tablet by mouth two times a day for seizures, order date [DATE]. The Misconduct Incident Report dated [DATE] and submitted by the facility, documents on [DATE] at 1:30PM, R1 was receiving cares from CNA-E after having a bowel movement. While CNA-E turned R1 on R1's left side, R1 rolled off the bed. R1 hit his head on the foot of the bedside table. The Nurse assessed R1 and observed a contusion to middle of the forehead. R1 was assisted off the floor by two CNAs with a Hoyer lift and pressure was applied to contusion. R1 was sent to the emergency room (ER.) On [DATE], at 11:32 AM, Surveyor interviewed CNA-E who stated R1 rolled off the bed during cares and hit his head on the foot of the bedside table. CNA-E stated R1 was bleeding from the forehead. CNA-E stated she panicked and left the room to find help. CNA-E reported she found another CNA who helped her transfer R1 off the floor and back into bed with the Hoyer lift. When R1 was in bed CNA-E then went to get a nurse. CNA-E reported a Registered Nurse (RN) and Licensed Practical Nurse (LPN) came to assess R1. R1 was actively bleeding from the middle of the forehead so CNA-E held pressure on the injury. The nurse then contacted the Nurse Practitioner in the building to come and assess. Surveyor asked CNA-E why she moved R1 back into the bed after a fall with head injury and she stated she was scared. On [DATE], at 12:00 PM, Surveyor interviewed Assistant Executive Director-C regarding R1's fall. Assistant Executive Director-C confirmed it is their policy that when a resident has a fall, they are to be assessed by a RN before moving the resident from the ground. On [DATE], at 9:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who stated she was working on the day R1 fell out of bed. LPN-H stated RN-G informed her of the fall and together they responded to R1's room. LPN-H stated R1 was in bed and was bleeding from the middle of the forehead. LPN-H stated RN-G assessed R1 and the NP in the building was called. Surveyor asked LPN-H if it was protocol to place a resident back in bed after a fall and she stated, no, that residents are to remain on the ground until an assessment is completed. LPN-H reported CNA-E was new to skilled care and that she panicked and moved R1 back into bed. LPN-H informed Surveyor the NP came to the room and ordered R1 to be sent out. Nurse Practitioner (NP)-F's encounter noted dated [DATE] documents, Provider was asked to urgently see patient for concerns of head trauma. Per staff, R1 was receiving cares after a bowel movement and rolled off the bed and onto the floor, hitting his head on the bed side table. Lying in bed - wet towel on his head - actively bleeding from wound to center top forehead. Large amount of blood present in his hair and on his pillow. PLAN: Staff instructed to hold pressure and call 911. Needs urgent evaluation of his head - on blood thinners with prior history of VP shunt. Will need imaging to ensure no hemorrhaging. On [DATE], at 9:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H. LPN-H stated she called [Bell] Ambulance as that was what she thought she was told to do. LPN-H informed Surveyor a few days later she was reeducated and told if a resident has a head injury, they should be sent out 911. LPN-H stated when [Bell] Ambulance arrived, they told her that 911 should have been called as R1 was on blood thinners and actively bleeding from the head. Licensed Practical Nurse (LPN)-H called for a private ambulance company to transport R1 to the emergency room , rather than calling 911. It was noted R1's fall occurred at approximately 1:30 PM, and R1 was not transported to the emergency room until 2:15 PM. R1 was noted to be on a blood thinner and was excessively bleeding from the contusion on R1's forehead. On [DATE], R1 was admitted to the hospital. The hospital admission note, dated [DATE], documents, CT of the head was obtained, showing new subdural hematoma along the right tentorium, and along the posterolateral margin of the right temporal lobe. Neuro critical care and neurosurgery teams were contacted. Patient's wife was also contacted. She confirmed Do Not Resuscitate status and did not want any neurosurgical treatments. Decision was made to admit the patient to the ICU (Intensive Care Unit) at this facility. DDAVP was recommended by critical care, as the patient is on aspirin and on dialysis. R1 was discharged from the hospital and readmitted back into the facility on [DATE]. Surveyor continued to review R1's medical record which included the Hospital Discharge Summary dated [DATE]. The Hospital Discharge Summary documents under Impression and interventions: Acute traumatic subdural hematoma. History of intraventricular hemorrhage (2017). Seizure disorder. No seizure overnight. Neurosurgical evaluation in 2 weeks, antiplatelet therapies on hold until evaluated as outpatient by Neurosurgery. SC (subcutaneous) Heparin ok. Repeat CT head prior to outpatient evaluation by Neurosurgery. R1's Hospital After Visit Summary documents that an appointment for CT head without contrast was scheduled for [DATE] and a follow up virtual visit with Neurosurgery was scheduled for [DATE]. NP-F Encounter note dated [DATE] documents, Large wound to center top of the forehead. 6 staples present. Plan: Follow up CT of head on [DATE] and follow up with Neurology as ordered. Epilepsy - stable, no seizure activity - seizure precautions. Continue Vimpat as ordered. History of falling - stable - fall precautions and bleeding precautions - continue Plavix and aspirin as ordered. Surveyor reviewed skilled/episodic notes for R1 from [DATE], [DATE], and [DATE] through [DATE] and all document generic neurological assessments completed and do not document any neurological changes to baseline. Surveyor notes there are no physician orders for neurochecks post fall to be completed once R1 returned from the hospital on [DATE]. On [DATE], at 1:36 PM, Surveyor interviewed the Interim Director of Nursing/Assistant Director of Nursing (IDON)-D who informed Surveyor that per hospital discharge paperwork a CT scan was scheduled for [DATE] at 5:00 PM. IDON-D stated the facility could not provide transportation at that time of day due to R1 using a Broda chair, so she had asked the scheduler to reschedule the scan. The CT scan was rescheduled for [DATE] for the morning. IDON-D stated they did not call the Neuro Clinic to ask if it was okay to reschedule this appointment after the recommended 2 weeks. IDON-D also stated she did not notify the NP (Nurse Practitioner) of the change and that the NP does not have direct access to the internal shared drive that is used by the facility to house resident appointments. On [DATE], at 2:00 PM, Surveyor interviewed NP-F who informed Surveyor that a CT scan of R1 was most likely scheduled to determine if the brain bleed was growing or not however, she explained she does not have a neuro background. NP-F stated she was not aware initially that the CT scan for [DATE] was rescheduled however she did find out after the fact. Surveyor asked NP-F if neurochecks for individuals after a head injury should be completed and NP-F stated neurochecks are usually completed 72 hours after a head injury and she would not typically order ongoing neurochecks. NP-F indicated it would be based on facility policy and that she was not aware of this facility's policy. Surveyor noted R1's daily progress notes regarding R1's staples and sutures do not include any documentation of any redness, drainage, or signs of infection from [DATE] through [DATE]. A Physician order dated [DATE] indicated to remove the 2 staples and 5 sutures from R1's forehead. NP-F Encounter note dated [DATE] documents, The provider was called to the patient's room to evaluate him as the nurse was removing his staples and sutures and noted what appeared to be pus coming from his head wound .The wound has started to dehisce again and is bleeding. Wound edges are red, extending into the surrounding tissue. The wound has also started to swell again. The wound was irrigated with normal saline and purulent drainage was noted as well .Follows with Wound MD in house. Plan: send to ER (emergency room ) for evaluation and treatment. Wound appears to be infected and has now started to dehisce. Needs evaluation from MD as well as possible imaging. R1's After Visit summary from the ER, dated [DATE], documents a diagnosis of infected wound and doxycycline (antibiotic) was started. R1 returned back to the facility. NP-F Encounter note dated [DATE] documents, Seen for follow up after ER visit .It does not appear any lab work or imaging was done in the ED (Emergency Department). R1 was returned with orders for doxycycline for wound infection. Plan: Continue doxycycline as ordered, wound MD to see in the AM (morning), follow up CT of head on [DATE] and follow up with Neurology as ordered. On [DATE], R1 was sent to Hemodialysis. Review of the Hemodialysis Communication form dated [DATE], documents, 1 small less than 1 minute seizure-like activity. Surveyor noted there was no indication the facility had notified dialysis of R1's head injury from the fall that occurred on [DATE] resulting in a subdural hematoma. Surveyor also reviewed the facility's nursing progress notes after [DATE] through [DATE] and there was no indication of the facility monitoring or following up on R1's seizure-like activity while at dialysis on [DATE]. On [DATE], at 9:31 AM, Surveyor interviewed Registered Nurse (RN)-G who stated she did complete the hemodialysis communication forms on [DATE], [DATE], and [DATE]. RN-G could not explain why she did not communicate to dialysis that R1 had a subdural hematoma due to a fall on [DATE]. On [DATE], at 11:09 AM, Surveyor call the Hemodialysis Clinic and spoke to the clinic manager. Clinic Manager explained that during R1's dialysis on [DATE] they observed seizure-like activity. The medical doctor on site assessed R1, administered normal saline, and determined not to send R1 to the ER. Clinic Manager stated they tried calling the facility however no one picked up, so they documented the seizure-like activity on the communication form. On [DATE], at 8:49 AM, Surveyor interviewed the IDON -D. Surveyor showed IDON-D a copy of the Hemodialysis Communication form dated [DATE] which documented, 1 small less than 1 minute seizure-like activity. IDON-D stated they were not aware of any seizure like activity at dialysis. IDON-D stated usually the dialysis center will send a resident to the ER if they have any seizure-like activity and then call and let us know. IDON-D informed Surveyor that typically the nurse on duty is responsible to complete the top portion of the form and fill in any relevant information, like any recent changes in condition and then the dialysis center completes the bottom portion of the form and when the resident returns to the facility the form is reviewed by the nurse on duty. IDON-D stated this was obviously missed .No one said anything and nothing is documented. Surveyor asked IDON-D if she would have known about R1's seizure activity while at dialysis would anything have been done differently? IDON-D responded with they would have notified the NP, obtained lab work on seizure medication, put resident on the 24 hour board for closer monitoring, and the NP may have even sent R1 out to ER. R1's facility progress notes continued to indicate: Progress Note dated [DATE] at 17:44 (5:44 PM) documents, Writer was called into this room and noted this PT (patient) to be unresponsive, SPO2 (oxygen saturation) at 86%, emesis behind his head and in his mouth. O2 (oxygen) applied at 2 LPM (liters per minute.) 911 called and NP updated about sending this PT out to the ER. Progress Note dated [DATE] at 22:18 (10:18PM) documents, .updated about this PT who was admitted with an extensive brain bleed, midline shift of about 6mm, pleural effusion and seizure. PT is on comfort care there and will either stay there to pass or family will take him home from there to pass. R1 expired on [DATE]. On [DATE], at 11:35 AM, Surveyor informed Assistant Executive Director-C of the concerns regarding R1's fall on [DATE] and the facility's failure to provide necessary care and treatment to R1 by not having an RN assess R1 immediately following a fall from bed with a head injury and prior to being transferred off of the floor. Surveyor shared concerns R1 was sent out by private ambulance and not 911 when R1 had a head injury which caused a delay in treatment. Surveyor shared with Assistant Executive Director-C the concern regarding the facility not checking with R1's physician in regard to delaying the CT scan of the head and follow-up with neurosurgery. Surveyor shared concern with lack of communication with the Dialysis Center informing them of R1's subdural hematoma and the missed communication regarding R1's seizure activity during dialysis treatment. There is no evidence the facility responded and followed up on this seizure-like activity and provided monitoring and MD notification for follow up. The facility's failure to ensure an RN assessment was conducted prior to transferring R1 back to bed, the failure of not calling 911 for R1 who had a head injury with bleeding, the postponement of obtaining a CT scan without physician consultation, the lack of communication with dialysis and missed communication of R1 having a seizure, and the lack of monitoring and follow up of R1 having a seizure created a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when: * On [DATE], the facility created a protocol on follow-up appointments that are critical, including that the ordering physician must be notified of appointment changes. Any appointment being rescheduled from the original schedule must have approval from the prescribing physician prior to making the changes. * On [DATE], the facility reviewed the falls policy and created protocol on post resident fall transfers. * All resident falls now require RN assessment prior to resident movement or transfer. * On [DATE], the facility reviewed hemodialysis policy and created communication protocol and processes with dialysis teams to allow for improved communication between facility and dialysis center. * Staff nurse will communicate via communication tool or record in writing to dialysis center including any changes to the residents condition since last treatment. * DON or designee to review all communication sheets prior to scanning into resident digital record. * All nursing staff were trained and educated prior to their next scheduled shift on understanding follow up to critical appointments, communication with the ordering physician on any changes or delays in the original appointment. * All nursing staff were educated on falls protocol and when to transfer a resident post fall. Training included education to report falls to Supervisor or RN. * All nurses were educated on dialysis communication protocol including the introduction of new dialysis communication tool/record. * All nursing staff were education on when to call 911 versus when to utilize private ambulance services. * Audits: - Critical Appointment Rescheduling - nursing staff will show competency of education, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - Falls and Post Fall - nursing staff will show a competency of policy and training, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - Dialysis Communication Protocol - nurses will show competency in updated protocol, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - When to call 911 - nursing staff will show competency in updated protocol, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - All audits will be presented in our Quality Assurance Performance Improvement Committee to monitor education provided as well as results of audits on competency and adherence to training received.

Based on record review and interview, the facility did not provide 2 out of 5 residents (R1 & R8) reviewed for falls with the supervision and assistance necessary to prevent accidents. * R1 was assessed to need 2 staff assistance for transfers and bed mobility. R1 was also assessed to need 2 staff assistance for personal cares due to left sided hemiparesis. On [DATE], Certified Nursing Assistant (CNA)-E was providing incontinence cares to R1, who was in bed, with no other assistant. As R1 was rolled to his left side and CNA-E proceeded to change R1's brief, R1 rolled from the bed, falling to the floor. R1 hit his head on the metal base of the bedside table. CNA- E did not follow R1's care plan by having 2 staff members assist with R1's turning and repositioning in bed while performing incontinence cares. This fall resulted in R1 obtaining a contusion to the forehead which was actively bleeding. R1 was on medication that causes the thinning of R1's blood and it was noted that R1 was bleeding excessively. R1 was sent to the emergency room and was admitted with a diagnosis of a subdural hematoma. R1 received staples and sutures to the forehead and was admitted into the Intensive Care Unit (ICU.) R1 was readmitted into the facility on [DATE]. On [DATE] while removing the sutures, the area appeared infected and R1 was sent to the emergency room and diagnosed with an infection. R1 was placed on an antibiotic and returned to the facility. On [DATE], R1 became unresponsive and was readmitted into the hospital with extensive brain bleed, seizure, and pleural effusion. R1 was placed on comfort care and expired on [DATE]. The facility's failure to provide the necessary assistance as directed in R1's care plan with the use of 2 staff for turning, repositioning, and with personal cares while in bed created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator-A and Assistant Executive Director-C of the immediate jeopardy on [DATE] at 12:45 p.m. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of D (potential for harm/ isolated) as the facility continues to implement and monitor its action plan and as evidenced by: * On [DATE], R8 fell in the bathroom when left alone for privacy. R8 did not use the call light for assistance. A fall assessment completed on [DATE] indicated R8 to be at high risk for falls. R8's care plan was updated to re-educate R8 to use the call for assistance however R8's Kardex was not updated to include instructions for nursing staff on the type of assistance R8 needs when toileted. Additionally, R8's fall care plan included interventions to prevent the potential for injury for any further falls such as the use of a low bed. On [DATE] R8 was observed sleeping in bed. The bed was not in the low position. Findings include: Surveyor reviewed the facility's policy Falls Clinical Protocol revised [DATE], which includes in part the following: Cause Identification: (includes) 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Monitoring and follow-up: (includes) 1. The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. R1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting left dominant side, other nontraumatic intracerebral hemorrhage, epilepsy, type 2 diabetes mellitus with diabetic chronic kidney disease, aphasia, heart disease, end stage renal disease, peripheral vascular disease, and vascular dementia. R1's Fall Risk assessment, dated [DATE], assessed R1 as a high risk for falls. R1's Quarterly MDS (Minimum Data Set) dated [DATE], documents a BIMS (Brief Interview of Mental Status) of 5 indicating R1 is severely cognitively impaired. R1 has an activated POA (Power of Attorney.) R1's functional status for bed mobility, transfers, dressing, and toilet use are all assessed as extensive assist with two + person physical assist. R1's physician orders include Plavix Oral tablet 75mg (milligrams) once daily and Aspirin oral tablet 81mg once daily for anticoagulants and Vimpat tablet 150mg - give 0.5 tablet by mouth two times a day for seizures, order date [DATE]. Plavix is an antiplatelet medication. According to WebMD, Easy bleeding/bruising are side effects of Plavix and persons taking it should take precautions to lower the risk of being cut. https://www.webmd.com/drugs/2/drug-5869/plavix-oral/details R1's care plan dated [DATE] documents R1 as being at risk for injury due to falls due to incontinence, unaware of safety needs, needs assistance with mobility. Interventions include keep bed in low position when R1 is in it to prevent R1 from being injured if R1 rolls out with a start date of [DATE] and fall mat placed at bedside to prevent injury related to fall with a start date of [DATE]. R1's care plan also documents an ADL (activities of daily living) self-care performance deficit due to need for assistance with mobility, stroke, incontinence, dementia, anemia, and ataxia with interventions that include 2 staff members to reposition and turn in bed with a start date of [DATE]. Other interventions include, totally dependent on staff for toileting with a start date of [DATE] and bed to be located against wall at all times, left side of body should be located closest to wall with a start date of [DATE]. R1's CNA Kardex documents bed mobility: requires 2 staff members to reposition and turn in bed and transferring: requires 2 staff assist with transfers. The Misconduct Incident Report submitted by the facility, dated [DATE], documents on [DATE] at 1:30PM R1 was receiving cares from CNA-E after having a bowel movement. While CNA-E turned R1 on R1's left side R1 rolled off the bed. R1 hit the head on the foot of the bedside table. Nurse assessed R1 and observed a contusion to middle of the forehead. R1 was assisted off the floor by two CNAs with a Hoyer lift and pressure applied to contusion. R1 was sent to the emergency room (ER.) Nurse Practitioner (NP)-F encounter note dated [DATE] documents, Provider was asked to urgently see patient for concerns of head trauma. Per staff, R1 was receiving cares after a bowel movement and rolled off the bed and onto the floor, hitting his head on the bed side table. Lying in bed - wet towel on his head - actively bleeding from wound to center top forehead. Large amount of blood present in his hair and on his pillow. PLAN: Staff instructed to hold pressure and call 911. Needs urgent evaluation of his head - on blood thinners with prior history of VP shunt. Will need imaging to ensure no hemorrhaging. R1 was admitted to the hospital on [DATE]. The hospital admission note dated [DATE] documents, CT of the head was obtained, showing new subdural hematoma along the right tentorium, and along the posterolateral margin of the right temporal lobe. Neuro critical care and neurosurgery teams were contacted. Patient's wife was also contacted. She confirmed Do Not Resuscitate status and did not want any neurosurgical treatments. Decision was made to admit the patient to the ICU at this facility. DDAVP was recommended by critical care, as the patient is on aspirin and on dialysis. R1 was discharged from the hospital on [DATE]. The Hospital Discharge Summary dated [DATE] documents under Impression and interventions: Acute traumatic subdural hematoma. History of intraventricular hemorrhage (2017). Seizure disorder. No seizure overnight. Neurosurgical evaluation in 2 weeks, antiplatelet therapies on hold until evaluated as outpatient by Neurosurgery. SC Heparin ok. Repeat CT head prior to outpatient evaluation by Neurosurgery. Surveyors continued review of R1's medical record, which documented in part: R1's daily progress notes regarding R1's staples and sutures do not include any documentation of any redness, drainage, or signs of infection from [DATE] through [DATE]. Surveyor noted a Physician order to remove 2 staples and 5 sutures to forehead dated [DATE]. NP-F Encounter note dated [DATE] documents, The provider was called to the patient's room to evaluate him as the nurse was removing his staples and sutures and noted what appeared to be pus coming from his head wound .The wound has started to dehisce again and is bleeding. Wound edges are red, extending into the surrounding tissue. The wound has also started to swell again. The wound was irrigated with normal saline and purulent drainage was noted as well .Follows with Wound MD in house. Plan: send to ER (emergency room ) for evaluation and treatment. Wound appears to be infected and has now started to dehisce. Needs evaluation from MD as well as possible imaging. R1's After Visit summary from the ER, dated [DATE], documents a diagnosis of infected wound and doxycycline (antibiotic) was started. R1 returned back to the facility. R1's Progress Note dated [DATE] at 17:44 (5:44 PM) documents, Writer was called into this room and noted this PT (patient) to be unresponsive .911 called and NP updated about sending this PT out to the ER. Progress Note dated [DATE] at 22:18 (10:18 PM) documents .updated about this PT who was admitted (to hospital) with an extensive brain bleed, midline shift of about 6mm, pleural effusion and seizure. PT is on comfort care there and will either stay there to pass or family will take him home from there to pass. R1 expired on [DATE]. On [DATE] at 11:32 AM, Surveyor interviewed CNA-E who stated R1 rolled off the bed during cares and hit his head on the foot of the bedside table. CNA-E stated R1 was bleeding from the forehead. CNA-E stated she panicked and left the room to find help. CNA-E reported she found another CNA who helped her transfer R1 off the floor and back into bed with the Hoyer lift. When R1 was in bed CNA-E then went to get a nurse. CNA-E stated a Registered Nurse (RN) and Licensed Practical Nurse (LPN) came to assess R1. R1 was actively bleeding from the middle of the forehead so CNA-E held pressure on the injury. The nurse then contacted the Nurse Practitioner in the building to come and assess. CNA-E explained she was trained R1 was a one person assist for ADL cares. She was not aware R1 required two-person physical assist. CNA-E explained she recently was retrained for several days and she is now aware R1 was a two person assist. On [DATE] at 12:00 PM, Surveyor interviewed the Assistant Executive Director-C regarding R1's fall. Assistant Executive Director-C informed Surveyor R1 was a 2 person transfer at the time of the fall and that CNAs have access to resident information on the Kardex on tablets and staff can ask a nurse if they have any questions. Assistant Executive Director-C explained CNA-E was recently hired at the facility in [DATE] and received Relias training and shadowing with another seasoned CNA for 2 shifts prior to working independently with residents. Assistant Executive Director-C stated when they were made aware of R1's fall, after investigating they felt it would be best to give CNA-E, 6 additional shifts to train with a seasoned staff. Assistant Executive Director-C explained CNA-E was retrained on safe patient handling and resident centered cared. Retraining occurred [DATE] through [DATE]. Surveyor asked if retraining occurred with all staff and Assistant Executive Director-C stated they had only focused retraining CNA-E. Surveyor asked Assistant Executive Director-C if there is a system in place to monitor staff following resident care plans. Assistant Executive Director-C said no. Assistant Executive Director-C reported training of staff and following care plans are not a topic reviewed at Quality Assurance and Performance Improvement at meetings at this time. On [DATE], at 11:35 AM, Surveyor informed Assistant Executive Director-C of the concerns regarding R1's fall on [DATE]. CNA-E was not following R1's care plan to prevent the fall from occurring, which caused R1 to sustain a subdural hematoma. The facility did not complete a thorough investigation of the fall to determine all the facts and training of all staff was not included as part of their follow up. The facility's failure to follow R1's care plan and provide the necessary assistance with bed mobility during incontinence care lead to a fall with injury (subdural hematoma,) creating a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when: * The facility reviewed the care plan policy and created a protocol with education for how to access care plans on various devices in the facility within the electronic medical record. * The facility updated fall assessments for each resident in the facility. * Initiated a facility wide audit of all resident care plans to ensure each resident has a comprehensive ADL care plan with complete interventions. Conducted audits to review care plans and to ensure care plans reflect current fall risks as well as interventions. Audits to begin on [DATE]. Identified resident's care plan was updated on [DATE] with current ADL needs. The Director of Nursing (DON) or designee will complete the audit. The Regional Clinical Director will verify the audit for completeness. Audits completed by [DATE]. * All nursing staff will be trained prior to the beginning of their next scheduled shift on care plans, understanding care plans and how to access care plans and Kardex's. All Nursing staff will be re-educated on use of care cares and where to find updates and changes to the resident's Kardex. The DON or designee will re-educate. Education will begin [DATE] and will be completed before the start of their next shift. * Facility implemented shift huddles including nurses and CNAs to identify and communicate care plan changes to CNA staff on their respective assignments. * All care plan changes will be listed on Nursing 24 hour board for communication. Nurse leaders will communicate care plan updates through the nursing 24 hour communication board. Certified nursing Assistants and Nurses will be responsible for reviewing and initialing the 24 hour communication board prior to the beginning of each shift. This new process will be initiated on [DATE] and an audit will begin on [DATE]. Administrator or designee will audit daily to ensure each staff member is reviewing and singing the 24 hour communication board. * Care plans nursing staff will show competency in resident care plans and show competency with accessing care plans in real time, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. * All audits will be presented in the Quality Assurance Performance Improvement Committee to monitor education provided as well as results of audits on competency and adherence to training received. The deficient practice continues at a scope and severity level of D (potential for harm/isolated) as evidenced by: 38829 2. Surveyor reviewed the facility's Comprehensive Care Plans policy and procedure implemented on [DATE] as it pertains to updating care plans with any resident changes: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan of each Resident, consistent with Resident rights, that includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs are identified in the Resident's comprehensive assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . R8 was admitted to the facility on [DATE] with diagnoses of Burns involving ,d+[DATE]% of body surface with third degree burns, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Need for Assistance with Personal Care, Transient Cerebral Ishemic Attack, Peripheral Vascular Disease, Chronic Kidney Disease, Stage 4, Absence of Right Great Toe, Major Depressive Disorder, and Unspecified Mood Disorder. R8 is his own person. R8's Admission Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview for Mental Status (BIMS) score is 13, indicating R8 is cognitively intact for daily decision making. R8's MDS also documents that R8 requires limited assistance for bed mobility, extensive assistance for transfers of 2, and extensive assistance for toileting of 1. R8 has range of motion impairment on one side of lower extremity. R8's MDS states R8 is only able to stabilize with staff assistance for walking/moving from seated to standing. Surveyor reviewed R8's Admission Care Area Assessment (CAA) signed [DATE] which documents R8 is at risk for falls due to history of falls, weakness, impaired mobility, and gait. Surveyor reviewed R8's electronic medical record (EMR) and notes R8 does not have an admission fall assessment completed. On [DATE] at 3:30 PM, Administrator (NHA)-A confirmed fall assessments should be done at time of admission on all residents. Surveyor was provided R8's Kardex on [DATE], a tool nursing staff utilizes to be informed of how to care for R8 and notes the following for: Safety -Be sure call light is within reach when R8 is in room and encourage R8 to use it before attempting to transfer -Ensure R8 has unobstructed path to bathroom -Ensure appropriate footwear when out of bed -Keep bed in low position when R8 is in to prevent R8 from rolling out and being injured -Make sure floor/path is clutter free and properly lighted -Re-education on use of call light-verbalized and demonstrated understanding Toileting -ADL: Toilet Use On [DATE] at 9:55 AM, Surveyor interviewed Interim Director of Nursing (IDON)-D in regards to what ADL: Toilet Use means on R8's Kardex. IDON-D stated, It means that it is not filled out. IDON-D agreed that a CNA or nurse would not know how to care for R8's toileting needs. IDON-D indicated it is not clear if R8 can be left alone in the bathroom or not. Surveyor reviewed R8's comprehensive care plan for falls and activities of daily living (ADLs) (toileting specific) and noted the following: 1. R8 has an ADL Self Care Performance Deficit-initiated [DATE] -Toileting: R8 is a stand pivot transfer from the wheelchair to the toilet. R8 utilizes a 2 wheeled walker, gait belt, and assist of 1 for toilet transfers Initiated [DATE] -Toilet Use: R8 needs extensive assistance from staff for toileting/incontinence care. Initiated [DATE] On [DATE] at 9:55 AM, IDON-D stated that 'extensive assistance' means that R8 requires physical help from staff to get on and off the toilet. IDON- D agreed that as of [DATE], it is unclear based on R8's comprehensive care plan whether R8 requires extensive assistance of 1 or 2 staff. IDON- D stated that R8's care plan had been revised on [DATE] after Surveyor left the facility. Care plan includes: 2. R8 is at risk for injury due to falls due to gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs-initiated [DATE] -Encourage to be in common areas when awake-Initiated [DATE] -Re-education on use of call light-verbalized and demonstrated understanding-Initiated [DATE] -Be sure call is within reach when in room and encourage to use it before attempting transfer-Initiated [DATE] -Need activities that minimize the potential for falls while providing diversion and distraction-Initiated [DATE] -Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated-Initiated [DATE] -Ensure wearing appropriate footwear when out of bed-Initiated [DATE], Revised [DATE] -Make sure floor/path is clutter free and properly lighted-Initiated [DATE], Revised [DATE] -Keep bed in low position when in it to prevent me from rolling out and being injured-Initiated [DATE] and RESOLVED on [DATE] On [DATE] at 6:40 PM, R8 had a fall in the bathroom and did not sustain an injury. R8 was assisted to the toilet by a CNA. R8 requested privacy for a few minutes so CNA left R8 alone and informed R8 to pull the cord or call out for assistance and went to the room next door to assist another resident. A loud bang was heard and CNA immediately went to check on R8 and observed R8 on the floor. It is documented that R8 did not use the cord. Surveyor notes that a registered nurse (RN) assessment was completed, and then R8 was mechanically lifted from the ground. Neuro-checks were completed as well as physician and family notification. A fall assessment was completed on [DATE] at 7:30 PM for R8 which documents a score of 17, indicating R8 is high risk for falls. Surveyor notes that R8's comprehensive care plan was updated to re-educate R8 to use the call for assistance, however, R8's Kardex which instructs nursing staff on what type of assistance R8 requires for toileting was not updated. On [DATE] at 8:05 AM, Surveyor observed R8 in bed sleeping, and the bed is in the regular position and was not in low position as indicated in R8's fall care plan dated [DATE]. On [DATE] at 8:17 AM, Surveyor observed Occupational Therapist (OT) I enter R8's room. Surveyor asked OT I if R8's bed was in the low position. OT I stated it did not look like it was and then said, Why? Is that on the care plan? OT I then demonstrated for Surveyor that R8's bed was not in the low position and stated, I would have to say the bed was not in the low position. On [DATE] at 8:40 AM, Surveyor spoke to Medication Tech (MT)-J who also floats as a Certified Nursing Assistant (CNA) when needed. On this day, MT-J was assigned to R8 as a CNA. MT-J stated that MT-J's initial rounds when coming on shift is just to make sure all MT-J's Residents are breathing. MT-J stated this morning, MT-J just put an eye on R8. MT-J indicated that MT-J knew R8 was to be in a low bed, observed R8's bed to not be in the low position, however, confirmed that MT-J did not put the bed in low position upon observation. MT-J stated, It was a snafu that I did not check the bed. MT-J informed Surveyor that MT-J did not check R8's Kardex prior to going into the room to review R8's care instructions. MT-J stated R8 is extensive assistance for toileting, which means giving R8 time in the bathroom and assisting R8 on and off the toilet. MT-J would step out of the room to go get supplies. MT-J does attend the 'huddle' in between shifts and sometimes checks the 24 hour board for any changes. On [DATE] at 9:55 AM, Surveyor spoke to IDON-D in regard to R8's bed not being in the low position. IDON-D confirmed that R8's Kardex and comprehensive care plan document R8 should be in a low bed, and if that is what is documented then the expectation would be that when R8 is in bed, the bed should be in the low position. IDON-D understands the concern. On [DATE] at 10:24 AM, Surveyor shared the concern with NHA-A and Assistant Executive Director (AED)-C that R8's Kardex documented R8 is to be in a low bed for safety to prevent injury and this was not followed by MT-J. Surveyor also shared that R8's Kardex was not updated with care instructions after R8's [DATE] fall in the bathroom. Both NHA-A and AED-C understood the concerns and provided no further information at this time. On [DATE] at 2:48 PM, AED-C acknowledged that R8's intervention of a low bed was added on [DATE], 11 days after admission, but nobody from the clinical team is able to provide a reason why the intervention was added and then resolved today after Surveyor informed the facility of R8's bed being in the regular position.

The facility did not ensure 3 (R56, R12 and R71) of 3 residents received adequate supervision by staff to prevent accidents *R56 is severely cognitively impaired and was identified to be at high risk for elopement. R56 eloped from the facility on 5/31/22 after a staff person disabled the wanderguard alarm because of the number of times R56 had set it off. R56 was found approximately 1 mile from the facility without proper footwear in rainy weather. Staff was not aware that R56 had left the building for approximately 75 minutes before they noticed her missing and local law enforcement. The facility's failure to ensure a door alarm was activated to alert staff if a resident with a Wanderguard bracelet attempted to leave out the door, the failure to have a care planned approach to monitor/supervise R56's whereabouts, the failure to know of R56's whereabouts and to conduct a thorough investigation into the elopement created a condition of an immediate jeopardy starting on 5/31/22. The immediate jeopardy began on 5/31/22. NHA (Nursing Home Administrator)-A was notified of the immediate jeopardy on 8/11/22 at 12:00 PM. The immediate jeopardy was removed on 8/19/22. The deficient practice 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 and as evidenced by the following noncompliance for R12 and R71. * The facility did not conduct a through investigation when facility staff spilled a hot beverage on R12's lap. * R71 was admitted with a fractured neck following a fall at assisted living and wears a cervical collar. R71 fell 15 times in 4.5 months following admission. The facility did not conduct through investigations of R71's falls including a root cause analysis and did not revise R71's care plan to reduce the risk of further falls and injury. Findings include: 1. R56 was admitted to the facility on [DATE] with diagnoses of subdural hemorrhage, metabolic [CONDITION(S)] and dementia without behavioral disturbance. R56's Admission MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 03, indicating R56 is severely impaired for daily decision making skills. R56's Admission MDS indicates resident requires supervision to limited assistance with activities of daily living including transfers and ambulation. Resident's gait is coded as not stable but able to stabilize without staff assistance. R56 does not require the use of mobility devices. R56's Admission MDS indicates R56 exhibits wandering behavior on a daily basis. An Elopement assessment dated [DATE] indicates R56 is at risk for elopement. R56's comprehensive care plan dated 5/24/22 indicates resident is at risk for falls and includes intervention of wearing proper footwear when out of bed. R56's comprehensive care plan dated 3/28/22 indicates R56 is at risk for elopement due to attempts to leave facility. Interventions include; Redirection of [R56] from exit doors, Distract from wandering with pleasant diversion including offering activities and snacks, and Placement of Wanderguard bracelet to the left ankle. R56's Wanderguard is to be checked for placement every shift and checked for function on night shift by nursing staff. This is being documented by nursing staff on the R56's MAR (Medication Administration Record). Surveyor reviewed R56's medical record. Surveyor noted a Facility self report dated 6/7/22. The facility's self report indicates on 5/31/22 at 10:23 PM, R56 was found to be missing by facility staff. ADON (Assistant Director of Nursing)-H via phone directed nursing staff to initiate a missing resident code at the facility and to call local law enforcement. ADON-H notified DON (Director of Nursing)-B. NHA (Nursing Home Administrator)-A was notified of missing resident via phone. Per Police report, officers arrived at the facility on 5/31/22 at approximately 10:34 PM. Facility staff showed police officers the facility's wandering book which included photos of R56. On 5/31/22 at approximately 10:37 PM, Police were called to investigate a suspicious person from a concerned citizen in the community. Officers found R56 approximately 1 mile from the facility wearing a hooded sweatshirt, pants and stocking feet with no shoes. Police returned R56 to the facility on [DATE] at approximately 11:00 PM. A head to toe assessment was conducted upon resident's return which found resident to be without injury. Residents pants and socks were notably soiled with mud as it had been raining off and on during the evening of 5/31/22. Surveyor noted the National Weather Service indicated that the lowest recorded temperature on 5/31/22 was 57 degrees Fahrenheit. Surveyor could not confirm through documentation or interviews conducted by facility staff that R56 had been seen on 5/31/22 after 6:30 PM. On 8/10/22 at 4:00 PM, Surveyor met with NHA-A to discuss R56's elopement and elopement investigation. Surveyor asked NHA-A if the facility has cameras for surveillance. NHA-A informed Surveyor on 5/31/22 an agency nurse presumably became annoyed with the number of times R56 set off the Wanderguard alarm to the doorway at the end of the hall, and she turned off the alarm. NHA-A reported they had video footage of a former agency nurse, who is no longer employed by the facility, disabling the skylight north exit doors code alert system, leaving the exit without an engaged alarm. Surveyor noted there were 4 residents with Wanderguard bracelets on this unit; all would have had the opportunity to leave out the unalarmed door at the end of the unit. Surveyor asked NHA-A if they had conducted interviews of facility staff who worked on 5/31/22 in relation to R56's elopement. NHA-A told Surveyor that it hadn't occurred to him to interview staff because of the video footage of the individual eloping through the Skylight North exit door. NHA-A reported R56 was in the facility until approximately 9:15 PM when there was footage of an individual exiting through the Skylight North exit door. Surveyor asked how it was confirmed that the exiting individual was R56. NHA-A told Surveyor that it was difficult to see the camera footage due to condensation on the camera lens from rain. NHA-A indicated at 10:30 PM staff noticed R56 was missing and were unable to find him in the building. The LPN called ADON-H who instructed LPN to initiate a code and to call local law enforcement. Police arrived at 10:34 PM. Police responded to a call placed by a concerned citizen and located R56. The police returned R56 to the facility on [DATE] at about 11:00 PM. R56 was not injured. On 8/10/22 at 10:05 AM, Surveyor interviewed Maintenance Director-U. Surveyor asked Maintenance Director-U who is responsible for checking the functionality of the facility's code alert system. Maintenance Director-U informed surveyor that they had not been checking the facility's exit doors for code alert functioning until 8/8/22. Maintenance Director-U informed surveyor that they are planning to check exit doors for code alert system every Monday, Wednesday, and Friday. On 8/10/22 at 1:35 PM, Clinical Care Manager-K was interviewed by Surveyor. Surveyor asked Clinical Care Manager-K how nursing staff would know how to identify a resident who is at risk for elopement. Clinical Care Manager-K told Surveyor that residents who wander would be listed in the facility's wander books, which are available at the main entrance, activity department, maintenance department, kitchen and nursing station. The wander books include resident photos, demographic information and location of their Wanderguard devices. Surveyor asked Clinical Care Manager-K how often a resident who is at risk for elopement should be checked on by staff. Clinical Care Manager-K told Surveyor that if a resident is at risk for elopement that they should be checked on frequently. Surveyor asked Clinical Care Manager-K to define what frequently would mean to them. Clinical Care Manager-K told Surveyor that they would expect a resident at risk for elopement to be checked on about every 15 minutes. On 8/10/22 at 3:20 PM, Surveyor conducted an interview with ADON-H. Surveyor asked ADON-H how nursing staff would know how to identify a resident who is at risk for elopement. ADON-H told Surveyor that residents who wander would be listed in the facility's wander books. Surveyor asked ADON-H how often a resident who is at risk for elopement should be checked on by staff. ADON-H K told Surveyor that if a resident is at risk for elopement that they should be checked on at least every half hour. Surveyor asked ADON-H what they had recalled about R56's elopement on 5/31/22. ADON-H told Surveyor that they had not been in the building at the time of R56's elopement but received a call from facility staff asking for direction. ADON-H had spoken to a nurse who is no longer is employed by the facility and directed them to initiate a wandering code at the facility and to call the police. ADON-H then notified DON-B. ADON-H did not have any further involvement related to R56's elopement investigation. Surveyor asked NHA-A how often the code alert system should be checked for functioning. NHA-A says that they would like the system checked daily but knows that it has not recently been checked daily due to changes in maintenance staff. NHA-A told surveyor that they are in negotiations to upgrade the code alert system at this time as their system is antiquated. Surveyor shared concerns related to R56's elopement on 5/31/22 related to the facility's inability to identify when R56 was last checked on and staff disabling the facility's door alarm system allowing for R56 to elope without the door alarm sounding. R56 wandered approximately 1 mile from the facility while raining without appropriate footwear. This facility is also located on a high traffic state highway. R56's elopement care plan was not updated after R56's elopement on 5/31/22, which causes continued concern for R56's safety. The facility's failure to ensure a door alarm was activated to alert staff if a resident with a Wanderguard bracelet attempted to leave out the door, the failure to have a care planned approach to monitor/supervise R56's whereabouts, the failure to know of R56's whereabouts, and the failure to conduct a thorough investigation into the elopement created a reasonable likelihood for serious harm given R56's cognitive status and the facts that R56 was outside at night in rainy conditions. This led to a finding of immediate jeopardy starting on 5/31/22. The IJ was removed on 8/18/22 when; ~ Assessments were conducted for all residents identified to be at risk for wandering. ~ Orders were updated to include Wander Guard Placement for all residents who need wander guards. ~ Care plan audits were conducted for all residents identified to be at risk for wandering. Cardexs were updates for all residents identified to be at risk for wandering. ~ The facility's Wander books were updated including policy and demographics. The Wanderguard books were updated to include distractions specific to each resident at risk. Structured activities, diversions, re-orientations strategies, food, television and conversations for identified residents. ~ 15 minute checks for preventative measures were implemented for resident identified in this deficiency. ~ Education for all staff on Elopement and Wandering resident policy was completed including tips for elopement prevention. Non-Pharmacological interventions were discussed for nursing staff. ~ The Procedure for wander/door alarm inspection for maintenance was updated. Nursing staff demonstrated deactivation and activation of the door alarm system. Alarm keys were removed from all key rings but for the supervising nurse set and DON. The door alarm will be replaced when able. ~ Elopement drills will be performed weekly X4, bi-weekly X2 months, monthly X3, and quarterly thereafter for 6 months. Results will be brought through Quality Assurance Process Improvement (QAPI). ~ Door alarm audits daily for 30 days and 3 x week for 11 months. Results will be brought through QAPI. QAPI to review quarterly residents at risk for wandering with the Medical Director. The deficient practice continues at a scope and severity level of E (potential for harm/pattern) as evidenced by; 2. On 8/7/22 at 11:20 a.m. R12 informed Surveyor about three or four months ago she received a burn on her leg. Surveyor inquired what had happened. R12 explained a dietary worker was bringing in her tray, the cup of coffee was knocked over and scalded her legs. R12 indicated there was a sheet and blankets over her legs and she couldn't take the blanket off which was full of hot coffee. R12 informed Surveyor the dietary worker didn't know what to do and she asked him to take off the sheet. The nurses note dated 4/8/22 documents when staff brought her supper tray to her room res (resident) moved her TV tray and a cup of coffee spilled on her right lower leg no redness noted no blisters applied cold wash cloth to area immediately, no increase in warmth to area. 3 blankets were on res at the time the coffee spilled on res, res requested to go to ER (emergency room ) writer called [name of] her son and made aware. [name of] NP (nurse practitioner) aware [name of] ambulance called to transport to ER (emergency room ). RN (Registered Nurse) supervisor was present with writer for skin check. The nurses note dated 4/8/22 documents, On call RN made aware of res going to ER and the spilled coffee that occurred. The nurses note dated 4/8/22 documents res returned to facility. right lower leg wrap with kerlix and Vaseline gauze. res had no c/o (no complaint) pain or discomfort at this time. new order received. The hospital after visit summary dated 4/8/22 under diagnoses documents thermal burn & superficial burn of right lower leg, initial encounter. The physician order with an order date of 4/8/22 includes a treatment of cleanse right lower leg with normal saline, pat dry, apply Vaseline gauze and wrap with kerlix daily. This treatment was discontinued on 5/9/22. The nurses note dated 4/9/22 documents, Resident in good spirits. No c/o discomfort to RL (right lower) calf. Area that sustained burn is wrapped. Res stated they told her to leave wrap on a few days. She also stated that the bed she was in at hosp (hospital) had a scale and she weighed 55kg (kilograms). The nurses note dated 4/9/22 documents, Resident monitored for RLE (right lower extremity). Lower leg is wrapped. No drainage. Complaining of burning sensation. Given Tylenol for comfort twice this evening. The nurses note dated 4/10/22 documents, Pt (patient) is being followed for RLE where coffee got spilled. Pt is alert and orientated per baseline. RLE wrapped. Pt has no c/o pain or discomfort at this time. Pt is in bed sleeping. The dietary note dated 4/11/22 includes documentation of Resident is being followed for coffee got spilled, resident agreed to special mug with cover for beverages. Kitchen aware. On 8/8/22 at 1:41 p.m. Surveyor asked CCM (Clinical Care Manager)-K if she was aware of R12 being burned by spilled coffee. CCM-K informed Surveyor apparently there was a day the tray tipped in the room and R12 was burned with coffee. CCM-K informed Surveyor she was not working that day but knows R12 was on report after. On 8/8/22 at approximately 3:00 p.m. Surveyor asked Administrator-A for the Facility's investigation regarding R12 being burned by coffee. On 8/9/22 at 8:42 a.m. Surveyor asked Administrator-A if there is an investigation for when R12 was burned by spilled coffee. Administrator-A informed Surveyor he is still looking for the investigation and wasn't aware of the incident until yesterday. On 8/9/22 at 12:52 p.m. Surveyor asked Administrator-A if he was able to locate an investigation for R12. Administrator-A informed Surveyor he has an IRIS which is the Facility's incident report which he will bring to Surveyor. On 8/9/22 at 1:03 p.m., Surveyor reviewed the Facility's incident report dated 4/8/22 which documents for initial reported description, When staff brought her supper tray to her room res (resident) moved her TV tray and a cup of coffee spilled on her right lower leg no redness noted no blisters applied cold wash cloth to area immediately. no increase in warmth to area. 3 blankets were on res at the time of the coffee spilled on res. res requested to go to ER (emergency room ) writer called [name of] her son and made aware. [Name of] NP (Nurse Practitioner) aware [name of]ambulance called to transport to ER. RN supervisor was present with writer for skin check. Under immediate action reported documents cool wash cloth applied blankets removed skin check done. Under section for review follow up for contributing factors is checked for Patient/Family - Failure to Follow Plan of Care. The Facility did not investigate R12's burn caused by spilled coffee to prevent further occurrences to R12 or other Residents. There is no evidence the Facility investigated the temperature of coffee when Residents receive this beverage to determine if the temperature is too hot, if there are other Residents at risk and what interventions were implemented to prevent this occurrence to other Residents. 3. The Fall and Fall Risk, Managing Policy from 2001 Med-Pass Inc (Revised March 2018) under the section Resident-Centered Approaches to Managing Falls and Fall Risk documents If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. R71 was admitted to the facility on [DATE] with diagnoses which includes dementia with behavioral disturbances, hypertension, anxiety disorder, panic disorder, and depressive disorder. The at risk for injury related to falls care plan initiated 3/1/22 & revised 6/6/22 has the following approaches: * Encourage me frequently to ask for assistance or use call bell for any assistance. Initiated & revised 3/1/22. * Encourage me to be in common areas when I am awake. Initiated & revised on 3/1/22. * Encourage me to walk short distances assisted by staff when physically able, to avoid attempting self ambulation. Initiated 7/13/22. * Insure Broda Chair is reclined to prevent falling forward. Initiated 6/14/22. * Please check and change or toilet me every midnight to prevent me from self transferring or self toileting d/t TTWB (toe touch weight bearing) status and to prevent falls or injuries. Initiated & revised 3/1/22. * Provide frequent reminders to ask for assistance, rather than attempting to provide self care. Initiated 5/17/22. * Resident was moved to room closer to nurses station. Initiated 3/2/22. * Safety mat next to bed to prevent injury. Initiated 6/4/22. * PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Initiated & revised 3/1/22. * Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. Initiated & revised 3/1/22. * Educate me/family/caregivers about safety reminders and what to do if a fall occurs. Initiated & revised 3/1/22. * I need activities that minimize the potential for falls while providing diversion and distraction. Initiated & revised 3/1/22. * I need to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness. Initiated & revised 3/1/22. * Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated. Initiated & revised 3/1/22. * Ensure that I am wearing appropriate footwear when out of bed. Initiated & revised 3/1/22 * Make sure that my floor/path is clutter free and properly lighted. Initiated & revised 3/1/22. * Keep my bed in low position when I am in it to prevent me from rolling out and being injured. Initiated 3/1/22. The actual fall with no injury care plan initiated & revised on 3/1/22 includes approaches of: * Continue interventions on the at risk plan. Initiated & revised 3/1/22. * For no apparent acute injury, determine and address causative factors of the fall. Initiated & revised 3/1/22. * Keep resident in common areas when awake for safety due to severe dementia and anxiety. Initiated & revised 3/1/22. * Monitor/document/report PRN ( as needed) x (times ) 72h (hour) to MD (medical doctor) for s/sx (signs/symptoms): Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Initiated & revised 3/1/22. * Neuro-checks x 5 hours. Initiated & revised 3/1/22. * Pharmacy consult to evaluate medications. Initiated & revised 3/1/22. * Promote activities that promote exercise and strength building where possible. Provide 1:1 activities if bed bound. Initiated & revised 3/1/22. * PT (physical therapy) consult for strength and mobility. Initiated & revised 3/1/22. The admission MDS (Minimum Data Set) with an assessment reference date of 3/2/22 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R71 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use, ambulated in room once or twice with two plus person physical assist, is occasionally incontinent of urine and continent of bowel. R71 is coded as having fallen within one month of admission, fell during two to six months prior to admission and had a fracture related to a fall in the six months prior to admission. R71 has fallen since admission with no injury. The Fall CAA (Care Area Assessment) dated 3/11/22 under analysis of findings for nature of the problem/condition documents [AGE] year old female patient with Dx (diagnoses) of multiple fractures, dementia, [CONDITION(S)] (hypertension), anxiety, depression, GERD (gastroesophageal reflux), failure to thrive, DM2 (diabetes mellitus), HLD ([CONDITION(S)]), Vitamin D deficiency, insomonia, and [CONDITION(S)] admitted to facility status post fall who demonstrates decreased mobility, weakness, and pain. Patient had unwitnessed fall in room on 3/1/22; was sent to ER (emergency room ) for evaluation with no injury noted. CAA triggered due to need for staff assistance to stabilize during transfers and ambulation, recent history of fall with fracture prior to admission, fall in facility post admission, and use of antianxiety and antidepressant medications. The fall risk assessment dated [DATE], 3/15/22, 3/17/22, 3/26/22, 3/27/22, 4/12/22, 4/18/22, 5/12/22, 5/16/22, 6/4/22, 6/8/22, 6/13/22 & 7/13/22 all have scores indicating R71 is at high risk for falls with the exception of 4/6/22 which has a score indicating moderate risk. The nurses note dated 3/1/22 documents Resident is alert and can make needs known. Resident tried self transferring several times. Resident also had complaints of wanting to go to the bathroom, and was toileted several times with 2 outputs. No complaints of pain, burning or any discomfort with urination. Resident has a neck collar on that should remain on at all times. Resident is a high fall risk. No cough, no SOB (shortness of breath), no respiratory issues, and no sudden loss of taste. No complaints of pain or discomfort noted. Will continue to monitor. FALL #1 The nurses note dated 3/1/22 documents Resident had unwitnessed fall in her room. She was sitting on the floor next to bed, head up and arms and legs at normal position. Able to move upper and lower extremities. No respiratory distress. No s/s (signs/symptoms) of active bleeding. No new skin issues noted. [name of] NP (Nurse Practitioner) was notified. Order to send her for evaluation. [name] was also notified. VSS (vital signs) stable. The Resident Fall Data Collection Tool for fall dated 3/1/22 under summary statement/root cause documents Resident admitted to SNF (skilled nursing facility) post fall in assisted living resulted in resident going to hospital and fracture of C, C2 diagnosed . C-Collar was on at times. Resident very anxious (baseline). Doesn't use call light for assistance. Resident on commode and attempted to transfer self to bed. Resulted in resident losing balance. Resident sent to ER for evaluation related to her already diagnosed C1-C2 fracture as a precautionary measure. Sent back, no new orders or diagnosis related fall. Moved to room closer to nurses station. R71's falls care plan was updated 3/2/22 with the intervention to move to a room closer to nurses station. FALL #2 The nurses note dated 3/15/22 documents Observed res (resident) lying on her right side in fetal position in skylight south dining room area. Wheelchair was behind res. no c/o (complaint of) pain or discomfort. cervical collar in place. ROM WNL (range of motion within normal limits) RN (Registered Nurse) present. Called [name] and order to send out to [name of hospital] ER (emergency room ). Contacted friend [name]. [Name of] ambulance contacted. Res remained on the floor. Pillow placed under her head. T (temperature) 97.6 P (pulse) 72 R (respirations) 18 B/P (blood pressure)125/71 Pox (pulse oximetry) 98 RA (room air). The nurses note dated 3/16/22 documents 0050 (12:50 a.m.) return from ER per stretcher, assisted back to bed by [name of] EMS (emergency medical services), no new order received from ER. The IRIS (incident report) dated 3/15/22 under initial reported description documents Unwitnessed fall. Resident was found lying on the floor on her right side in a fetal position. No respiratory distress. Able to move upper and lower extremities. No skin injuries were noted. No s/s of active bleeding. No s/s of pain. Under contributing factors is checked for patient/family - failure to follow plan of care & patient/family - patient altered mental status. The Resident Fall Data Collection Tool for fall dated 3/15/22 under summary statement/root cause documents Observed resident in skylight south dining room lying on right side in fetal position. Denies pain. Range of motion within normal limits for resident cervical collar in place T97.6, B/P (blood pressure) 125/71, pulse 72, respiration 18, Pox 98% on room air. Sent resident out to [name of hospital] per order to send when fall present. order received to send to emergency room . remained on the floor pillow placed under head. RN (registered nurse) present. This is a summary statement and does include a root cause for R71's fall. This fall data collection tool does not include staff statements/interviews as to who last observed R71, when was she observed, were prior interventions in place, etc. The RN Supervisor/Unit Manager Review is blank for summary statement/root cause. R71's falls care plan was not revised until 5/17/22. FALL #3 The nurses note dated 3/17/22 documents Resident was in the dining room eating breakfast and somehow got up and walked away from her Broda chair. Found by staff on the floor. Writer was called to assess resident. Resident on the floor with her cervical collar in place. Resident denied pain when asked. Resident to be sent out to hospital for eval and treat for existing neck injury. Updated Guardian [name] and informed NP [name]. Called up [name of] Ambulance for transport and [name of hospital] nurse [name] for report. The nurses note dated 3/17/22 documents Resident was very restless and keep trying to get out of Broda chair. Requested for toileting and toileted x (times) 3. Unable to redirect. 1:1 supervision given until 2100 (9:00 p.m.) No new injury noted from her fall. C Collar in place. Transfer with 1 assist. Occasional calling out for help. The IRIS (incident report) dated 3/17/22 under initial reported description documents Resident was eating breakfast in the dining room in Lead unit and was sitting in Broda chair. Somehow stood up and walked away from chair. Resident has history of multiple falls. Under contributing factors is checked for patient/family - failure to follow plan of care & patient/family - patient altered mental status. The Resident Fall Data Collection Tool for fall dated 3/17/22 under summary statement/root cause documents Resident is a fall risk. Has been in bed or Broda chair and walking away from it. Resident this morning was in lead dining room sitting in Broda chair and somehow stood up and walked away from Broda chair. Found lying on the floor. The RN Supervisor/Unit Manager Review for summary statement/root cause documents Resident has history of multiple falls. Has anxiety self transfers. This fall data collection tool does not include staff statements/interviews as to who last observed R71 & when, were prior interventions in place or the root cause of R71's fall. R71's falls care plan was not revised until 5/17/22. FALL #4 The nurses note dated 3/26/22 documents Resident found on the floor @ 11:30 a.m. Found side lying on the floor next to Broda chair in dining room in lead unit. Resident is alert. Cervical collar in place. Informed NP [name]. Updated Guardian [name]. Called up [name] Ambulance to transport . Called up [hospital name] ER nurse [name] to give report. Sent resident to ER for further eval and treat. Left message to phone of Caseworker [name] to call facility for update. The nurses note dated 3/26/22 documents Pt returned from ER with NNO (no new orders) at this time. The IRIS (incident report) dated 3/26/22 under initial reported description documents Found resident lying on her side on the floor next to Broda chair in Lead dining room. Under contributing factors is checked for communication - language barrier or comprehension deficit, patient/family - failure to follow plan of care & patient/family - patient altered mental status. The Resident Fall Data Collection Tool for fall dated 3/26/22 under summary statement/root cause documents Resident frequent [NAME]. Somehow resident walked away from Broda chair while in the dining room. The RN Supervisor/Unit Manager Review for summary statement/root cause documents Resident frequent falls history. Resident tries to self transfer most of the time. This fall data collection tool does not include staff statements/interviews as to who last observed R71 & when, were prior interventions in place or the root cause of R71's fall. R71's falls care plan was not revised until 5/17/22. FALL #5 The nurses note dated 3/27/22 documents was notified by RN supervisor that my resident fell . The aides on that hall said they found her on the floor crawling to her bed, she was in her wheelchair the last they saw her. I notified the doctor on call as well as her #1 emergency contact. I called [name] but they told me to call 911 because they already had two pickups from this facility. Vital signs 116/68 Pulse 77 T 97.3 and R 18. No pain or injuries noted. The nurses note dated 3/27/22 documents Writer called [hospital name] ER and was told the pt will be discharged back to the facility shortly. The nurses note dated 3/28/22 documents No new orders from the ER. Surveyor was not provided with an IRIS (incident report) for R71's 3/27/22 fall. The Resident Fall Data Collection Tool for fall dated 3/27/22 under summary statement/root cause documents Resident found on floor crawling to bed, was in wheelchair. The RN Supervisor/Unit Manager Review for summary statement/root cause was not included in this resident fall data collection tool. This fall data collection tool does not include staff statements/interviews as to who last observed R71 & when, were prior interventions in place or the root cause of R71's fall. R71's falls care plan was not revised until 5/17/22. FALL #6 The nurses note dated 4/3/22 documents Patient noted to be lying on right side on dining room floor on Skylight South unit. UWF (unwitnessed fall) wi [TRUNCATED]

Based on interview and record review, the facility did not ensure that residents were free from abuse for 2 of 2 (R58 and R237) residents reviewed for sexual abuse. In addition, the facility did not provide a safe resident environment to protect other residents from abuse. On 6/2/22, R237 reported an allegation of sexual abuse. The facility did not assess R237, did not investigate what occurred, did not implement increased monitoring of the accused R41, did not revised the accused R41's care plan to put measures in place to prevent further abuse. On 6/11/22, R58 was involved in an incident of sexual abuse by R41. When staff notified R58's family, they asked to have a psychologist talk to R58 due to a history of abuse. The facility did not thoroughly investigate this incident of sexual abuse. The facility placed R41 on 15 minute checks which were not consistently implemented. R41 wheels himself about the facility and staff on different units were not aware of R41 needing supervision. Although not a smoker, R41 goes outside to sit on the patio which is not supervised. In addition, Surveyor was informed R41 had a room change as a result of this incident however; R41 was noted to be residing in the same room. The facility did not implement interventions to protect residents from abuse. The facility's failure to keep residents free from sexual abuse due to the facility's inaction after each incident, such as not reporting, not investigating, not assessing and not putting interventions in place to prevent further abuse placed female residents at risk for further abuse and created a situation of immediate jeopardy beginning on 6/2/22. Administrator A was notified of the immediate jeopardy on 8/11/22 at approximately 12:00 PM. The immediate jeopardy was removed on 8/19/22; however, the deficient practice continues at a scope and severity level of E (potential for harm/pattern) as the facility continues to implement and monitor its action plan. Findings include: The Facility policy titled: Abuse, Neglect and Exploitation revised 7/2022 documents (in part) . .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse is non-consensual sexual contact of any type with a resident. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Mistreatment means inappropriate treatment or exploitation of a resident. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. F. Providing residents, representatives and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause, and; 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during during and after the investigation, as needed. VII. Reporting/Response 1. Reporting of alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect occurred and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. R41 was involved in 2 alleged sexual abouse allegations with the first incident occurring on 6/2/22 involving R237 and a second incident occurring on 6/11/22 involving R58. R41 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Annual Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment for daily decision making skills. R41's daughter was Power of Attorney (POA) until an Incapacity assessment dated [DATE] recommendations documented: De-activate POA for Healthcare. Is able to evaluate information well enough to give informed consent. R41's Annual Minimum Data Set (MDS) dated [DATE] section E0200: Behavioral Symptoms - Presence & Frequency documents: A. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) - 0. Behavior not exhibited R237 admitted to the facility on [DATE] and discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R237's BIMS dated 6/23/22 documented a score of 13 - indicating R237 as cognitively intact for daily decision making skills. R58 admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R58's Quarterly MDS dated [DATE] documents a BIMS score of 15 - indicating cognitively intact for daily decision making skills. During review of a Facility Reported Incident dated 6/11/22 (which involved R41), Surveyor located progress notes entered on 6/4/22, which documented the Nurse Practitioner was called to inform about accusations against R41. Surveyor asked Director of Nursing (DON)-B about the progress notes on 6/4/22 which documented accusations against R41 and monitoring closely due to accusations. Surveyor asked DON-B if R41 had previous incidents of sexual abuse. DON-B stated, Well, there was one time when he touched or rubbed another female residents' arm. Surveyor asked what accusation the progress notes on 6/4/22 was referring to. DON-B reported he did not know, but will find out. No additional information was provided by DON-B. Nursing Home Administrator (NHA)-A provided Surveyor with a Facility Reported Incident dated 6/4/22. This Facility Reported Incident included the following; Clinical Care Manager (CCM)-K statement dated 6/4/22 documents, On 6/2/22 (R237) reported to me that a male resident kissed her on the cheek. R237 did not know who the resident was and reported it did not really bother her. Surveyor noted CCM-K did not get a full statement from R237 about what had occurred and did not follow up or investigate the allegation regarding R237 allegedly reporting being kissed on the cheek. On 6/3/22 when CCM-K was leaving the building, R237 informed CCM-K she knew who the resident was. CCM-K stated: OK, you could let me know when I return. Surveyor noted although R237 informed CCM-K she could identify the resident involved in the alleged sexual abuse, CCM-K did not follow up or investigate the allegation. On 6/4/22 CCM-K received a call from the Registered Nurse (RN) stating that R237 is telling them that the man touched her nightgown that day (6/2/22) also. CCM-K interviewed R237 on the phone and R237 stated R41 came into her room, lifted her nightgown and pointed at her private area and gestured for her to move her leg. R237 reported he lifted up the night gown, pointed at her private area, smiled and said me and you like he wanted sex. He kissed her cheek and she told him no way and to go away. CCM-K's statement further documented DON-B was notified and she was directed to tell the RN to do the follow-up. There was no evidence an assessment was completed on R237 to determine her ability to consent. Surveyor noted there was no follow up or thorough investigation related to the allegation of sexual abuse involving R237 and R41. R41 does not have a care plan related to sexual behaviors. There was no evidence of increased monitoring of R41. There was no psychiatric or psychotherapy interventions to determine the possible cause of R41's behavior. There was no evidence the facility implemented any interventions following the incident on 6/2/22 to keep R237 and other residents safe, placing other residents in the facility at risk for sexual abuse. Nine days later, on 6/11/22, another incident of sexual abuse occurred, this time between R41 and a different female resident (R58). Graduate Practical Nurse (GPN)-E's statement documented she was walking down the hall and noticed R58 sitting on the couch. R41 was sitting behind R58 with his hand in the back of her brief near her butt. GPN-E told R41 to take his hand out R58's pants. The residents were separated and went back to their rooms. R58 was asked if she was OK and she reported yes, he was just rubbing my back. GPN-E reported the incident to the Supervisor. Surveyor was unable to locate evidence an interview was completed with R58 following the incident. There was no assessment of R58 to determine her ability to consent. On 8/8/22 at 1:30 PM Surveyor asked DON-B if he had any additional information regarding the investigation and incident between R41 and R58. DON-B reported he did not have any additional information. Surveyor advised the investigation did not include an interview with R58, and asked if there were any other staff or resident interviews. DON-B stated, I guess there isn't. On 8/7/22 at 2:19 PM Surveyor spoke with R58 in her room about the incident involving R41. R58 reported she was in the TV room and R41 placed his right hand near her groin (demonstrating with her right hand). Surveyor asked if R41's hand was on the inside or outside of her pants, to which she stated, Inside. R58 reported she did not ask R41 to put his hand in her pants, but did not tell him no, and did not stop him. R58 reported she let him do it for awhile, then told him to stop after a couple minutes. Surveyor asked if this bothered her, R58 replied, No. It's fine. I'm a grown woman. On 8/9/22 NHA-A provided an interview with R58 dated 6/11/22. Licensed Practical Nurse (LPN)-N statement documented, On 6/11/22 at roughly 3 :00 PM, she interviewed R58. R58 was asked how she was feeling, which she reported fine. She was asked about the interaction with R41. R58 reported he started to rub her shoulders and back, she liked it and it felt good. She did not ask him to do this. She stated he was touching inside the front of her pants. She reported she was not sad, upset or scared. LPN-N reassured her she did nothing wrong, and she was safe. Registered Nurse (RN)-O statement dated 6/11/22 documented he spoke to DON-B and was informed to keep the residents separated and start 15 minute checks for R41. RN-O called R58's son and daughter-in-law. Family in agreement but added that resident (R58) has had similar issues in her past and they would like to have psychologist talk with resident during the next visit to the facility. R58's Psychiatric consult dated 7/8/22 documents (in part) .resident states doing good, feels mental health is stable, does not want medications adjusted. Denies auditory or visual hallucinations. Surveyor noted there was no mention of the sexual abuse incident between R58 and R41. After reviewing the 6/11/22 Facility Reported Incident, Surveyor spoke with DON-B who stated, Staff was there and said they were both being flirty with each other. Surveyor located no documentation in the facility self report or staff statements to support this statement. DON-B reported staff intervened when it turned to inappropriate touching. Surveyor asked DON-B if he interviewed the residents involved. DON-B stared at Surveyor and did not answer. After a long pause, DON-B reported he would look to see if there was any more information somewhere else. Surveyor asked if R41 speaks English. DON-B reported he does speak English, but has some cognitive deficits. Surveyor asked DON-B what was done after the incident. DON-B reported R41 was moved to another unit and 15 minute checks were initiated. Surveyor noted the facility made no revisions to R41's care plan following either sexual abuse incident on 6/2/22 or 6/11/22. R41 has no care plan interventions related to sexually inappropriate behavior, and no care plan about 15 minute checks or increased monitoring. R41's Certified Nursing Assistant (CNA) care card did not include documentation of behaviors or increased monitoring. CNA behavior charting included a standard template which included a column sexually inappropriate which Surveyor noted included no check marks for the past 30 days. There was no documentation of any further inappropriate sexual behavior or wandering into other resident rooms since the last incident on 6/11/22. DON-B reported R41 transferred rooms after the incident on 6/11/22. Surveyor's review of R41's census revealed R41 has resided in the same room (on Skylight East) since November 2021 and was not moved as DON-B reported. In addition, 15 minute checks were not consistently completed. Surveyor's review of documentation revealed 15 minute check forms missing for 6/21/22, 6/28/22, 6/29/22, 6/30/22, 7/18/22, 7/22/22 and 7/25/22. Surveyor reviewed 5 random 15 minute check forms for R41 which revealed incomplete documentation, indicating monitoring of R41 was not consistently completed: Time started at midnight through 11:45 PM: 6/16/22 - blank/no entry of monitoring for the hours of 7:30 AM - 2:45 PM. 6/22/22 - blank/no entry of monitoring for the hours of Midnight - 6:15 AM or 3:15 PM - 11:45 PM. 6/27/22 - blank/no entry of monitoring for the hours of Midnight - 6:15 AM or 3:15 PM - 11:45 PM. 7/9/22 - blank/no entry of monitoring for the hours of Midnight - 2:30 PM. 7/23/22 - blank/no entry of monitoring for the hours of 6:45 AM - 2:45 PM. On 8/8/22 at 11:10 AM Surveyor spoke with Certified Medication Aid (CMA)-D who works on Skylight north (back of building where R41 resides). CMA-D reported she is familiar with R41. She reported R41 is on 15 minute checks and stated, We all know if he's up and around in his wheelchair to keep eye on him, he can be a little grabby with women. On 8/8/22 at 11:23 AM Surveyor spoke with Graduate Practical Nurse (GPN)-E who works on R58's unit. GPN-E reported she is familiar with R41 and who stated, Oh yes, I am very aware of (R41), he's on 15 minute checks. Surveyor asked if this is documented anywhere. GPN-E stated, Not really, pretty much everyone knows to keep eye when he is tooling around in his wheelchair. Surveyor asked GPN-E if she knew why R41 was to be monitored, to which she replied, He's had some incidents with some of the female residents. When asked what type of incidents, GPN-E stated, Touching them. On 8/8/22 at 11: 35 AM Surveyor spoke with RN-F who works on the Heritage unit (front of building near entrance). RN-F reported she knows who R41 is stating, I know he wheels himself around in the wheelchair. RN-F reported R41 does come to the front of the facility, on the Heritage unit, and she sometimes sees him go outside to sit. Surveyor asked RN-F if she has been informed of anything else regarding R41 such as increased monitoring, to which she replied, No. Surveyor had observations of R41 sitting alone outside near the front entrance of the facility while on Survey. On 8/10/22 at 2:11 PM Surveyor spoke with the Social Service Director (SSD)-C and asked what she could tell about the incident on 6/11/22 involving R41 and R58. SSD-C stated, Well, I know he tried to kiss her, and that's about it. SSD-C denied knowing anything else about the incident and reported DON-B was more involved. Surveyor asked SSD-C about the statement from R58's family that she has had similar issues in her past and they would like to have psychologist talk with her. Surveyor asked if she knew what issues the family was referring to. SSD-C stated, No, but maybe it has to do with her ex-husband taking advantage of her. When asked what she meant, SSD-C stated, Her sister-in-law told me her ex-husband took advantage of her sexually and she did not want her ex-husband to be allowed to take her out of the facility. SSD-C reported this conversation occurred after R58 was admitted to the facility and before the sexual incident between R58 and R41. The facility was aware of R58's history of sexual abuse and the care plan was not revised to include information or interventions related to her previous sexual abuse. The facility was aware of the allegation of sexual abuse that occurred between R41 and R237 on 6/2/22. The facility did not complete a thorough investigation of the allegation and no interventions were implemented to keep R237 and other residents safe. Nine days later a second incident involving sexual abuse occurred this time between R41 and R58, with R58 having a history of sexual abuse by her ex-husband. The facility did not complete a thorough investigation and appropriate interventions were not implemented to keep R58 and other residents safe. R41 is mobile throughout the facility and staff on other units are not aware of his sexual behavior and increased monitoring, placing other vulnerable residents at risk. Neither R237 nor R58 appeared overly distressed or upset by what had occurred. R58 even stated that it didn't bother her - she was a grown woman. It should be noted, however, given R58's history of sexual abuse, that she may have been used to being used and abused and that this was a familiar pattern to her to which she was accustomed. Her reaction was markedly incongruent to what a reasonable person might experience. Using the reasonable person concept, R58 or any other resident who is sexually abused could feel Recurrent (i.e., more than isolated or fleeting) debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of a specific staff member). A person who has been sexually assaulted could also experience Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation . The failure of the facility to keep residents free from sexual abuse due to the facility's inaction after each incident, such as not reporting, not investigating, not assessing and not putting interventions in place to prevent further abuse placed female residents at risk for further abuse. This created a reasonable likelihood for serious harm and, thus, created a finding of immediate jeopardy beginning on 6/2/22. The immediate jeopardy was removed on 8/19/22 when the facility: Medication reviews were conducted, psych evaluations conducted and the Medical Doctor reviewed the residents identified in this deficiency. Education Policy and procedural updates were completed and non-Pharmacological Interventions identified for clinical staff. Staffing changes were made to protect the residents from the alleged perpetrator. Per policy on Abuse, Neglect, and Exploitation increased supervision was provided for the perpetrator. A policy for Sexual Expression for residents was developed, brought through the Quality Assurance Program Improvement (QAPI), implemented and educated on. Staff were educated on the policy for Sexual Expression of Residents as well as abuse, neglect and exploitation, and compliance with reporting allegations of abuse/neglect/exploitation. Social Service, ADON, Unit Managers, Administrator and Associate Administrator received training trained on Sexuality and Intimacy in Long Term Care. Assessments were completed for all residents using sexual expression assessment. A care conference will be held for residents following the display of sexual expression where it will be determined the capacity of consent and review of solution that best meets the needs of and the protection of those involved. Care plan audit were conducted for residents identified through sexual expression assessment with updates as needed. Cardex Updates were completed for all residents identified through sexual expression assessment. Residents displaying inappropriate sexual behaviors will be referred for a psychologist consult. Any state reported incident will be evaluated through the RISK process as well as APIA. APIA will review residents who triggered sexual expression assessment with the Medical Director.

Based on interview and record review the Facility did not ensure that 5 (R12, R71, R14, R35, R31 ) of 18 Residents reviewed received treatment and care in accordance with professional standards of practice. * R12's bowel movements were not being monitored. R12 did not have a bowel movement on 7/14/22, 7/15/22, 7/16/22, & 7/17/22. No bowel assessment was completed on 7/14/22, 7/15/22, 7/16/22, 7/17/22, 7/18/22. Review of R12's July MAR (medication administration record) shows neither milk of magnesia 30 ml prn ( as needed) or [MEDICATION(S)] suppository 10 mg prn was administered during this time. R12 did not have a bowel movement on 7/19/22, 7/20/22, or 7/21/22. No bowel assessment was completed on 7/19/22, 7/20/22, 7/21/22, 7/22/22. Review of R12's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 is checked as not having any bowel movement on 7/24/22. On 7/25/22 R12 is documented as not having a bowel movement & small bowel movement, and on 7/26/22 no bowel movement. No bowel assessment was completed on 7/24/22, 7/25/22, 7/26/22 and 7/27/22. Review of R12's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 did receive Senna-[MEDICATION(S)] sodium 8.6-50 mg on 7/25/22. On 8/4/22 R12 is checked as not having a bowel movement and small bowel movement, 8/5/22 & 8/6/22 no bowel movements, 8/7/22 there is no documentation for bowel movements, & 8/8/22 is checked as having no bowel movements. R12 did not receive any as needed bowel medication during this time. On 8/3/22, R12 requested to go to the hospital and returned back to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital after visit summary dated 8/6/22 under diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . * Neuro checks were not consistently completed following unwitnessed falls for R71. * R31, R35, & R14 did not have sleep assessment completed. Example involving R12 rises to a scope and severity level of G (harm/isolated) Findings include: 1. R12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 receives a regular diet with regular texture and thin consistency liquids. The quarterly MDS (Minimum Data Set) with an assessment reference date of 5/10/22 has a BIMS (Brief Interview Mental Status) score of 14 which indicates cognitively intact. R12 requires extensive assistance with two plus person physical assist for bed mobility, has transferred only once or twice with two plus person physical assist, doesn't ambulate and is dependent with two plus person physical assist for toilet use. R12 is coded as always being incontinent of bowel. On 8/7/22 at 11:01 a.m. Surveyor observed R12 in bed on her back with the head of the bed elevated. R12 informed Surveyor she went to the hospital due to pain in her leg. R12 explained she was taken off a narcotic because she was getting constipated. R12 informed Surveyor at the hospital they did lab work and a CT scan which showed an area of impaction. R12 informed Surveyor she had to be disimpacted in the emergency room . R12 also informed Surveyor staff thought her constipation was opoid induced but she was impacted and no one caught it. Surveyor reviewed R12's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] patch 12.5 mcg (microgram) every 3 days with an order date of 4/17/22 [MEDICATION(S)] 10 mg (milligrams) every 6 hours as needed with an order date of 11/22/21 [MEDICATION(S)] HCL 2 mg every 4 hours as needed with an order date of 10/4/21 Surveyor noted bowel medications of: [MEDICATION(S)] Suppository 10 mg every 24 hours as needed with an order date of 7/29/21 [MEDICATION(S)] 145 mcg once daily with an order date of 7/29/21 Milk of magnesia 30 ml (milliliter) every 24 hours as needed with an order date of 7/29/21 [MEDICATION(S)] 17 grams as needed for constipation with an order date of 8/3/22 Senna Plus 8.6-50 mg 1 tablet daily with an order date of 8/6/22 Senna Plus 8.6-50 mg 2 tablets at bedtime with an order date of 8/6/22. On 8/11/22 at 7:59 a.m. Surveyor asked CCM (Clinical Care Manager)-K how Resident's bowel movements are monitored. CCM-K informed Surveyor the CNA's (Certified Nursing Assistant) document in point of care. CCM-K explained they get an alert if a Resident does not have a bm (bowel movement) in three days. If no bm in three days then the nurse is to do a bowel assessment with the Resident and provide an intervention if necessary. Surveyor asked if bowel assessments are documented. CCM-K informed Surveyor any physical assessment should be documented in the nurses notes. Surveyor asked who receives the alert that a Resident has not had a bm in 3 days. CCM-K informed Surveyor everyone does, the floor nurse & managers and the alert comes in their care management dashboard. CCM-K informed Surveyor small bowel movements do not count as having a bowel movement, only medium or large. CCM-K informed Surveyor the first intervention is to provide the Resident with milk of magnesia. If the milk of magnesia doesn't work within the shift then a [MEDICATION(S)] suppository would be administered. CCM-K informed Surveyor if the suppository doesn't work then they should notify the doctor or NP (nurse practitioner). CCM-K also informed Surveyor if during the bowel assessment the Resident's abdomen is extended, or it there are no bowel sounds or hypoactive bowel sounds then the nurse should notify the doctor right away. Surveyor reviewed R12's bowel documentation for the past 30 days. Surveyor noted R12 is checked as not having any bowel movement on 7/14/22, 7/15/22, 7/16/22, & 7/17/22. An alert should have been sent as R12 went 4 days without a bowel movement. Surveyor reviewed R12's nurses notes and was unable to locate a bowel assessment on 7/14/22, 7/15/22, 7/16/22, 7/17/22 and 7/18/22. Review of R12's July MAR (medication administration record) shows neither milk of magnesia 30 ml prn (as needed) nor [MEDICATION(S)] suppository 10 mg prn was administered during this time. R12 is documented as having a large bowel movement on 7/18/22. Senna-[MEDICATION(S)] Sodium 8.6-50 mg with directions to give 2 tablets at hour of sleep was started on 7/19/22 and was discontinued on 7/27/22. On 7/27/22 Senna-[MEDICATION(S)] Sodium 8.6-50 mg was ordered with directions to give one tablet every 12 hours. R12 did not have a bowel movement on 7/19/22, 7/20/22, or 7/21/22. Surveyor reviewed R12's nurses notes and was unable to locate a bowel assessment on 7/19/22, 7/20/22, & 7/21/22. Review of R12's July MAR (medication administration record) shows neither milk of magnesia 30 ml prn nor [MEDICATION(S)] suppository 10 mg prn was administered during this time. R12 is documented as having a large bowel movement on 7/22/22. R12 is checked as not having any bowel movement on 7/24/22. 7/25/22 is documented as not having a bowel movement & small bowel movement, and on 7/26/22 no bowel movement. Surveyor reviewed R12's nurses notes and was unable to locate a bowel assessment on 7/24/22, 7/25/22, 7/26/22, or 7/27/22. Review of R12's July MAR (medication administration record) shows neither milk of magnesia 30 ml prn nor [MEDICATION(S)] suppository 10 mg prn was administered during this time. R12 did receive Senna-[MEDICATION(S)] sodium 8.6-50 mg on 7/25/22. On 7/27/22 R12 had a medium bowel movement. The nurses note dated 8/3/22 documents Writer was called to resident's room for resident wanting to go to hospital. Writer asked what was going on and resident said she wants [MEDICATION(S)] injection for her constipation. Explained to resident that it is not medication for constipation and offered Laclulose for her constipation. Resident refused. Offered Dulcolax suppository and prune juice but refused as well as all stool softeners. Informed NP [name]. NP [name] came to resident's room, spoke to resident but insist on going to the hospital. The nurses note dated 8/3/22 documents Resident returned from hospital with the following orders: Stop taking Senna-S 50-8.6 mg and [MEDICATION(S)]. New order for [MEDICATION(S)] 17 g (grams) daily as needed for constipation. The hospital after visit summary dated 8/3/22 under diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/4/22 R12 is checked as not having a bowel movement and small bowel movement, 8/5/22 & 8/6/22 no bowel movements, 8/7/22 there is no documentation for bowel movements, & 8/8/22 is checked as having no bowel movements. R12 did not receive any as needed bowel medication during this time. The nurses note dated 8/4/22 documents Resident is monitored due to constipation. [MEDICATION(S)] was given due to left hip pain and effective. The nurses note dated 8/5/22 documents No c/o (complaint of) constipation noted this night shift. Tolerates fluids. The nurses note dated 8/6/22 documents Alert and able to make needs known, no c/o constipation or abdominal discomfort. C/o lower back pain, prn pain med given with good result. Slept well, no further complaints. The hospital after visit summary dated 8/6/22 under diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses note dated 8/7/22 documents Patient returned from ER (emergency room ) per ambulance and new order noted for Senna S but patient already is on. The nurses note dated 8/8/22 documents No c/o ABD (abdominal) pain or discomfort noted. BS (bowel sounds) x (times) 4. Resting in bed. No BM noted. The nurse note dated 8/9/22 documents Resident taking scheduled Senna plus, abdomen soft nontender with bowel sounds x4 quads. (quadrants). no nausea or vomiting. ate both meals this shift. On 8/11/22 at 12:12 p.m. Administrator-A and Corporate Consultant-M were informed of the above. 2. The Neurological Assessment policy & procedure from Med-Pass Inc. (Revised October 2010) under General Guidelines documents 1. Neurological assessments are indicated: a. Upon physician order; b. Following an unwitnessed fall; c. Following a fall or other accident/injury involving head trauma; or d. When indicated by resident's condition. R71's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 at 7:51 a.m. Surveyor asked ADON (Assistant Director of Nursing)-H when neuro checks are completed for a Resident who has fallen. ADON-H informed Surveyor per the paper neuro checks are completed every 15 minutes four times, 30 minutes two times and every 1 hour four times. On 8/10/22 at 8:10 a.m. ADON-H informed Surveyor after the paper neuro checks, which end after 1 hour four times, the Resident is put on the 24 hour report and is monitored, meaning neuro checks are done every shift for 3 days. Surveyor inquired where these neuro checks can be located. ADON-H informed Surveyor neuro checks should be in the progress notes. Surveyor inquired what if the neuro checks aren't in the progress notes. ADON-H informed Surveyor if they aren't there she doesn't know what to say. On 8/10/22 at approximately 8:15 a.m. Surveyor reviewed R71's medical record and noted the following: * The nurses note dated 4/12/22 documents Informed by CNA (Certified Nursing Assistant) that resident slid self from Broda chair while dinner trays were being passed, no injury noted, assisted back into Broda chair with 2 assist and gait belt. Call placed to [name of] Hospice and spoke with [name] RN, will send out nurse to assess resident. Left voice mail for guardian [name] to call facility and voice mail left for CM (Case Manager) [name] to call facility. The neuro check flow sheet dated 4/12/22 are incomplete at 1640 (4:40 p.m.), 1655 (4:55 p.m.), 1710 (5:10 p.m.), 1725 (5:25 p.m.), 1755 (5:55 p.m.), 1810 (6:10 p.m.), 1910 (7:10 p.m.), 2010 (8:10 p.m.), &2110 (9:10 p.m.). The sections for consciousness level, responds to tactile stimuli, responds to visual stimuli, hand grasp & visual response to light have not been completed. At 2210 (10:10 p.m.) the sections for consciousness level, responds to tactile stimuli, responds to visual stimuli, hand grasp, visual response to light, & vital signs have not been completed. The nurses note dated 4/13/22 at 11:46 a.m. includes documentation of neuro check negative. There is no other documentation of neuro checks each shift for three days. * The nurses note dated 4/18/22 documents Resident monitored for fall. Agitated this afternoon. Had an unwitnessed fall in hallway. Managed to get to her room and get into bed. Hospice and POA notified. Hospice nurse will be coming tomorrow morning to evaluate her. There is no evidence neuro checks were completed for R71 following the 4/18/22 fall with the exception of nurses note dated 4/20/22 at 1:46 p.m. which includes documentation of neuro checks negative. * The nurses note dated 5/12/22 documents Writer was notified that that resident was on the floor. She was found sitting on hallway in front of her room. Resident was alert and verbally responsive. Able to move upper and lower extremities. No injuries noted from fall. No s/s of active bleeding. Resident denies pain. Resident was transferred to Broda chair. [name] hospice was notified and [name] too. The neuro check flow sheet dated 5/12/22 are incomplete at 2030 (8:30 p.m.), 2045 (8:45 p.m.), 2100 (9:00 p.m.), 2130 (9:30 p.m.), 2200 (10:00 p.m.), & 2300 (11:00 p.m.) for consciousness level. At 2400 (12:00 a.m.) 1:00 a.m. & 2:00 am the sections for consciousness level, responds to tactile stimuli, responds to visual stimuli, hand grasp, visual response to light, & vital signs have not been completed. Surveyor was unable to locate documentation neuro checks were completed each shift for three days following the paper neuro check flow sheet. * The IRIS (incident report) dated 5/16/22 under initial reported description documents Resident was alone in the common dining area. She scooted herself off the chair onto the floor. Found sitting on her butt. Zero injuries. Neuro checks WNL (within normal limits). Zero c/o (complaint of) pain. Under contributing factors is checked for patient/family - failure to follow plan of care. There is no evidence neuro checks were completed for R71 following the 5/16/22 fall. * The nurses note dated 6/4/22 documents Med tech from S. South notified writer that resident was found sitting on the floor at hallway at S. South in front of her room. Prior to unwitnessed fall, resident was lying in bed and sleeping. Writer found resident sitting on the floor with arms and legs in a normal position. Resident is alert and verbally responsive. No respiratory distress. Able to move upper and lower extremities. No injuries were noted during skin assessment. No s/s of active bleeding. Resident denies pain. [name] was notified. [name] RN from [name of] Hospice was notified too. Hospice said that nurse will come to facility to assess resident tomorrow (6/5/22). The neuro check flow sheet dated 6/4/22 are incomplete at 0055 (12:55 a.m.), 0155 (1:55 a.m.), 0255 (2:55 a.m.). The for sections for consciousness level, responds to tactile stimuli, responds to visual stimuli, hand grasp, visual response to light, & vital signs have not been completed. Sleeping was written across the vital sign sections. At 0355 (3:55 a.m.) the section for consciousness level, responds to tactile stimuli, responds to visual stimuli, hand grasp, & visual response to light were not completed. The nurses notes dated 6/6/22 at 9:43 a.m. & 6/7/22 at 9:53 a.m. includes documentation of neuro check negative. There is no other documentation of neuro checks each shift for three days. * The nurses note dated 6/8/22 documents Resident observed sitting on the floor by her room res stated she slid out of bed landing on her buttocks. no c/o pain or discomfort. ROM WNL (range of motion within normal limits) for Resident. alert per res baseline. RN present for body check Contacted [name] NP who is on call for [Physician's name]. [Name] POA called and message left with case worker [name] to call facility. res transferred into wheelchair and is sitting in common area with staff. T 97.7 P 68 R 16 B/P 122/64. The neuro check flow sheet dated 6/8/22 are incomplete at 2315 (11:15 p.m.) 0015 (12:15 a.m.), 0115 (1:15 a.m.), 0215 (2:15 a.m.) & 0315 (3:15 a.m.). The sections for consciousness level, responds to tactile stimuli, responds to visual stimuli, hand grasp, visual response to light, & vital signs have not been completed. Surveyor was unable to locate documentation neuro checks were completed each shift for three days following the paper neuro check flow sheet. * The nurses note dated 7/13/22 documents Patient discovered on the floor in the dining room on Skylight South. Patient was sitting on her bottom with palms against floor at time of discovery. She is awake, alert and oriented to self and situation which is her baseline. Patient appears restless. When asked what she was trying to do at the time of fall, pt. stated she was looking at the ground and wanted to sit down. No indication of injury, no new open areas or redness noted. Pt. follows simple commands. PERRLA (pupils equal, round, reactive to light and accommodation). Hand grasps firm. Upper and lower extremities assessed. No c/o pain or discomfort when asked. VS (vital signs) obtained by floor nurse. Pt. wearing gripper socks. Pt. assisted back to chair. CNA and floor nurse with patient at this time. [name] NP updated. [name] (guardian) updated on fall. Surveyor was unable to locate any further neuro checks following R71's 7/13/22 fall. On 8/11/22 at 12:12 p.m. Administrator-A and Corporate Consultant-M were informed of the above. 3. Surveyor reviewed R14's medical record on 8/10/22. According to the July and August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 has been receiving the [MEDICATION(S)] capsules at HS daily. Surveyor reviewed a Behavior Solutions Inc. (BSI) psych note dated 8/3/22 which documented in part; [MEDICATION(S)] 8 mg at HS for [CONDITION(S)] . sleep pattern varies per resident and he notes sometimes I can't sleep. [MEDICATION(S)] was increased at last visit to address with no improvement per resident, denies napping. Resident with stable mood on decrease dose of [MEDICATION(S)] however [CONDITION(S)] continues to be a concern per resident. Wound recommend obtaining a sleep study to assess sleep pattern with follow up in 2 months. Recommendation: Sleep study X3 nights and update BSI if abnormal. R14's 8/18/22 annual Minimum Data Set (MDS) was not yet complete however, R14's last quarterly MDS dated [DATE] indicates R14 as having a Brief Interview for Mental Status score of 11 indicating R14 is moderately impaired for daily decision making skills. The quarterly MDS indicates R14 does not have trouble falling asleep, staying asleep or sleeping too much. R14 has a care plan addressing the use of an antidepressant initiated 5/28/19 with an intervention of monitoring/document side effects and effectiveness of the antidepressant and to monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, irritable, anger, crying, shame, disrupted sleep . initiated on 5/28/19 however; R14's care plan does not identify R14 as having a concern with sleep, nor does it address R14 as having a sleep study conducted. R14's care plan does not address R14's use of [MEDICATION(S)] for sleep or interventions that may assist R14 with sleep. On 8/8/22 02:45 pm Surveyor interviewed Assistant Director of Nursing H who stated she has been employed at the facility since the end of December 2021 and that no sleep assessments have been conducted since that time. On 8/10/22 Surveyor interviewed Clinical Care Manager LPN K regarding Behavior Solution's recommendation for R14 to have a sleep assessment. Clinical Care Manager K stated the Behavior Solution's recommendation would first go to the pharmacist and Director of Nursing for their review before being scanned in. Clinical Care Manager LPN K was not aware of any sleep assessment having been conducted for R14. On 8/10/22 at 2:45 pm, Surveyor shared with Administrator A and Corporate Consultant M, that no sleep study was located in R14's medical record. Corporate Consultant M indicated an awareness of needing to conduct sleep studies. 4. On 8/9/22 Surveyor reviewed R35's medical record. On 8/9/22, Surveyor interviewed R35 who reported leaving for [CONDITION(S)] at 4:15 am, chair time from 5-8:30 am back by 9:30 am, 3 times a week. Surveyor reviewed R35's admission Minimum Data Set (MDS) dated [DATE] which indicates R35 has a Brief Interview for Mental Status score (BIMS) of 15 indicating R35 is cognitively intact for daily decision making skills. This MDS indicates yes for R35 having trouble falling or staying asleep or sleeping too much. The MDS also indicates R35 is noted as feeling tired with little energy. A 06/22/2022 14:02 (2:02pm) Social Services Note Text documents: Care Plan meeting held today with resident and Power of Attorney's knowledge. No concerns expressed at this time. Resident requires assistance with ADL's (activities of daily living) and transfers. Resident is alert and able to express self well. Resident continues on [MEDICATION(S)] (antidepressant) for [CONDITION(S)], [MEDICATION(S)] for depression and Aripiprazol and [MEDICATION(S)] for Hallucinations and [CONDITION(S)] disorder. R35's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's plan of care does not reflect R35's use of [MEDICATION(S)] for [CONDITION(S)] nor any indication that a sleep assessment was completed. R35 has no interventions to assist with R35's sleep issues. On 8/8/22 02:45 pm, Surveyor interviewed Assistant Director of Nursing (ADON) H as to whether a sleep assessment was conducted for R35. ADON H reported she has been at the facility since the end of December and no sleep assessment has been completed since that time. ADON- H stated the MD ordered Trazadone for depression and it is PRN, receiving it on 8/1/22. On 8/10/22 at 2:45 pm, Surveyor shared with Administrator A and Corporate Consultant M, that no sleep study was located in R35's medical record. Corporate Consultant M indicated an awareness of needing to conduct sleep studies. 5. R31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] indicate R31 is cognitively impaired needs extensive assistance with bed mobility, dressing, hygiene and transfers. The 7/24/22 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 Surveyor reviewed R31 medical record and there wasn't a sleep assessment or care plan addressing R31 [CONDITION(S)]. On 8/10/22 at 2:30 p.m. during the daily exit meeting with NHA A and Corporate Consultant M, Surveyor explained R31 is receiving Trazadone for [CONDITION(S)] and does not have a sleep assessment and care plan addressing the [CONDITION(S)]. Corporate Consultant M stated anyone on a sleep medication should have a sleep assessment done. NHA A and Corporate Consultant M understood the concern and had no further information.

Based on observations, record review and interviews with staff, the facility did not provide consistent interventions to prevent the development of pressure injuries for 5 of 8 residents (R26, R75, R19, R71, R12) at risk for pressure injuries. * R26 was observed with their heels not being offloaded on 8/7/22. On 8/8/22, R26 was noted with an unstageable pressure injury to the left heel. * R75 was observed not wearing pressure reducing heel boots throughout the survey. * On 7/15/22, R19 who was assessed at risk for the development of pressure injuries acquired a stage 3 pressure injury to the left heel. On the initial assessment for R19's left heel pressure injury there was no documentation of the percentage of the wound bed for granulation tissue & slough. There was no indication the facility used pressure relieving boots or offloaded R19's heels prior to the development of this pressure injury. R19's left heel was not assessed from 7/22 through 8/4/22. The facility did not identify R19 having a pressure injury to the left heel until it was a Stage 3. * R71 was observed with heels not being offloaded throughout the survey. * R17 was observed with heels not being offloaded throughout the survey. * R12 was observed with heels not being offloaded throughout the survey. Examples for R26 and R19 rises to a scope and severity level of a G (harm/isolated) Findings include: 1. R26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicates that R26 requires extensive assistance of 1 staff member with bed mobility. Per R26's medical record, a Braden assessment conducted on 8/8/22 indicates a score of 14, which indicates R26 is at moderate risk for pressure injuries. On 8/07/22 at 9:10AM, R26 was observed in bed with heels directly on their mattress laying on right side wearing a hospital gown and incontinence product in bed. No pressure relief boots were noted at this time. R26 is unable to reposition self independently due to [CONDITION(S)] to their left upper and lower extremities. R26 requires assistance to move their extremities. On 8/07/22 at 12:10 PM, R26 was observed in bed with heels directly on their mattress laying on right side wearing hospital gown and incontinence product in bed. No pressure relief boots were noted at this time. R26 is unable to reposition self independently due to [CONDITION(S)] to their left upper and lower extremities. R26 requires assistance to move their extremities. On 8/07/22 at 2:30 PM, R26 was observed in a wheelchair wearing shoes to bilateral feet. On 8/08/22 at 9:02 AM, R26 was observed in a wheelchair, wearing a pressure relieving boot to the left foot. On 8/08/22 at 11:22 AM, R26 was observed in a wheelchair, wearing a pressure relieving boot to the left foot. O8/08/22 at 1:32 PM, R26 was observed resting in bed on their back wearing a pressure relieving boot to the left foot. On 8/09/22 at 12:32 PM, R26 was observed resting in bed on their back wearing a pressure relieving boot to the left foot. On 8/09/22 at 3:17 PM, Surveyor reviewed R26's CNA (Certified Nursing Assistant) care Kardex form. R26's Kardex indicates that pressurve relieving heel boots are to be worn at all times when in bed. On 8/10/22 at 9:30 AM, Surveyor conducted interview with CNA-I. Surveyor asked CNA-I how they would know if a resident is at risk for pressure injuries and if they would need specialty equipment such as pressure relieving heel boots. CNA-I told Surveyor that this information should be on the resident's Kardex. On 8/10/22 at 9:52 AM, Surveyor observed Clinical Care Manager-J conducting dressing change to R26's left heel. Surveyor observed a circular wound to the left heel with approximately 80% of wound bed covered in yellow fibrous slough tissue. Surveyor asked Clinical Care Manager-J if a resident is at risk for pressure injuries or has pressure injuries to their feet if they should wear pressure relieving heel boots. Clinical Care Manager-J responded that unless the resident was ambulatory and it would be a safety risk, they would prefer that residents at risk for pressure injuries should wear bilateral heel boots. Clinical Care Manager-J indicated that R26 has had previous pressure injuries to the left heel in the past. Surveyor questioned whether a resident should wear heel boots at all times if they have a pressure injury. Clinical Care Manager-J stated, Yes I would like them to wear heel boots when they have pressure injuries to heel. If resident is ambulatory with a foot wound, they should only wear them in bed per Wound MD recommendations so they do not sustain an injury. R26 has had this same injury before so we do not recommend she wear shoes. On 8/10/22 at 3:20 PM, Surveyor conducted an interview with ADON (Assistant Director of Nursing)-H. Surveyor asked ADON-H if residents at risk for pressure injuries or with current pressure injuries should wear pressure relieving heel boots. ADON-H responded that residents at risk for pressure injuries should have heel boots in place to lessen the risk of acquiring pressure injuries unless it poses a safety risk to the resident. On 8/10/22 at 4:00 PM, Surveyor shared serious concerns with NHA (Nursing Home Administrator)-A related to R26's observations of no pressure relieving heel boots in place to bilateral feet per CNA Kardex on 8/7/22 and the discovery of an unstageable pressure injury to the left heel on 8/8/22. The facility provided no additional information to the Surveyor at this time. 2. R75 was admitted to the facility 9/21/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R75's Significant change MDS dated [DATE] indicates that R75 requires extensive assistance of 1 staff for bed mobility. R75 has range of motion limitations to their upper and lower extremities. R75's Braden assessment dated [DATE] indicates R75 has a score of 12, indicating R75 is at high risk for pressure injuries. R75 was enrolled in hospice/comfort care on 1/21/22 due to severe protein malnourishment and failure to thrive. On 8/07/22 at 9:10 AM, R75 was observed laying on their right side wearing hospital gown and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/07/22 at 11:30 AM, R75 was observed laying on their right side wearing a hospital gown and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/07/22 at 1:35 PM, R75 was observed laying on their right side wearing a hospital gown and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/07/22 at 3:05 PM, R75 was observed laying on their right side wearing a hospital gown and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/08/22 at 8:26 AM, R75 was observed laying on their right side wearing a hospital gown and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/08/22 at 10:36 AM, R75 was observed laying on their right side wearing a black and white striped sweater and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/08/22 at 11:35 AM, R75 was observed laying on their right side wearing a black and white striped sweater and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/08/22 at 1:38 PM, R75 was observed laying on their right side wearing a black and white striped sweater and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/09/22 at 9:08 AM, R75 was observed laying on their right side wearing hospital gown and incontinence product in bed. R75's heels are observed directly on their mattress. On 8/10/22 at 9:30 AM, Surveyor conducted an interview with CNA-I. Surveyor asked CNA-I how they would know if a resident is at risk for pressure injuries and if they would need specialty equipment such as pressure relieving heel boots. CNA-I told Surveyor that this information should be on the resident's Kardex. Surveyor observed R75's heels at this time and did not identify any open areas at this time. R75 does not have pressure relieving heel boots in place at the time of observation. On 8/10/22 at 9:52 AM, Surveyor conducted an interview with Clinical Care Manager-J. Surveyor asked Clinical Care Manager-J if a resident is at risk for pressure injuries or has pressure injuries to their feet if they should wear pressure relieving heel boots. Clinical Care Manager-J responded that unless the resident was ambulatory and it would be a safety risk, they would prefer that residents at risk for pressure injuries should wear bilateral heel boots. Clinical Care Manager-J indicated that R75 should wear bilateral heel boots. On 8/10/22 at 3:20 PM, Surveyor conducted interview with ADON-H. Surveyor asked ADON-H if residents at risk for pressure injuries or with current pressure injuries should wear pressure relieving heel boots. ADON-H responded that residents at risk for pressure injuries should be put in place to lessen risk of acquiring pressure injuries unless it poses a safety risk to the resident. On 8/10/22 at 4:00 PM, Surveyor shared concern with NHA-A related to observations of R75 not wearing pressure relieving heel boots to bilateral feet per CNA Kardex on 8/7/22-8/10/22. The facility provided no additional information to the Surveyor at this time. 3. R19's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure injury CAA (care area assessment) dated 2/22/22 under analysis of finding for nature of the problem/condition documents [AGE] year old female with Dx (diagnoses) of spinal stenosis, CHF (congestive heart failure), Alzheimer's disease/dementia, CKD3 (chronic kidney disease 3), DM2 (diabetes mellitus 2), [CONDITION(S)] (hypertension), [CONDITION(S)], HLD ([CONDITION(S)]), OSA (obstructive sleep apnea), Vit (vitamin) D deficiency, [CONDITION(S)], depression, and [CONDITION(S)] exhibits potential for pressure ulcer/injuries due to need for extensive assistance with bed mobility, incontinence of bowel and bladder, and Braden score of 12. The at risk for skin breakdown care plan initiated & revised on 3/3/22 documents the following approaches: * Encourage me/assist me with repositioning routinely and PRN (as needed). Initiated & revised 3/3/22. * Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . * I have a pressure reducing cushion in my chair. Initiated & revised 3/3/22. * Inform me/family/caregivers of any new area of skin breakdown. Initiated 3/3/22. * Monitor/document/report to MD (medical doctor) PRN changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x (times) width x depth), stage. Initiated 3/3/22. * Pressure relieving mattress on bed. Initiated 3/3/22. Surveyor noted the at risk for skin breakdown care plan does not address offloading R19's heels. The Braden assessment dated [DATE] has a score of 15 which indicates at risk. The quarterly MDS (Minimum Data Set) with an assessment reference date of 5/20/22 documents a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R19 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfer & toilet use and does not ambulate. R19 is always incontinent of urine and bowel, is at risk for pressure injuries and is coded as not having any pressure injuries. The weekly wound tracking dated 7/15/22 for the question where is the wound located documents left posterior heel, for the question was this condition/wound present on admission is no, and wound classification is Pressure Injury Stage 3. Measurements are 2.2 cm (centimeter) length, 1.7 cm width, & depth 0.4 cm. The wound progress/evaluation documents first observation, no reference. The visible tissue is checked or granulation tissue and slough. Surveyor noted this assessment does not document the percentage of granulation tissue & slough in the wound bed. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After R19 developed a stage 3 pressure injury, the Facility developed a care plan for I have a pressure ulcer to my left heel-stage 3 care plan initiated & revised 7/15/22 documents the following approaches: * Assess/record/monitor wound healing (FREQ). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Initiated 7/15/22. * I require supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Initiated 7/15/22. * Measure wounds weekly and notify MD of any s/s of worsening or if not improving. Initiated 7/15/22. * Monitor my wound with dressing changes and PRN. Monitor for s/s of infection/worsening (redness, increased pain/tenderness/drainage, [CONDITION(S)], warmth) PRN. Initiated 7/15/22. * Offer to assist me with toileting routinely and PRN. Assist with incontinence care as needed to keep skin warm and dry. Provide barrier cream after incontinence care and PRN. Initiated 7/15/22. * Provide treatments as ordered. Initiated 7/15/22. * Seen by [name of wound company] wound. Initiated & revised 7/22/22. Although this care plan does not include any approaches to offload R19's heels, Surveyor noted in the CNA (Certified Nursing Assistant) documentation heel boots at all times was being initialed starting during the evening shift on 7/15/22. Prior to this date the dates & times are X out indicating R19 did not have heel boots. Also starting during the evening shift on 7/15/22 the CNA's were initialing to elevate legs/feet when sitting to avoid pressure to heels. Prior to the evening shift on 7/15/22 the dates & times are X out. The nurses note dated 7/16/22 documents Dressing dry & intact to left heel. No complaint of pain or signs/symptoms of discomfort noted. Heels elevated. The wound doctor initial wound evaluation & management summary dated 7/21/22 for history of present illness documents, At the request of the referring provider, [physician's name], a thorough wound care assessment and evaluation was performed today. She has a stage 3 pressure wound to the left heel for at least 2 days duration. There is light sero-sanguineous exudate. There is no indication of pain associated with this condition. For etiology documents Pressure. MDS 3.0 documents 3 and wound size documents 2 x (times) 1.5 x 0.2. Granulation tissue is 100%. Recommendations are off-load wound, float heels in bed. The nurses note dated 7/21/22 documents Pt. (Patient) was seen by [name of wound doctor] and wound nurse for wound to left heel. Wound assessment and evaluation performed by wound MD. Pt. has a stage 3 wound to her left heel. Light serosanguineous drainage noted with 100% granulation tissue. Pt. denies pain. Pt. will continue with current orders. Wound cleansed and tx (treatment) applied. Heel boots in place. [name of resident representative] updated. Pt. will be seen on the next weekly wound round. The weekly wound tracking dated 7/22/22 for the question where is the wound located documents sacrum, for the question was this condition/wound present on admission is no, and wound classification is Pressure Injury Stage 3. Measurements are 2 cm (centimeter) length, 1.5 cm width, & depth 0.1 cm. The wound progress/evaluation documents first observation, no reference. The visible tissue is checked or granulation tissue. Percentage of necrotic tissue present in wound is 0. After R19 developed a Stage 3 pressure injury on her sacrum the Facility developed a care plan I have a pressure ulcer to my sacrum stage 3 on 7/22/22 with all approaches dated 7/22/22 of the following: * Assess/record/monitor wound healing (FREQ). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. * I require supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. * Measure wounds weekly and notify MD of any s/s of worsening or if not improving. * Monitor my wound with dressing changes and PRN. Monitor for s/s of infection/worsening (redness, increased pain/tenderness/drainage, [CONDITION(S)], warmth) PRN. * Offer to assist me with toileting routinely and PRN. Assist with incontinence care as needed to keep skin warm and dry. Provide barrier cream after incontinence care and PRN. * Provide me with treatments per my orders. * Seen by [name of wound company] wound. The wound doctor progress note dated 7/28/22 documents The patient's visit has been rescheduled. The nurses note dated 7/28/22 documents Wound visit rescheduled. Pt. did not want to go back to bed for assessment. Family from out of town visiting with patient. There is no assessment of R19's Stage 3 sacrum and left heel pressure injuries until 8/4/22. This assessment was 14 days for R19's left heel and 13 days for the sacrum. The wound doctor's wound evaluation & management summary dated 8/4/22 for focused wound exam (site 1) for etiology documents Pressure, MDS 3.0 Stage is 3 and wound size is 1.5 x 1.5 x 0.2 cm. Slough is 20% and granulation tissue is 80%. The nurses note dated 8/4/22 documents Pt. was seen by [name of wound doctor] and wound nurse for multiple wounds. Wound to sacrum has resolved. Improvement noted to heel wound. Pt. denies pain. Pt. will continue with current orders. Wound cleansed and tx applied. Heel boots in place. Pt. will be seen on the next weekly wound round. On 8/7/22 at 9:40 a.m. Surveyor observed R19 sitting in a Broda chair in the dining area. Surveyor observed R19 is wearing pressure relieving boots. On 8/8/22 at 7:39 a.m. Surveyor observed R19 awake in bed on her back with the head of the bed elevated. Surveyor observed R19 is wearing pressure relieving boots. On 8/8/22 at 11:16 a.m. Surveyor asked CMA (Certified Medication Aide)-X when R19 started wearing pressure relieving boots. CMA-X informed Surveyor she doesn't know the exact date but it's been a couple weeks. On 8/8/22 at 12:47 p.m. Surveyor asked CCM (Clinical Care Manager)-J, who is the Facility's wound nurse, how she is informed a Resident has developed a pressure injury. CCM-J informed Surveyor if someone has a wound and she's in the facility staff will call her to take a look. CCM-J informed Surveyor she will measure the wound, get a treatment in place through the NP (nurse practitioner) or wound MD, make sure the family has been updated, make sure there is a care plan in place, complete a Braden assessment and complete the unavoidable form for every wound. CCM-J explained if the pressure injury is found on the weekend she will assess the pressure injury on Monday and the wound doctor will see the Resident on Thursday as this is the only day the wound doctor comes in. CCM-J explained the nurse can assess the pressure injury but they are not allowed to Stage. CCM-J indicated the nurse can measure and describe the wound bed. CCM-J informed Surveyor once the wound doctor sees the Resident she no longer completes the Resident's weekly wound tracking. Surveyor informed CCM-J on the initial assessment for R19's left heel pressure injury there was no documentation of the percentage of the wound bed for granulation tissue & slough. CCM-J stated there is no place to document this and they only document the percentage of necrotic tissue. Surveyor inquired if R19 ever refuses. CCM-J informed Surveyor R19 refused when her family was here otherwise she doesn't refuse. Surveyor informed CCM-J of the concern R19's pressure injuries not assessed after the family left or another day and noted there was no assessment of the pressure injuries until 8/4/22 approximately two weeks later. Surveyor inquired why the pressure injury wasn't identified until it was a Stage 3. CCM-J informed Surveyor she couldn't tell Surveyor as she doesn't see everybody every week. CCM-J informed Surveyor when a new admission comes in she sees them for the first 3 to 4 weeks and then the nurses on the floor need to do their assessments. On 8/9/22 at 10:12 a.m. to 10:16 a.m. Surveyor observed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no deficient practice identified during this treatment observation. On 8/9/22 at 10:17 a.m. Surveyor asked CCM-J how R19 developed the pressure injury on her left heel. CCM-J informed Surveyor R19 was wearing a certain kind of shoe which rested on the foot pad of the Broda chair. CCM-J indicated she didn't know if it was the shoe or foot pad of the Broda. 4. R12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The at risk for skin breakdown care plan initiated 7/30/21 includes an approach dated 7/30/21 of Elevate my heels off of my mattress with a pillow or other device. The quarterly MDS (Minimum Data Set) with an assessment reference date of 5/10/22 documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R12 requires extensive assistance with two plus person physical assist for bed mobility, transferred only once or twice during the assessment period with two plus person physical assist, and does not ambulate. R12 is at risk for developing pressure injuries and is coded as not having any pressure injuries. On 8/7/22 at 11:15 a.m. Surveyor observed R12 in bed on her back with the head of the bed elevated. There is a pressure relieving boot on R12's left foot and the right foot is not being offloaded. R12 did not have a boot on the right foot. On 8/8/22 at 7:35 a.m. Surveyor observed R12 asleep in bed on her back with the head of the bed elevated. Surveyor observed R12's heels are resting directly on the mattress and the pressure relieving boot is in a chair in the corner of R12's room. On 8/8/22 at 11:04 a.m. Surveyor observed R12 continues to be asleep in bed on her back with the head of the bed elevated. Surveyor observed R12's heels are resting directly on the mattress and the pressure relieving boot is in a chair in the corner of R12's room. On 8/8/22 at 1:31 p.m. Surveyor observed R12 in bed visiting with the visitor. R12 is on her back with the head of the bed elevated. R12's heels are not being offloaded and the pressure relieving boot continues to be in the chair in the corner of the room. Surveyor asked R12 asked about the pressure relieving boot on the chair. R12 informed Surveyor she hasn't had the boot on all day. On 8/11/22 at 7:52 a.m. Surveyor asked CCM (Clinical Care Manager)-K why R12 only wears a pressure relieving boot on the left foot. CCM-K informed Surveyor because R12 complains there is pain in her heel/foot. Surveyor inquired how staff should off load R12's heels. CCM-K informed Surveyor staff uses pillows to offload. Surveyor informed CCM-K of the observations of R12's heels not being offloaded. 5. R71's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The at risk for skin breakdown d/t (due to) diabetes, immobility, incontinence care plan initiated & revised 3/1/22 has the following approaches: * Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated & revised 3/1/22. * Administer treatments as ordered and monitor for effectiveness. Initiated & revised 3/1/22. * Encourage me/assist me with repositioning routinely and PRN (as needed). Initiated & revised 3/1/22. * Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . * I have a pressure reducing cushion in my chair. Initiated & revised 3/1/22. * Inform me/family/caregivers of any new area of skin breakdown. Initiated & revised 3/1/22. * Monitor/document/report to MD (medical doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x (times) width x depth), stage. Initiated & revised 3/1/22. * Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Initiated & revised 3/1/22. * Pressure relieving mattress to bed. Initiated & revised 3/1/22. Surveyor noted there are not approaches to prevent pressure injuries from developing on R71's heels. The quarterly MDS with an assessment reference date of 7/16/22 documents a BIMS score of 7 which indicates severe impairment. R71 requires extensive assistance with one person physical assist for bed mobility, transfer & toilet use, ambulates in the room with limited assistance with one person physical assist, dependent with one person physical assist for ambulating in the corridor. R71 is at risk for pressure injury development and is coded as not having any pressure injuries. On 8/7/22 at 9:28 a.m. Surveyor observed R71 in bed on her left side. Surveyor observed R71's heels are resting directly on the mattress and are not being offloaded. On 8/7/22 at 9:59 a.m. Surveyor observed R71 continues to be on the left side. Surveyor observed R71's heels are resting directly on the mattress and are not being offloaded. On 8/7/22 at 10:20 a.m. Surveyor observed R71 in bed on her back. There is a pillow under R71's calves with the right heel floating and the left heel resting directly on the pillow. On 8/7/22 at 11:27 a.m. Surveyor observed R71 in bed on her back. Surveyor observed R71 has a pillow under her calves and R71's heels are being offloaded. On 8/9/22 at 8:17 a.m. Surveyor observed R71 in bed on her left side. Surveyor observed R71's heels are not being offloaded. On 8/9/22 at 2:11 p.m. Surveyor asked CCM (Clinical Care Manager)-K what the Facility is doing to prevent pressure injuries from developing on R71's heels. CCM-K informed Surveyor she thought R71 was wearing boots. Surveyor informed CCM-K Surveyor didn't note any interventions on R71's skin integrity care plan to prevent pressure injuries from developing on R71's heels. CCM-K looked at R71's electronic medical record and informed Surveyor there isn't an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing R71's care plan, CCM-K stated nope there isn't anything. Surveyor asked CCM-K if staff should be offloading R71's heels. CCM-K replied they should be. Surveyor informed CCM-K of the observations of R71's heels not being offloaded. On 8/10/22 at 7:31 a.m. Surveyor observed R71 awake in bed leaning towards the right side. Surveyor observed R71 is wearing gripper socks, there is not a pillow under R71's calves and R71's heels are resting directly on the mattress. On 8/11/22 at 8:29 a.m. Surveyor observed R71 in bed on her left side. R71's heels are not being offloaded.

Based on observation, interview, and record review, the facility did not ensure 3 (R1, R2, R3) of 3 Residents reviewed who are at risk for falls received the necessary services and supervision to prevent an injury from a fall. *On 3/29/22, R1 received a fracture to the right tibial as a result of a transfer by Hoyer lift with the assistance of 1 certified nursing assistant (CNA). *R2 had 2 falls with no new updated interventions on R2's care plan. Current fall interventions were observed during the survey process not to be followed. *R3 had multiple falls with missing neurochecks and missing incident reports with no complete investigation of the falls. Findings Include: Surveyor reviewed the undated facility Transfer, Mechanical Lift policy and procedure and noted the following: Policy: A minimum of two staff are required to assist in a transfer when a mechanical lift is used. Procedure: Two staff members must be present and actively assisting with mechanical lift transfer. Surveyor also reviewed the facility's Fall Risk Assessment revised March 2018 and noted the following: Policy Statement The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document Resident risk factors for falls and establish a Resident-centered falls prevention plan based on relevant assessment information. Policy Interpretation and Implementation 6. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as [CONDITION(S)]) 1. R1 was admitted to the facility on [DATE] with diagnoses of Metabolic [CONDITION(S)], [CONDITION(S)], Age-Related [CONDITION(S)], Major Depressive Disorder, and Unspecified Dementia without Behavioral Disturbance. R1 is her own person. R1's Quarterly Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R1 is cognitively intact for daily decision making. R1's MDS also documents that R1 requires the assistance of 1 for bed mobility, dressing, and toileting. R1 requires the assistance of 2 for transfers. R1 has range of motion impairment of the lower extremities. Surveyor notes that both R1's comprehensive care plan and care card as of 4/20/22 both indicate that R1 is assist of 2 with the sit to stand. Surveyor reviewed the documentation and notes that on 3/29/22 it is reported that R1 allegedly bumped R1's knee on the wheelchair pedal during a transfer from the Hoyer lift to the wheelchair in the shower room. It was noted that the agency Certified Nursing Assistant (CNA) was alone in operating the Hoyer lift at the time of R1's transfer. At the time, R1 complained of pain. On 3/30/22, R1's advance practice nurse evaluated R1 and noted any movement/palpation to R1's right leg makes R1 cry out in pain and mentation was not at baseline. R1 was sent to the hospital and found to have a right tibial fracture and urinary tract infection. R1 returned to the facility on [DATE] with a detailed hospital discharge summary. The facility completed an investigation and confirmed that R1 had been transferred by 1 CNA using the Hoyer lift from the shower chair to R1's wheelchair. Surveyor reviewed the hospital discharge summary dated 4/1/22 and confirmed the right tibial fracture. After review of R1's electronic medical record (EMR), Surveyor notes that a fall assessment has not been completed per facility policy on R1 at time of admission or after that. On 4/20/22 at 10:52 AM, Surveyor spoke to Clinical Care Manager (CCM-E) in regards to R1. CCME-E confirmed that a fall assessment should have been done in regards to R1 on admission, and on a quarterly basis thereafter. CCM-E stated that R1 used to be a sit to stand transfer but has been a Hoyer lift transfer for a little over 1 year. CCM-E confirmed that the agency CNA had transferred R1 by herself using the Hoyer lift from the shower chair to the wheelchair. CCM-E also confirmed that no incident report was completed on 3/29/22 when the agency CNA reported R1 had hit R1's knee on the foot pedal. CCM-E confirmed standard of practice is to have 2 people to operate the Hoyer lift. CCM-E also confirmed that R1 has been on the buddy system for cares for a couple of years. CCME-E confirmed that R1's care card which documents that R1 is assist of 2 with the sit to stand is not accurate and understands the inaccuracy of the care card is a problem. CCM-E agreed that new or agency staff directed to take care of R1 would have a problem implementing the correct interventions on how best to take care of R1. CCM-E stated it is the responsibility of the interdisciplinary team (IDT) to update Resident care plans and care cards as needed. On 4/21/22 at 10:00 AM, Surveyor shared the concern with Administrator (NHA-A) that per facility policy a fall assessment should have been completed on R1 and had not been done. Surveyor also shared that R1's comprehensive care plan and care card directing staff on how best to take care of R1 was inaccurate in that they still documented that R1 was assist of 2 with sit to stand instead of R1 requiring the Hoyer lift with assist of 2. Surveyor also shared that R1 was transferred by an agency CNA in the shower room by assist of 1 instead of 2 which resulted in R1 slipping in the sling and allegedly hit R1's knee on the foot pedal. Facility policy is a Hoyer lift transfer is to be completed at minimum of 2 assist. The incident resulted in a right tibial fracture for R1. NHA-A acknowledges the concern and provided no further information at this time. 2. R2 was admitted to the facility on [DATE] with diagnoses of Dementia without behavioral disturbance, [CONDITION(S)] and muscle weakness. R2's Quarterly MDS (Minimum Data Set) dated 4/5/22 documents R2's BIMS (Brief Interview for Mental Status) score of 03, indicating R2 does not have the cognitive capacity for daily decision making. R2's MDS also documents that R2 requires extensive assistance of 2 staff for bed mobility, transfers toileting. R2 requires the assistance of 2 for transfers. R2 is at high risk for falls. On 4/20/22 at 10:40 AM, Surveyor made observations of R2 at the facility. R2 was attending facility's morning activity group. R2 was sitting in their wheelchair wearing non skid socks. Surveyor noted that R2 had a purple discoloration to the right side of their forehead. On 4/20/22 at 12:48 PM, Surveyor had observations of R2 in the facility's main dining room. R2 was sitting in their wheelchair sleeping at this time. Surveyor did not have any observations of staff in the dining room at this time. Surveyor reviewed R2's medical record including physician's orders, progress notes, CNA (certified nursing assistant) care card and comprehensive care plans. Surveyor noted R2 had sustained falls on 3/30/22 and 4/5/22. Surveyor requested R2's fall investigations for 3/30/22 and 4/5/22. Surveyor reviewed a fall huddle report dated 3/30/22. The Summary statement states R2 had sustained a fall from their bed during a self transfer and had an injury to their head. R2 was sent out the emergency room for evaluation. Surveyor noted that the facility did not provide a through investigation of R2's 3/30/22 fall, with no root cause analysis and no witness statements from staff were provided to Surveyor. Surveyor reviewed the fall huddle report dated 4/5/22. The Summary statement states R2 had sustained a fall from their wheelchair in the dining room. R2 was sent out the emergency room for evaluation. Surveyor noted the facility did not provide a through investigation of R2's 4/5/22 fall, with no root cause analysis conducted and no witness statements from staff were provided to Surveyor. Surveyor reviewed R2's Fall care plan dated 1/12/21. Surveyor did not note new interventions added to R2's care plan for their falls on 3/30/22 and 4/5/22. On 4/20/22 at 3:35 PM, Surveyor conducted interview with Clinical Care Manager-E. Surveyor asked Clinical Care Manager-E if they recalled R2's fall on 3/30/22. Clinical Care Manager-E told Surveyor they had been working as a floor nurse on 3/30/22 when R2 sustained the fall from bed. Surveyor asked Clinical Care Manager-E if the facility has a specific protocol for residents who sustain unwitnessed falls. Clinical Care Manager-E told Surveyor there is a fall checklist they would follow and they would update the resident's family and doctor if there were any falls. Surveyor asked Clinical Care Manager-E who is responsible for completing incident reports on falls and updating resident care plans. Clinical Care Manager-E responded that the nurse that finds the resident is responsible for initiating an incident report and updating care plans. Surveyor asked why R2 did not have an incident report and/or investigation completed for their 3/20/22 fall. Clinical Care Manager-E told Surveyor there was no incident report completed or staff statements related to R2's fall as they were very busy on 3/30/22 and unable to complete an incident report or collect staff statements. Surveyor asked Clinical Care Manager-E what interventions were put into place after R2's fall on 3/30/22. Clinical Care Manager-E responded that R2 should have increased supervision after their fall on 3/30/22. Surveyor asked if a resident at risk for falls should be in the dining room without staff members present. Clinical Care Manager-E told Surveyor that residents who are fall risks should not be left alone in the dining room. On 4/20/22 at 2:35 PM, Surveyor conducted an interview with LPN-C. Surveyor asked LPN-C if they recalled R2's fall on 4/5/22. LPN-C told Surveyor they remember getting called to the dining room and R2 was noted on the floor and it was decided to send the resident to the emergency room . Surveyor asked LPN-C if the facility has a specific protocol for residents who sustain unwitnessed falls. LPN-C told Surveyor there is a fall checklist they would follow and they would update the resident's family and doctor if there were any falls. Surveyor asked LPN-C who is responsible for completing incident reports on falls and updating resident care plans. LPN-C responded that nursing management would be responsible for initiating an incident report and updating care plans. Surveyor asked why R2's incident report for their 4/5/22 fall did not have a complete investigation, including statements from staff. LPN-C responded they are not sure why there were no staff statements obtained related to R2's 4/5/22 fall. Surveyor asked LPN-C what interventions were put into place after R2's fall on 4/5/22. LPN-C responded R2 should be supervised when in the dining room. Surveyor asked if whether a resident who is at risk for falls should be in the dining room without staff members present. LPN-C told Surveyor that residents who are fall risks should not be left alone in the dining room. On 4/20/22 at 4:00 PM, Surveyor conducted interview with ADON (Assistant Director of Nursing) -F. Surveyor asked ADON-F if the facility has a specific protocol for residents who sustain falls. ADON-F told Surveyor there is a fall checklist they would follow and they would update the resident's family and doctor if there were any falls. Surveyor asked ADON-F who is responsible for completing incident reports/fall investigations. ADON-F responded that the nurse who found the resident after a fall should be initiating fall investigations and then the interdisciplinary team would review the fall. Surveyor asked ADON-F if staff witness statements should be part of a through fall investigation. ADON-F responded that staff statements should be part of the fall investigation. On 4/21/22 at 10:00 AM, Surveyor shared concerns with NHA-A related to R2's falls on 3/30/22 and 4/5/22, including lack of thorough fall investigations and R2 being observed without staff present in the dining room on 4/20/22. No additional information was supplied to Surveyor at this time. 3. R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, [CONDITION(S)] and muscle weakness. R3's Quarterly MDS (Minimum Data Set) dated 3/10/22 documents R3's BIMS (Brief Interview for Mental Status) score of 03, indicating R3 does not have the cognitive capacity for daily decision making. R3's MDS also documents that R3 requires extensive assistance of 2 staff for bed mobility, transfers and toileting. R3 is at high risk for falls. On 4/20/22 at 12:05 PM, Surveyor made observations of R3 at the facility. R3 was noted in the unit dining room self propelling their wheelchair with their feet. R3 was noted with non skid footwear. R3 was not interviewable at this time. Facility staff were present at the time of observation. Surveyor reviewed R3's medical record including physician's orders, progress notes, CNA care card and comprehensive care plans. Surveyor noted R3 had sustained falls on 1/3/22, 1/6/22, 1/10/22, 1/16/22, 1/21/22, 1/22/22, 1/23/22, 2/2/22, 2/6/22, 2/16/22, 2/19/22, 2/24/22, 2/25/22, 3/9/22, 3/15/22, 4/4/22, 4/6/22 and 4/9/22. Surveyor requested R3's complete fall investigations including root cause analysis and statements from staff. Surveyor reviewed R3's fall incident reports provided by the facility. The facility did not conduct root cause analysis of the above falls and did not obtain witness statements from staff members following R3's falls. On 4/20/22 at 3:35 PM, Surveyor conducted an interview with Clinical Care Manager-E. Surveyor Clinical Care Manager-E if the facility has a specific protocol for residents who sustain falls. Clinical Care Manager-E told Surveyor there is a fall checklist they would follow and they would update the resident's family and doctor if there were any falls. On 4/20/22 at 4:00 PM, Surveyor conducted an interview with ADON (Assistant Director of Nursing)-F. Surveyor asked ADON-F if the facility has a specific protocol for residents who sustain falls. ADON F told Surveyor there is a fall checklist they would follow and they would update the resident's family and doctor if there were any falls. Surveyor asked ADON-F who is responsible for completing incident reports/fall investigations. ADON-F responded that the nurse who found the resident after a fall should be initiating fall investigations and then the interdisciplinary team would review the fall. Surveyor asked ADON-F if staff witness statements should be part of a through fall investigation. ADON-F responded that staff statements should be part of the fall investigation. On 4/21/22 at 10:00 AM, Surveyor shared concerns with NHA-A related to a lack of thorough fall investigations including staff statements for R3's all the falls listed above. No additional information was supplied by facility at this time.

Based on observation, interview, and record review, the facility did not ensure 2 (R84, R87) of 5 residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease. ~ R84 was admitted to the facility without extensive contractures and the facility did not develop a restorative ROM (Range of Motion) care plan because the facility had no restorative program. ~ R87 had a splints order but no care plan and no verification that the splints were being used. Findings include: The facility policy, Splint/Brace/Device Wearing Schedule, dated 10/12/06, indicated: Residents will wear splints as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation of usage, refusal, and or removal shall be done on the appropriate forms. Splint schedules are documented in resident care plans. 1. R84 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R84's Quarterly MDS (Minimum Data Set), dated 5/7/21, indicated R84 was cognitively impaired, required extensive assistance with 2 staff for bed mobility, had functional impairments of both arms and legs, and no minutes recorded for ROM (Range of Motion). R84's Admission MDS, dated [DATE], indicated R84 was cognitively intact, required extensive assistance with 2 staff for bed mobility, had functional impairments of both arms and legs, and no minutes recorded for ROM. On 5/24/21, at 9:28 AM Surveyor conducted observations of R84 during wound rounds with MD-K (Wound Physician), RN-I (Wound Nurse), and CNA-N (Certified Nursing Assistant). Surveyor noted R84 cried out when R84 was turned by RN-I and CNA-N due to severe leg contractures. Surveyor observed legs were bent at the knees in a 90 degree angle with contractures and R84's arms to be flacid. MD-K stated R84 has no pain with wounds but pain due to the contractures. Surveyor observed CNA-N holding R84's bent contracted legs apart at the knees in order for wound care as R84 has shear wounds of the left anterior knee and left anterior upper leg from rubbing against the right contracted leg. MD-K stated R84's wounds are unavoidable given immobility, contractures, and multiple comorbidities. Surveyor noted R84 has a care plan and a CNA care card indicating R84 should have a pillow between legs and knees at all times, which Surveyor observed during the survey process. On 5/26/21, at 11:56 AM, Surveyor interviewed PT-J (Physical Therapy) who stated therapy worked with R84 when first admitted so she will look back in her notes. PT-J stated the facility does not have a restorative program for CNA's to follow for resident care. On 5/26/21, at 12:49 PM, Surveyor interviewed PT-J who stated PT initially saw R84 on 9/18/20 with goals of sitting tolerance for OT (Occupational Therapy) and transfers for PT (Physical Therapy). PT-J stated R84 did not have contractures of upper arms as R84's arms were flaccid, which Surveyor observed on 5/24/21. PT-J stated R84 did not have leg contractures on admission and PT gave R84 ankle dorsiflexor splints to prevent foot drop but now R84 has special boots for Pressure Injuries (PIs). Surveyor reviewed the PT notes from 9/18/20 to 9/30/20 which indicated: PROM (Passive Range of Motion) to both legs with the left leg demonstrating increased resistiveness however right leg with increased muscle guarding and increased hypersensitivity to touch and movement. Surveyor reviewed the OT notes from 9/18/20 to 10/8/20 which indicated : Deficits including physical and cognitive .comorbidities affect occupational performance: ataxic gait, MS, and [CONDITION(S)]. Surveyor reviewed R84's care plan, dated 10/6/20, which indicated: I have MS with a goal of remaining free of complications or discomfort related to MS. Interventions, dated 10/6/20, included: Give medications as ordered. Monitor/document for side effects and effectiveness. Obtain and monitor lab/diagnsotic work as ordered. Report results to MD and follow up as indicated. Pain Management as needed. See MD orders. Provide alternative comfort measures as needed. PT/OT/ST (Speech Therapy) evaluate and treat as ordered. R84's MS care plan did not indicate ROM exercises to prevent decline nor was it updated to reflect R84's current status of contractures. Surveyor noted R84's care plan did not address PROM or leg exercises to prevent decline in leg mobility and prevention of contractures. Surveyor noted that a plan of action to prevent contractures with splints and ROM was not incorporated into the care plan or noted on the CNA care card. On 5/26/21, at 1:25 PM, Surveyor interviewed RN-I who stated R84 cannot reposition self. RN-I stated R84 was admitted to the facility without leg contractures and R84's legs are now contracted so that makes it more difficult for repositioning R84. Surveyor noted R84 was admitted to the facility and able to perform ROM leg exercises with therapy on 9/28/20 but without a plan to prevent decline and leg contractures, Surveyor observed on 5/24/21, R84's legs were bent at the knees in a 90 degree angle with contractures. Surveyor noted tphyical therapy did not develpe a restorative care plan for range of motion services as the facility has no restorative program. On 5/26/21, at 4:00 PM, Survey Team shared the information with the NHA-A (Nursing Home Administrator) and DON-B (Director of Nursing) and no further information was provided. 2. R87 admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R87's Admission Minimum Data Set, dated dated dated [DATE], Care Area Assessment documented: [AGE] year old male patient with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is dependent on staff for bathing/showering and transfers with hoyer mechanical lift with assist/2. Patient presents to facility with significant contractures to bilateral upper extremities (BUE). Braden score of 7. On 5/23/21 during the screening process, Surveyor noted R87 was not wearing splints on his upper extremities. Surveyor subsequently interviewed R87 on 5/24/21 at 1:14 PM and asked if he had splints for his arms, to which he replied: Yeah, they're over there (R87 nodded toward the dresser). Surveyor observed (2) arm splints on the dresser. Surveyor asked the resident about the splints, and R87 stated: I haven't worn them since therapy. When Surveyor asked R87 why he has not worn the splints since therapy, he stated: They don't put them on. I'll wear them for a little while, but they want me to wear them too long - past all 3 meals and I can't do that, it hurts too much. I'm afraid if they put them on, I'll be stuck in them all day, so I tell them no. R87's therapy notes documented: PT (Physical Therapy) start of care 2/1/21 - end of care 2/15/21: This [AGE] year old Male presents to therapy with positioning deficits, including contractures in Bilateral UE (upper extremity) and LE (lower extremity) as a result of [CONDITION(S)] (central cord syndrome) for over a year now . The patient has declined from sitting in manual wc (wheelchair) to staying bed bound primarily, which impacts ROM (range of motion) in bilateral LE and UE. Previous positioning intervention includes staying in bed at group home. Analysis of Functional Outcome/Clinical Impression. The patient did not make significant progress toward goals. Treatment plan adjustments to be made include DC (discharge) as patient is not tolerating PROM (Passive Range of Motion) to bilateral hip and knee extension and with severe [CONDITION(S)] there is no carryover with program. Any motion gained during ROM is gone as soon as pressure is released from movement. OT (Occupational Therapy) start of care 2/2/21 - end of care 5/21/21: OT - Therapist Progress & Discharge Summary. Analysis of Functional Outcome/Clinical Impression. Patient continues to present with significant flexor tone and [CONDITION(S)] to BUE impacting positioning despite PROM (Passive Range of Motion) and elbow splints. No carry-over from staff regarding donning/doffing splints with patient not initiating nor requesting splints to be donned. At this time, medical complexity impacts maintenance of mobility as positioning has demonstrated no change since SOC (start of care). As a result, patient has achieved max benefit from therapy services at this time. On 5/24/21 at 12:59 PM Surveyor spoke with OT-D. Surveyor asked if R87 is supposed to be wearing splints on his arms. OT-D stated: Yes. We provided splints and educated the staff about them, but he never had the splints on anytime I worked with him. Between staff not putting them on and the resident not initiating they be put on, he just hasn't worn them. OT-D reported R87's contractures have remained unchanged and have not gotten worse. She stated: He came in already severely contracted of both arms and legs. Nothing could really be done with the legs, they were so contracted they couldn't even be stretched out. I was able to get his arms stretched enough to get the splints on. We already had a splint in house for the left arm and ordered one for the right arm on 3/3/21. Review of R87's Care Plan did not include a problem area of contractures and there were no interventions regarding splints to be worn to his BUE. R87's Certified Nursing Assistant (CNA) cardex (which is kept in a binder on the unit) dated as of 3/19/21 documented: Contractures: I have contractures of the BLE's (bilateral lower extremities). Provide skin care PRN (as needed) to keep clean and prevent skin breakdown. Surveyor noted there was no documentation regarding contractures or splints to be worn on his BUE. Surveyor noted R87 admitted to the facility with severe BUE contractures. He received therapy and BUE splints were ordered. There was no evidence R87's contractures worsened, however the facility did not implement a care plan addressing R87's contractures, including intervention of therapy orders for BUE splints to be worn. On 5/25/21 Director of Nursing (DON)-B was notified of the above concerns. DON-B provided Surveyor an updated CNA cardex dated 5/25/21, which documented: Skin: DON elbow splints after breakfast, off elbow splints after dinner. Contractures: I have contractures of the BLE's. Provide skin care PRN to keep clean and prevent skin breakdown.

Based on interview and record review, the facility did not ensure that 1 (R84) of 2 residents reviewed for pain management was provided services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Surveyor reviewed R84's Comprehensive Care Plan with initiation date of 10/6/20. There was no indication the details from the pain evaluation dated 5/13/21 were developed into a comprehensive care plan. R84's ineffective pain management caused increased pain during personal cares and wound treatments. Findings include: The facility policy, Pain Management, dated 11/28/16, indicated: It is the policy to outline a holistic and multidisciplinary approach to the management of residents experiencing anxiety, discomfort, and pain. The resident is the definitive voice in identifying and defining his/her pain. A treatment plan and individualized care plan will be developed. The resident's pain will be monitored and reassessed until the pain is managed to the resident's satisfaction and/or the non-verbal indicators of pain are no longer present. The treatment plan will be developed and revised based on the individualized ongoing pain assessment to include: The resident's pain goal, How the pain will be treated (pharmacological, non-pharmacological), Factors that improve and/or worsen the resident's pain. R84 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R84's Quarterly MDS (Minimum Data Set), dated 5/7/21, indicated R84 was cognitively impaired, required extensive assistance with 2 staff for bed mobility, had functional impairments of both arms and legs, and no minutes recorded for ROM (Range of Motion). R84's MDS Section J: Health Conditions/Pain Management indicated no scheduled pain medications and no prn (as necessary/needed) were given. R84 had a pain evaluation, dated 5/13/21 that indicated R84 had pain in the last 5 days with frequency at a moderate intensity. R84's assessment indicated the pain sites were back, bone, and soft tissue. R84 indicated pain increases with mobility and cares with the most likely cause of pain: pressure ulcer. R84's current pain medication regime indicated Acetaminophen and Narcotics. R84's Plan: referral to primary and initiate [MEDICATION(S)]/adjust frequency. R84's care plan, dated 10/6/20, indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions dated 10/6/20 included: Administer pain medication as ordered. Monitor for pain on scale 0-10. Notify MD if medication and non-medication intervention ineffective. Educate me regarding the side effects of my pain medication and the potential for falls: dizziness, drowsiness, nausea, constipation, and notify my physician as needed. I am able to call for assistance when I am in pain, reposition myself, ask for medication, tell you how much pain is experienced, tell you what increase or alleviate pain. Encourage me to do these things Monitor/record/report to Nurse any signs/symptoms of non-verbal pain: Changes in breathing; Vocalizations, Mood/Behavior, Eyes, Face, Body. Observe and report changes in usual routine, sleep patterns, decrease in functional status, decreased ROM, withdrawal or resistance to care. Provide me my pain medications prior to my therapy treatment. Provide me my pain medications when needed and/or requested. If my medication is not effective to relieve my pain, please contact my physician so it can be adjusted. Provide me with a warm and comfortable environment. Provide me with reassurance that pain is time-limited. Encourage me to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. Surveyor noted R84's interventions were dated 10/6/20 and not updated after the 5/13/21 pain evaluation and did not reflect R84's current physical limitations. Surveyor noted R84's care plan also indicated PI (pressue injury) problems with multiple dates but did not indicate an intervention for prophylactic pain medication prior to wound treatments and not updated after the 5/13/21 pain evaluation. Surveyor noted R84's care plan indicated a problem of MS, dated 10/6/20, with an intervention, dated 10/6/20, for pain management as needed, see MD orders, Provide alternative comfort measures as needed. Surveyor noted R84's interventions were dated 10/6/20 and not updated after the 5/13/21 pain evaluation and did not delineate what were the alternative comfort measures. Surveyor noted R84's care plan indicated a problem with ADL's (Activities of Daily Living) including bed mobility, dated 10/6/20 but did not have interventions for pain prevention/prophylaxis with ADL's and was not updated after 5/13/21 pain evaluation. Surveyor reviewed R84's Comprehensive Care Plan with initiation date of 10/6/20. There was no indication the details from the pain evaluation dated 5/13/21 were developed into a comprehensive care plan. On 5/24/21, at 9:28 AM Surveyor conducted observations of R84 during wound rounds with MD-K (Wound Physician), RN-I (Wound Nurse), and CNA-N (Certified Nursing Assistant). Surveyor noted R84 cried out when R84 was turned by RN-I and CNA-N due to severe leg contractures. MD-K stated R84 has no pain with wounds but pain due to the contractures. Surveyor observed CNA-N had to hold R84's legs apart for wound care as R84 has shear wounds of the left anterior knee measuring 1 x 1 x 0.1 cm and left anterior upper leg measuring 3.4 x 2 x 0.2 cm. Surveyor observed R84's left anterior leg cleansed and dressing applied while CNA-N held her legs apart. R84's left anterior knee and left anterior leg treatments were scheduled for day shift on Monday/Wednesday/Friday and as needed. RN-I then cleansed R84's sacral area wound and R84 cried out in pain, louder especially with cleansing and rubbing of the sacral wound measuring 3.4 x 2.2 x 0.6 cm. R84 continued to complain of pain, MD-K asked R84 if it was the sacral wound causing pain, and R84 stated yes it hurts. R84's sacral wound treatments were scheduled daily and as needed. Surveyor asked RN-I if R84 had been pre-medicated for pain prior to wound care. RN-I stepped to the hallway to ask RN-L (Registered Nurse) who stated no pain medications were given and she could have given R84 a [MEDICATION(S)] (Controlled Pain pill) but R84 had no pain at that time during med pass. RN-I removed the right lower buttock dressing which had massive bloody drainage soaking the dressing, the brief, and the sheets. RN-I cleansed the right lower buttock wound measuring 3.2 x 3 x 2.5 cm and R84 was moaning during the cleansing. MD-K stated he saw pus inside wound and proceeded to culture the right lower buttock wound when R84 complained of pain, stating that really hurts during the culture process. CNA-N offered for R84 to hold her hand during the process and R84 squeezed the CNA's hand. RN-I told R84 that pain medication would be given when MD-K was finished with all of R84's wounds. R84 continued to moan and cry out during the next procedure of MD-K's debridement of right lower buttock wound. MD-K stated the right lower buttock wound was not indurated but the area surrounding the wound was tender to touch. R84's right lower buttock wound treatments were scheduled daily and as needed then changed to every shift and as needed on 5/24/21 due to drainage and possible infection. R84's wound care treatments were completed at 10:15 AM, approximately 45 minutes from start to finish of R84's wound care treatments. Surveyor noted that R84's MAR/TAR (Medication Administration Record/Treatment Administration Record) indicated R84 received [MEDICATION(S)] 50 mg on 5/24/21 at 11:53 AM for a pain level of 4/10. R84's progress note on 5/24/2021 at 16:09 (4:09 PM), the Skin/Wound Note indicated R84 had no complaints of pain prior to wound dressing changes. On 5/25/21, at 12:54 PM, Surveyor interviewed CNA-N who stated while caring for R84 today, R84 was moaning with cares and being turned. CNA-N stated she does not know if she can say R84 feels pain or not . with cares, turning, and repositioning but R84 does cry out with pain. On 5/26/21, at 7:48 AM, Surveyor interviewed RN-L who stated R84 is watching TV this am, and RN-L gave her a pain pill because she knows R84's is going to have wound treatments today. RN-L stated the problem is when R84 is lying there, RN-L asks about pain, R84 has none but when R84 gets turned or wound treatments, then that is when R84 starts screaming with pain. RN-L asked R84 this am who stated no pain, so RN-L stated may I give you a pain pill. RN-L stated R84 stated I don't know, I don't care so RN-L feels R84 cannot decide for herself. On 5/26/21, at 8:06 AM, Surveyor interviewed LPN-M (Licensed Practical Nurse) who cared for R84 yesterday on 5/25/21. LPN-M stated R84 said no pain but RN-I asked that R84 get a pain pill as R84 has so much pain with the wound treatments. On 5/26/21, at 11:20 AM, Surveyor interviewed R84 who was s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R84 stated no pain right now but hurts with turning and my bottom. On 5/26/21, at 11:25 AM, Surveyor interviewed CNA-O who stated she just finished R84's bed bath who moaned and cried out with turning and cares but now R84 is situated and feels comfortable. On 5/26/21 11:30 AM, Surveyor interviewed RN-L who stated she assisted CNA-O with turning R84 during the bed bath. RN-L stated R84 moaned a lot with repositioning and the wound treatment today. RN-L stated she pre-medicated R84 at 7:18 this am so R84 was not screaming out like R84 did on 5/24/21 during wound treatments but today R84 was just going ohohoh and groaning. Surveyor reviewed R84's May 2021 MAR/TAR which indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R84's May 2021 MAR/TAR which indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted that Acetaminophen was not given for R84's pain management during the month of May. Surveyor noted that [MEDICATION(S)] was given for R84's pain management during the month of May only 4 times on 5/16/21 at 8:20 PM, 5/17/21 at 8:22 PM, 5/24/21 at 11:53 AM, and 5/26/21 at 7:18 AM. R84's ineffective pain management caused increased pain during personal cares and wound treatments. On 5/26/21, at 4:00 PM, the Survey Team shared the information with the NHA-A (Nursing Home Administrator) and DON-B (Director of Nursing) and no further information was provided.

Based on interview and record review the Facility did not have evidence 2 (R2 & R4) of 4 allegations of abuse, neglect, mistreatment and/or exploitation were investigated. The lack of a facility investigation into these allegations of abuse, neglect, mistreatment and/or exploitation allowed the potential for further abuse to occur. * On 5/11/20 the Facility was made aware of a six page log provided by the Ombudsman regarding R2. The six page log provided by the Ombudsman included allegations a Certified Nursing Assistant (CNA) was going to bring her dog into R2's room which made R2 feel threatened, taking a picture of R2 on a cell phone to show her husband/boyfriend, multiple allegations of staff swearing, yelling, being mean. R2 described staff behavior towards him as like Auschwitz, and the staff are like the Gestapo. As of 8/24/20, there is no evidence the Facility investigated these allegations. * In an email chain dated 7/30/20 & 8/3/20 from R4's son to Administrator-A, the Facility was made aware of an allegation on 7/21/20 R4 waited approximately 30 minutes to be taken off a bedpan. When the CNA came into R4's room she yelled at R4 and informed R4 I don't need this, you can sit on that bed pan and walked out without taking R4 off the bed pan. On 8/3/20 the Facility was made aware of R4 waiting in excess of one hour for the call light to be answered and Staff was unnecessarily rough when care were provided. R4's son states in this email to Administrator-A, These incidents of neglect and abuse need to stop immediately. As of 8/24/20, there is no evidence the Facility investigated these allegations. Findings include: The Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention and Reporting Policy revised November 2016 under Introduction documents Acknowledgement that no one should be subjected to violent, abusive, humiliating, exploitive or neglectful behavior is the single most critical step in detecting and preventing abuse, neglect, misappropriation of patient property as well as abuse to include taking or using photographs via audio/visual recording that would demean or humiliate a patient/resident. Under Investigate documents According to CMS (Centers for Medicare and Medicaid Services), the Facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation process is in progress. The key to investigation allegations of abuse is an environment that facilitates the reporting of such alleged allegations. Once reported, the center should conduct a timely, thorough and objective investigation of any allegation of abuse. Part of this investigation is the consideration of the indicators of possible abuse. 1. On 8/17/20 at 11:00 a.m. Surveyor started to review a complaint received by the Southeastern Regional Office involving R2. Attached to the complaint was a six page complaint log from 3/13/20 to 5/6/20 which included allegations of abuse, neglect, mistreatment, and exploitation. Surveyor noted the complaint log includes in part: On 3/22/20 Resident stated that his table tilted when he was getting out of bed because nobody would help me. He states he had the call light on for over an hour and a half. A nurse came in and said that he called her racial slurs. He threatened to call the police. He states that her claim was not true, that he has never seen this nurse/aide before except for her screaming at him, tell him he does this[***]all the time and what an[***] he is. On 3/22/20 Resident stated that he just had a girl threaten to bring her dog in to meet him. He felt threatened by this, that this was threatening his life. On 3/25/20 Resident states that yesterday he needed the toilet for a BM (bowel movement), but nobody answered the call button. He got himself on to the toilet. He asked for assistance getting off, nurse/CNA was mean. She snarled at him, telling him that if he got himself on, he can get himself off. They are rude and mean. On 4/3/20 He says his aide for the day, CNA (Certified Nursing Assistant)-R would not help him today. He states that it feels like Auschwitz, and the staff are like the Gestapo. He wondered how he will eat at 5:00 as he cannot sit at the end of the bed to eat, as he will fall. On 4/4/20 Resident states that the aide came in and said that he would eat at his bedside table. He told her that he could not sit up, he needed to be in his wheelchair to eat at the table. He said that she questioned him. He said that she said, F . you, motherf .er, and stormed from the room. On 4/4/20 Resident states that three minutes ago a CNA came bursting in with a hostile attitude. He states that she walked to the bed, glared at him, and demanded an apology from him for being disrespectful. He denied being disrespectful. He states that she then picked up one of the unemptied urinals and tilted it up over his chest, as if she would dump it on his chest and face. On 4/5/20 Resident states that he had a woman threaten him and call him a cracker. He told her to get the f . out of the room. She said that she would tell her husband. She took a picture of him in his Pull Ups. On 4/5/20 Resident states that one of the aggressive girls with tattoos and braids to her waist decided to call her husband about the way she was treated by him. He states she took pictures or filmed him lying in bed without his Pull Ups on. On 4/13/20 He states that she was rude, insulting his mother/family. He states that she is the aide that took photos of him with her cell phone when he was in bed, after having words. He states on that occasion his Pull Ups were down and he had no blankets. She told him that her husband was on the phone. On 4/13/20 Resident is setting up a place for himself on the floor to sleep. Two girls took his sleeping pillow the vindictive and mean ones. He was left with a hard, uncomfortable pillow he found in a closet. On 4/18/20 Resident stated there was an incident yesterday. A real mean CNA wouldn't get him out of bed to eat. He yelled for her. When she came she gave him a real slippery smile and said she couldn't hear him. On 4/29/20 Resident states the girl is very mean. He indicates that he was put into a position where he had to get in bed by himself. Staff did not respond and he fell over. He states that the aide came, tried to grab him by the ankles, tried to twist my right foot off my ankle/ tried to break his ankle. Resident states he call the South Milwaukee PD (police department), who will have a report. He also states that an aide came in to antagonize him last night when he was sound asleep. On 8/18/20 at 1:32 p.m. Surveyor asked Administrator-A for any investigations involving R2. On 8/18/20 at 3:10 p.m. Surveyor spoke with SSD (Social Service Director)-L on the telephone regarding R2. Surveyor inquired if R2 has an activated power of attorney. SSD-L informed Surveyor she doesn't believe R2 has an activated power of attorney. SSD-L informed Surveyor R2 is alert & orientated but is mentally ill and is [MEDICAL CONDITION]. Surveyor asked SSD-L if R2 voiced any concerns or had she heard about staff taking pictures of R2. SSD-L replied haven't heard that. Surveyor asked if SSD-L has heard about a staff member stating they were going to bring their dog into R2 and R2 felt threatened. SSD-L replied haven't heard that, never hear him saying that. Surveyor asked if R2 ever voiced a concern staff was disrespectful to him. SSD-L replied he says they are and explained to Surveyor R2 calls them f ing b ches. SSD-L informed Surveyor staff aren't going to stand there, they leave. SSD-L informed Surveyor she doesn't think staff disrespects R2 its the opposite R2 disrespects staff. On 8/19/20 at 3:45 p.m. Surveyor spoke with Ombudsman-U to inquire if she notified the Facility of R2's six page complaint log. Ombudsman-U explained she sent Former Administrator-V an email on 5/11/20 and then on the same day found out Former Administrator-V had left and Former Administrator-W was the interim administrator. Ombudsman-U indicated she sent Former Administrator-W an email on the same day. Surveyor verified with Ombudsman-U she sent the Facility the six page complaint log. Surveyor asked if Ombudsman-U she spoke with Former Administrator-W. Ombudsman-U informed Surveyor she and Former Administrator-W played phone tag but they never connected. Surveyor asked Ombudsman-U to forward the email she sent to Former Administrator-V & Former Administrator-W to the Surveyor. Surveyor reviewed the forwarded email and noted Former Administrator-V received an email from Ombudsman-U on 5/11/20 at 4:59 p.m. Included in the email to Former Administrator-V was one of the categories R2 has complaints regarding is Verbal/psychological abuse. Surveyor noted Former Administrator-W received an email from Ombudsman-U on 5/11/20 at 5:12 p.m. which included the email to Former Administrator-V and the six page complaint log. On 8/19/20 at 4:16 p.m. Surveyor spoke with Administrator-A on the telephone. Surveyor informed Administrator-A Surveyor had spoken with Ombudsman-U who verified Former Administrator-V & Former Administrator-W on 5/11/20 received an email with a six page complaint log regarding R2 which includes complaints regarding verbal/psychological abuse. Surveyor informed Administrator-A there are complaints about staff swearing at R2, a CNA threatening to bring her dog into R2's room, a CNA taking a picture of R2 in his brief along with other allegations. Surveyor asked Administrator-A for all investigations for R2. Administrator-A informed Surveyor RN/UM (Registered Nurse/Unit Manager)-C has a file on R2, will see what they have and send it to Surveyor. On 8/20/20 Surveyor received an email from Administrator-A with attachments. The attachment entitled R2's soft file included a psych consult dated 8/14/20, the six page complaint log from Ombudsman-U regarding R2, and various staff statements regarding R2's behavior dated 5/16, 4/6, 5/6, a statement not dated, 6/10, 7/3, 7/29, and two statements dated 8/14. Also attached to Administrator-A's 8/20/20 email is entitled Former Administrator-W statement. This statement documents Below is the statement from Former Administrator-W regarding the email in question for R2. I spoke with the Ombudsman about him and she knew him very well and said that we could never fix all his complaints and understands the situation and that we can just try to fix what we can but so know he (Sic) makes a lot of false allegations. Former Administrator-W, (name) 8/19/20. No investigations were provided to Surveyor. On 8/24/20 at 11:34 a.m. Surveyor asked Administrator-A if he had any additional information regarding R2's allegations of abuse, mistreatment, neglect and exploitation. Administrator-A informed Surveyor he has provided Surveyor with everything he has. No investigations were provided to Surveyor. On 8/24/20 at 4:15 p.m. Surveyor showed SSD (Social Service Director)-L the six page complaint log regarding R2 the Ombudsman had emailed Former Administrator-W and asked if Former Administrator-W provided her with a copy of this six page log. SSD-L replied no, didn't get it but informed Surveyor she had heard about it. Surveyor asked SSD-L if she was given any instructions regarding R2's allegations. SSD-L replied no and explained they were aware from Ombudsman-U R2 had called her twenty one times. Surveyor asked if any abuse investigations were done for the allegations on this six page complaint log. SSD-L replied no and explained that was the concerns that were brought forth on 3/25/20. Surveyor informed SSD-L there are multiple dates after 3/25/20 on the complaint log. SSD-L informed Surveyor if a resident tells her a concern she writes out a complaint form and then gives it to the department. SSD-L informed Surveyor if the complaints is an allegation of abuse Administrator-A or whomever was the Administrator would be notified immediately. As of 8/24/20, the facility did not investigate R2's allegations of abuse, neglect, exploitation and mistreatment. 2. On 8/17/20 at 12:00 p.m. Surveyor started to review a complaint received by the Southeastern Regional Office involving R4. Attached to the complaint was an email chain between R4's son and Administrator-A dated 7/30/20 & 8/3/20. Surveyor noted R4's son's email to Administrator-A dated Thursday, July 30, 2020 at 10:55 a.m. documents under First incident Tuesday, July 21 My Mom activated her call light to request assistance with using the bathroom at 11pm. Note that she currently is unable to use the toilet herself due to the recent surgery on her leg and the amputation of two toes on her left foot, and requires the use of a bedpan. At 11:30pm an aide responded and assisted getting her on the bedpan. At 11:35pm, she activated her call button again when she was finished. After receiving no response, at midnight she tried calling the nurses desk from her cell phone. As it was ringing, the aide came back in and said something to the effect of you can get off the phone. She was yelling at my Mom telling her that she was the only aide on the floor and that she would need to be patient as she was in with another patient. My mom responded to her that she didn't feel she needed to be talk to like that, to which the aide responded I don't need this, you can sit on that bed pan. When my Mom asked her name, she just walked off. A nurse who witnessed this exchange then came in and assisted my Mom. On 7/30/20 at 6:32 p.m. Administrator-A sent an email to R4's son which documents, I appreciate the information. I have started an investigation to take care of some of these items. I do apologize for the poor service which it sounds like your mother has had to endure. I have turned this over to the clinical team for some better answers for you. Please give me a few days and I will get back to you on the resolutions. I agree with you and none of these items are acceptable to any of our residents on campus. I will be in touch. Surveyor noted R4's son's email to Administrator-A dated Monday, August 3, 2020 documents, Unfortunately, I need to again bring to your attention another set of incidents that occurred Friday and Saturday evenings, July 31st & August 1st. This time I don't have as specific of details of the times/durations of the incidents, but it's my understanding that my Mom was made again to wait in excess of an hour for attention to her call light, and on one occasion that evening the light was turned off by someone on the staff without acknowledging my mother or asking her what she needed. And on one occasion when she was attended to, she made note that the attending aide was unnecessarily rough with her when assisting with wiping her after use of the bedpan. She ended up calling my sister in tears, as again she was in pain from having to wait so long to use the restroom. These incidents of neglect and abuse need to stop immediately. On 8/19/20 at approximately 2:10 p.m. Surveyor asked for Administrator-A any investigations for the allegations listed in Son-Z's email to him on 7/30/20 & 8/3/20. On 8/24/20 at 11:29 a.m. Surveyor asked Administrator-A if he had any further information for the allegations listed in R4's son email to him on 7/30/20 & 8/3/20. Administrator-A informed Surveyor only what he sent Surveyor already. Surveyor did not receive any investigations for R4. Surveyor inquired why there isn't evidence the allegations were investigated as Son-Z stated in his email on 8/3/20 the incidents of abuse and neglect need to stop. Administrator-A informed Surveyor they weren't valid accusations. Administrator-A explained he spoke with R4 who was happy & had no problems but told the son a different story. Administrator-A informed Surveyor R4 wanted to go home. Surveyor informed Administrator-A allegations of abuse & neglect were brought to his attention by R4's son and these allegations should have been investigated. On 8/24/20 at 4:21 p.m. asked SSD (Social Service Director)-L if she was directed to do a grievance or investigate allegations of abuse/neglect regarding R4's son email which were dated 7/30/20 & 8/3/20. SSD-L replied was not even aware of those.

Based on a complaint received at the Southeastern Regional Office, interview and record review the Facility did not ensure 2 (R2 & R4) of 4 Residents reviewed were free of abuse, neglect and exploitation. * On 5/11/20 the Facility was made aware of a six page log provided by the Ombudsman regarding R2. The six page log provided by the Ombudsman included allegations a Certified Nursing Assistant (CNA) was going to bring her dog into R2's room which made R2 feel threatened, taking a picture of R2 on a cell phone to show her husband/boyfriend, multiple allegations of staff swearing, yelling, being mean. R2 described staff behavior towards him as like Auschwitz, and the staff are like the Gestapo. As of 8/24/20, there is no evidence the Facility investigated, reported, or implemented any actions to prevent further abuse, neglect or exploitation from occurring in the future. As of 8/24/20, R2 still recalls his allegations of abuse and neglect with feeling threatened and angry. * In an email chain dated 7/30/20 & 8/3/20 from R4's son to Administrator-A, the Facility was made aware of an allegation that on 7/21/20 R4 waited approximately 30 minutes to be taken off a bedpan. When the CNA came into R4's room she yelled at R4 and informed R4, I don't need this, you can sit on that bed pan and walked out without taking R4 off the bed pan. On 8/3/20 the Facility was made aware of R4 waiting in excess of one hour for the call light to be answered and staff was unnecessarily rough when care were provided. R4's son states in this email to Administrator-A, These incidents of neglect and abuse need to stop immediately. As of 8/24/20, there is no evidence the Facility investigated, reported, or implemented any actions to prevent abuse &/or neglect in the future. As of 8/24/20, R4 still recalls how she was treated and how she felt like a little girl or a child when the CNA responded to R4's needs with I don't need this, I can walk, stay on the bedpan. Findings include: The Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention and Reporting Policy revised November 2016 under Introduction documents, Acknowledgement that no one should be subjected to violent, abusive, humiliating, exploitive or neglectful behavior is the single most critical step in detecting and preventing abuse, neglect, misappropriation of patient property as well as abuse to include taking or using photographs via audio/visual recording that would demean or humiliate a patient/resident. The Social Media Policy for CHI Living Communities - January 2020 documents, CHI Living Communities employees should never use their personal cell phone, camera, and/or video to take pictures of residents for their own personal use, to post on social media, or to send/email to someone else, even at a family member's request. 1. On 8/17/20 at 11:00 a.m., Surveyor started to review a complaint received by the Southeastern Regional Office involving R2. Attached to the complaint was a six page complaint log from 3/13/20 to 5/6/20 which included allegations of abuse, neglect, mistreatment, and exploitation. Surveyor noted the six page complaint log attached to the complaint intake includes: On 3/22/20 Resident stated that his table tilted when he was getting out of bed because nobody would help me. He states he had the call light on for over an hour and a half. A nurse came in and said that he called her racial slurs. He threatened to call the police. He states that her claim was not true, that he has never seen this nurse/aide before except for her screaming at him, tell him he does this[***]all the time and what an[***] he is. On 3/22/20 Resident stated that he just had a girl threaten to bring her dog in to meet him. He felt threatened by this, that this was threatening his life. On 3/25/20 Resident states that yesterday he needed the toilet for a BM (bowel movement), but nobody answered the call button. He got himself on to the toilet. He asked for assistance getting off, nurse/CNA was mean. She snarled at him, telling him that if he got himself on, he can get himself off. They are rude and mean. On 4/3/20 He says his aide for the day, CNA (Certified Nursing Assistant)-R would not help him today. He states that it feels like Auschwitz, and the staff are like the Gestapo. He wondered how he will eat at 5:00 as he cannot sit at the end of the bed to eat, as he will fall. On 4/4/20 Resident states that the aide came in and said that he would eat at his bedside table. He told her that he could not sit up, he needed to be in his wheelchair to eat at the table. He said that she questioned him. He said that she said, F . you, motherf .er and stormed from the room. On 4/4/20 Resident states that three minutes ago a CNA came bursting in with a hostile attitude. He states that she walked to the bed, glared at him, and demanded an apology from him for being disrespectful. He denied being disrespectful. He states that she then picked up one of the unemptied urinals and tilted it up over his chest, as if she would dump it on his chest and face. On 4/5/20 Resident states that he had a woman threaten him and call him a cracker. He told her to get the f . out of the room. She (the woman) said that she would tell her husband. She took a picture of him (R2) in his Pull Ups. On 4/5/20 Resident states that one of the aggressive girls with tattoos and braids to her waist decided to call her husband about the way she was treated by him. He states she took pictures or filmed him lying in bed without his Pull Ups on. On 4/13/20 He states that she was rude, insulting his mother/family. He states that she is the aide that took photos of him with her cell phone when he was in bed, after having words. He states on that occasion his Pull Ups were down and he had no blankets. She told him that her husband was on the phone. On 4/13/20 Resident is setting up a place for himself on the floor to sleep. Two girls took his sleeping pillow the vindictive and mean ones. He was left with a hard, uncomfortable pillow he found in a closet. On 4/18/20 Resident stated there was an incident yesterday. A real mean CNA wouldn't get him out of bed to eat. He yelled for her. When she came she gave him a real slippery smile and said she couldn't hear him. On 4/29/20 Resident states the girl is very mean. He indicates that he was put into a position where he had to get in bed by himself. Staff did not respond and he fell over. He states that the aide came, tried to grab him by the ankles, tried to twist my right foot off my ankle/ tried to break his ankle. Resident states he called the South Milwaukee PD (police department), who will have a report. He also states that an aide came in to antagonize him last night when he was sound asleep. On 8/18/20 at 3:10 p.m. Surveyor spoke with SSD (Social Service Director)-L on the telephone regarding R2. Surveyor inquired if R2 has an activated power of attorney. SSD-L informed Surveyor she doesn't believe R2 has an activated power of attorney. SSD-L informed Surveyor R2 is alert & orientated but is mentally ill and is [MEDICAL CONDITION]. Surveyor asked SSD-L if R2 voiced any concerns or had she heard about staff taking pictures of R2. SSD-L replied haven't heard that. Surveyor asked if SSD-L has heard about a staff member stating they were going to bring their dog into R2 and R2 felt threatened. SSD-L replied haven't heard that, never hear him saying that. Surveyor asked if R2 ever voiced a concern staff was disrespectful to him. SSD-L replied he says they are and explained to Surveyor R2 calls them f ing b ches. SSD-L informed Surveyor staff aren't going to stand there, they leave. SSD-L informed Surveyor she doesn't think staff disrespects R2 its the opposite R2 disrespects staff. On 8/19/20 at 3:45 p.m. Surveyor spoke with Ombudsman-U to inquire if she notified the Facility of R2's six page complaint log. Ombudsman-U explained she sent Former Administrator-V an email on 5/11/20 and then on the same day found out Former Administrator-V had left and Former Administrator-W was the interim administrator. Ombudsman-U indicated she sent Former Administrator-W an email on the same day. Surveyor verified with Ombudsman-U she sent the Facility the six page complaint log. Surveyor asked Ombudsman-U if she spoke with Former Administrator-W. Ombudsman-U informed Surveyor she and Former Administrator-W played phone tag but they never connected. Surveyor asked Ombudsman-U to forward the email she sent to Former Administrator-V & Former Administrator-W to the Surveyor. Surveyor reviewed the forwarded email and noted Former Administrator-V received an email from Ombudsman-U on 5/11/20 at 4:59 p.m. Included in the email to Former Administrator-V was one of the categories R2 has complaints regarding is Verbal/psychological abuse. Surveyor noted Former Administrator-W received an email from Ombudsman-U on 5/11/20 at 5:12 p.m. which included the email to Former Administrator-V and the six page complaint log. On 8/19/20 at 4:16 p.m. Surveyor spoke with Administrator-A on the telephone. Surveyor informed Administrator-A Surveyor had spoken with Ombudsman-U who verified Former Administrator-V & Former Administrator-W on 5/11/20 received an email with a six page complaint log regarding R2 which includes complaints regarding verbal/psychological abuse. Surveyor informed Administrator-A there are complaints about staff swearing at R2, a CNA threatening to bring her dog into R2's room, a CNA taking a picture of R2 in his brief along with other allegations. Surveyor asked Administrator-A for all investigations for R2. Administrator-A informed Surveyor RN/UM (Registered Nurse/Unit Manager)-C has a file on R2, will see what they have and send it to Surveyor. On 8/20/20 Surveyor received an email from Administrator-A with attachments. The attachment entitled R2's soft file included a psych consult dated 8/14/20, the six page complaint log from Ombudsman-U regarding R2, and various staff statements regarding R2's behavior dated 5/16, 4/6, 5/6, a statement not dated, 6/10, 7/3, 7/29, and two statements dated 8/14. Also attached to Administrator-A's 8/20/20 email is entitled Former Administrator-W statement. This statement documents Below is the statement from Former Administrator-W regarding the email in question for R2. I spoke with the Ombudsman about him and she knew him very well and said that we could never fix all his complaints and understands the situation and that we can just try to fix what we can but so know he (sic) makes a lot of false allegations. Former Administrator-W, (name) 8/19/20. On 8/24/20 at 11:34 a.m. Surveyor asked Administrator-A if he had any additional information regarding R2's allegations of abuse, mistreatment, neglect and exploitation. Administrator-A informed Surveyor he has provided Surveyor with everything he has. On 8/24/20 at 2:14 p.m. Surveyor spoke with R2 regarding his allegations of abuse, neglect which he conveyed to the Ombudsman about. Surveyor asked R2 if he remembered a CNA saying she would bring her dog in. R2 replied yes. Surveyor asked R2 if he felt threatened when the CNA said this to him. R2 informed Surveyor he didn't feel good about it. R2 asked Surveyor what if she brought the dog in and it bites or attacks me. R2 said he would have to hurt the dog. Surveyor asked if any staff has taken a picture of him without his permission. R2 informed Surveyor she had a phone, I don't know if she took a print or was filming me, said it would be on line and she walked out. R2 said he was laying in bed with a pull up on and R2 asked her what she was doing. R2 informed Surveyor the CNA said she was taking a picture and was going to show it to her boyfriend. R2 informed Surveyor he said F . you to her. R2 informed Surveyor he was not a happy camper especially with these phones and their capabilities. R2 stated I don't want to be filmed with a brief on. Surveyor asked R2 how this made him feel. R2 replied made me feel angry, she should know better than that, she wanted me to feel angry, she reached her goal. Surveyor asked R2 if anyone at the Facility spoke to him about this. R2 replied no. Surveyor asked R2 how staff speak to him. R2 informed Surveyor sometimes they swear. On 8/24/20 at 4:15 p.m. Surveyor showed SSD (Social Service Director)-L the six page complaint log regarding R2 the ombudsman had emailed Former Administrator-W and asked if Former Administrator-W provided her with a copy of this six page log. SSD-L replied no, didn't get it but informed Surveyor she had heard about it. Surveyor asked SSD-L if she was given any instructions regarding R2's allegations. SSD-L replied no and explained they were aware from Ombudsman-U R2 had called her twenty one times. Surveyor asked if any abuse investigations were done for the allegations on this six page complaint log. SSD-L replied no and explained that was the concerns that were brought forth on 3/25/20. Surveyor informed SSD-L there are multiple dates after 3/25/20 on the complaint log. SSD-L informed Surveyor if a resident tells her a concern she writes out a complaint form and then gives it to the department. SSD-L informed Surveyor if the complaints is an allegation of abuse Administrator-A or whomever was the Administrator would be notified immediately. 2. On 8/17/20 at 12:00 p.m. Surveyor started to review a complaint received by the Southeastern Regional Office involving R4. Attached to the complaint was an email chain between R4's son and Administrator-A dated 7/30/20 & 8/3/20. Surveyor noted R4's son's email to Administrator-A dated Thursday, July 30, 2020 at 10:55 a.m. documents under First incident Tuesday, July 21 My Mom activated her call light to request assistance with using the bathroom at 11pm. Note that she currently is unable to use the toilet herself due to the recent surgery on her leg and the amputation of two toes on her left foot, and requires the use of a bedpan. At 11:30pm an aide responded and assisted getting her on the bedpan. At 11:35pm, she activated her call button again when she was finished. After receiving no response, at midnight she tried calling the nurses desk from her cell phone. As it was ringing, the aide came back in and said something to the effect of you can get off the phone. She was yelling at my Mom telling her that she was the only aide on the floor and that she would need to be patient as she was in with another patient. My mom responded to her that she didn't feel she needed to be talk to like that, to which the aide responded I don't need this, you can sit on that bed pan. When my Mom asked her name, she just walked off. A nurse who witnessed this exchange then came in and assisted my Mom. On 7/30/20 at 6:32 p.m. Administrator-A sent an email to R4's son which documents I appreciate the information. I have started an investigation to take care of some of these items. I do apologize for the poor service which it sounds like your mother has had to endure. I have turned this over to the clinical team for some better answers for you. Please give me a few days and I will get back to you on the resolutions. I agree with you and none of these items are acceptable to any of our residents on campus. I will be in touch. Surveyor noted R4's son's email to Administrator-A dated Monday, August 3, 2020 documents Unfortunately, I need to again bring to your attention another set of incidents that occurred Friday and Saturday evenings, July 31st & August 1st. This time I don't have as specific of details of the times/durations of the incidents, but it's my understanding that my Mom was made again to wait in excess of an hour for attention to her call light, and on one occasion that evening the light was turned off by someone on the staff without acknowledging my mother or asking her what she needed. And on one occasion when she was attended to, she made note that the attending aide was unnecessarily rough with her when assisting with wiping her after use of the bedpan. She ended up calling my sister in tears, as again she was in pain from having to wait so long to use the restroom. These incidents of neglect and abuse need to stop immediately. On 8/18/20 at 1:45 p.m. Surveyor spoke with Son-Z regarding R4. Son-Z informed Surveyor he sent Administrator-A an email with the issues and didn't hear anything back from Administrator-A. Son-Z informed Surveyor he has had no further correspondence since he received an email back from Administrator-A which indicated he would be looking into his concerns. Son-Z informed Surveyor the Facility should have all the information. On 8/19/20 at approximately 2:10 p.m. Surveyor asked for Administrator-A any investigations for the allegations listed in Son-Z's email to him on 7/30/20 & 8/3/20. On 8/24/20 at 11:29 a.m. Surveyor asked Administrator-A if he had any further information for the allegations listed in R4's son email to him on 7/30/20 & 8/3/20. Administrator-A informed Surveyor only what he sent Surveyor already. Administrator-A informed Surveyor there was an initial concern which was sent to the clinical team and the Director of Nursing (DON) at that time did investigate and resolved all the issues. Administrator-A informed Surveyor they had two short term DON's and he didn't always get their notes. Surveyor asked who's decision it is on whether to report allegations to the State Survey Agency. Administrator-A replied I do If I'm the Administrator. Surveyor asked Administrator-A if he was the Administrator on 7/30/20 & 8/3/20. Administrator-A replied yes. Surveyor inquired why there isn't evidence the allegations were investigated or reported as Son-Z stated in his email on 8/3/20 the incidents of abuse and neglect need to stop. Administrator-A informed Surveyor they weren't valid accusations. Administrator-A explained he spoke with R4 who was happy & had no problems but told the son a different story. Administrator-A informed Surveyor R4 wanted to go home. Surveyor informed Administrator-A allegations of abuse & neglect were brought to his attention. These allegations should have been reported & investigated. The Facility did not protect R4 from potential further incidents. On 8/24/20 at 2:19 p.m., Surveyor interviewed R4 regarding the quality of life at the facility. Surveyor asked R4 if she had any problems with abuse and or neglect. R4 informed Surveyor that some time back, her (R4) call light had stopped working and that she was given a bell to ring so that she could get staff to assist her. R4 informed Surveyor that during this time, she rang the bell for assistance in getting off the bed pan and that a CNA, whom she was unable to name, had come and told her (R4) that she was assisting another resident and that she need to wait. R4 informed Surveyor that she told the CNA that she did not appreciate being talk to in that manner to which the CNA told her (R4) I don't need this, I can walk, stay on the bedpan. R4 informed Surveyor that she reported this incident to the facility and that the interaction with the CNA, and the fact that she stayed on the bed pan, made her feel like a little girl or a child. R4 informed Surveyor that despite informing the facility of this incident, she (R4) had not been informed of any action that was taken to prevent any future incidents. On 8/24/20 at 4:21 p.m. asked SSD (Social Service Director)-L if she was directed to do a grievance or investigate allegations of abuse/neglect regarding R4's son email which were dated 7/30/20 & 8/3/20. SSD-L replied was not even aware of those.

Based on observation, record review and interview, the facility did not ensure pressure injuries were assessed or treated per standards of practice and interventions were in place in place for prevention of pressure injuries for 3 (R1, R9, and R2) of 4 residents reviewed for pressure injuries. *R1 was admitted to the facility with a Stage 2 pressure injury on 10/22/2019 and the wound was not assessed by a Registered Nurse (RN) until 11/8/2019. R1's skin integrity care plan was not initiated until 11/8/2019. R1's wound worsened 11/15/2019 and was not comprehensively assessed. *R9 developed an unstageable pressure injury 1/18/2020 and did not have a comprehensive assessment until 1/22/2020. R9's At Risk for Skin Breakdown Care Plan was not revised with interventions to address the new pressure injury. *R2 was observed during the survey process not to have pressure reducing interventions in place per care plan. Findings: The facility policy and procedure entitled Wound Assessment, Measurement, and Documentation dated 2/10/2017 states: Policy: (the facility) residents with skin integrity impairment will receive consistent, accurate and thorough assessment and data collection by licensed nurses to establish a baseline of the wound; to assist in determining the cause of wound, to evaluate the interventions/treatments in place to promote healing and to prevent need for further medical intervention/complications related to the wound. Objective: To provide early identification and on-going, consistent, assessment/data collection and evaluation. The plan of care to promote healing and prevent complications related to the wound will be modified as needed to accomplish this objective. Procedure: 1. General skin assessment. a. Careful inspection of the skin, with focus on high risk areas . 2. Wound assessment. a. Wounds include surgical wounds, [MEDICAL CONDITION], pressure injuries, vascular wounds, skin tear, blisters, incontinence [MEDICAL CONDITION], rashes and [MEDICAL CONDITION]. b. Data is collected and documented that characterizes the status of the wound and surrounding tissue or periwound. c. Assessment is completed by visual observation palpation, and smell. d. Assessment by the wound team is completed. Weekly and during routine dressing changes. 1.) R1 was admitted to the facility 10/22/2019 after hospitalization for a left femoral fracture and a right humerus fracture with the following Diagnoses: [REDACTED]. On 10/22/2019 on the admitting Skin Observation Tool One Time Only form, Licensed Practical Nurse (LPN)-C documented R1's coccyx had an open area measuring 1.5 cm x 3 cm with a pink wound base and no drainage. Generalized excoriation was noted by LPN-C. The physician was notified and a treatment was obtained: cleanse the wound with normal saline, dry the area, and cover with [MEDICATION NAME] dressing daily and as needed. A Registered Nurse did not assess the wound and a skin integrity care plan was not initiated at that time. R1's admission Minimum Data Set (MDS) assessment dated [DATE] coded R1 as being severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 and needing extensive assistance with bed mobility, toileting and hygiene. The Pressure Ulcer/Injury Care Area Assessment stated R1 had a score of 10 on the admission Braden assessment indicating high risk for pressure injury, was frequently incontinent of bladder and always incontinent of bowel. On 11/8/2019 on the Skin and Wound Weekly Documentation form, nursing charted this was the first observation of the coccyx Stage 2 pressure injury. (The wound was discovered on admission 10/22/2019.) The wound measured 2 cm x 2 cm x 1 cm with [MEDICATION NAME] tissue present. No percentage was documented of tissue type. R1's Skin Breakdown: Right Coccyx Stage 2 Care Plan was initiated on 11/8/2019 with the following interventions: -Apply protective ointments after incontinent episodes. -Inspect skin on a regular basis. -Place a pressure reduction support surface in the chair. -PT/OT (Physical Therapy/Occupational Therapy) to screen for mobility and positioning for maximal remobilization -Turn and reposition at regular intervals. -Use low air loss mattress and cushion for resident with a stage 3 or 4 wound. In wheelchair provide air cell cushion. On 11/13/2019 on the Skin and Wound Weekly Documentation form, nursing charted R1's coccyx upper wound Stage 2 pressure injury measured 2 cm x 2 cm x 1 cm with granulation tissue present. No percentage was documented of tissue type. On 11/15/2019 on the Skin Observation Tool One Time Only form, nursing documented an open area was noted to the top aspect of the coccyx, an open area was noted to the lower aspect of the coccyx area, moisture associated damage areas were noted to bilateral buttocks, and moisture associated damage was noted to the crease aspect of the right buttock. No measurements or wound base descriptions were documented. The form indicated to continue the same treatment. The physician was not notified of the worsening of the coccyx wound or the moisture associated skin damaged areas. On 11/19/2019 on the Skin Observation Tool One Time Only form, nursing documentation was identical to the documentation on the 11/15/2019 Skin Observation Tool One Time Only form. No measurements or wound base descriptions were documented. The form indicated to continue the same treatment. The physician was not notified of the worsening of the coccyx wound or the moisture associated skin damaged areas. On 11/20/2019, R1 discharged to the hospital. On 2/12/2020 at 1:55 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C regarding R1's coccyx wound. LPN-C had documented on 11/20/2019 at 10:04 AM in the progress notes that wound care was completed to the buttocks and coccyx prior to being transferred to the hospital. LPN-C could not recall what R1's coccyx pressure injury looked like. On 2/12/2020 at 3:00 PM, Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B to discuss the above findings: R1 was admitted on [DATE] with a Stage 2 pressure injury to the coccyx that wasn't assessed until 11/8/2019, seventeen days later. R1's Skin Breakdown: Right Coccyx Stage 2 Care Plan wasn't initiated until 11/8/2019. When R1's wound worsened with two additional open areas, the wounds were never assessed or treated and the physician was not notified. No further information was provided at that time. On 2/13/2020 the facility faxed more documentation related to R1. The fax included physician progress notes [REDACTED]. The facility physician progress notes [REDACTED]. (R1) does have sacrococcygeal pressure wound present on admission, may shows signs of worsening along with unstageable heel ulcers . (R1) also had right ischial pressure wound currently covered with dressing. No documentation was found regarding R1's heels or the right ischial pressure injury. The hospital physician progress notes [REDACTED]. #Pressure ulcer of the lower extremity, stage Unstageable bilateral heels and left lateral leg POA (present on admission), #Pressure ulcer, other site, stage III coccyx and sacral region, right ischium POA (present on admission). The Inpatient Wound Care Consult Note dated 11/21/2019 states: R1 is noted to have multiple pressure ulcers, present upon admission. Wound care has been asked to evaluate and offer recommendations. It is unclear how long these injuries have been present . Per wound care RN (Registered Nurse) (R1) with pressure injuries to the coccyx and sacral region, left lateral leg and bilateral heels. On 2/17/2020 at 1:53 PM, DON-B stated over the phone R1 did not have a wound on the ankle while at the facility. Surveyor reviewed the facility physician progress notes [REDACTED]. These pressure injuries were all present on admission to the hospital on [DATE] and the facility had no documentation of the heels, the left lateral leg, or the right ischium. DON-B stated she did not see any documentation about R1's heels or left leg and didn't recall seeing these wounds on R1 when R1 was at the facility. No further information was provided at that time 2.) R9 was admitted to the facility 2/22/2019 with the following Diagnoses: [REDACTED]. R9 was admitted with a Stage 3 pressure injury to the coccyx that healed. R9's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R9 as having moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 and needing supervision with bed mobility. R9 had no impairment to either arms or legs. R9's At Risk for Skin Breakdown Care Plan was initiated on 2/22/2019 with the following interventions: -Administer medications as ordered, monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Educate me/my family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. -Encourage me to turn sided to side when in bed to decrease pressure on my back. -Encourage/assist me with repositioning routinely and as needed. -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -I have a pressure reducing cushion in my wheel chair. -I need moisturizer as needed applied to my skin. Do not massage over bony prominences and use mild cleansers for peri-care/washing. -If I refuse treatment, confer with me, the interdisciplinary team and family to determine why and try alternative methods to gain my compliance; document alternative methods. -Inform me/family/caregivers of any new area of skin breakdown. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -Monitor/document/report to physician as needed changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size, stage. -Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. -Pressure relieving mattress to bed. On 1/18/2020, R9's Braden score which measures the risk of developing a pressure injury was 18 indicating R9 was at risk. On 1/18/2020 at 9:00 PM in the progress notes, nursing charted two open areas were found to R9's upper inner rear thigh. It was not documented if the areas were on the right or left thigh. The Registered Nurse notified a Nurse Practitioner and got a wound treatment order: cleanse open areas with normal saline, pat dry, and apply [MEDICATION NAME] daily to the right posterior inner upper thigh. The wounds were not measured and no description of the wound base was given. R9's At Risk for Skin Breakdown Care Plan was not revised with the discovery of the new pressure injury. The dietician was not notified of R9's wounds. On 1/22/2020 on the Skin and Wound Weekly Documentation form, nursing documented this was the first observation of the wound with no reference for comparison. R9 had an Unstageable pressure injury to the right buttock measuring 2 cm x 2.3 cm x 0.1 cm with 80% necrotic tissue and 20% granulation tissue with scant serous drainage. The wound physician was present during the assessment of the wound, debrided the wound, and changed the treatment order: cleanse right upper buttocks wound with normal saline, pat dry, apply [MEDICATION NAME] followed by bordered gauze daily. The Unstageable right buttock pressure injury was assessed and treated weekly by the wound physician with treatments changed as indicated. On 2/11/2020 at 2:23 PM, R9 was observed sitting in the wheelchair self-propelling with the feet in R9's room. On 2/12/2020 at 8:00 AM, R9 was observed sitting in the wheelchair in the main dining room for breakfast. On 2/12/2020 at 9:42 AM, R9 was observed getting wound care by Wound Medical Doctor (MD)-H assisted by Registered Nurse (RN)-D and Licensed Practical Nurse (LPN)-C. R9's wound was on the right ischial tuberosity (the area where the pressure is the greatest when sitting) measuring approximately 2.5 cm x 1.5 cm with yellow slough covering 80% of the center of the wound with granulation tissue around 20% of the edge of the wound. Wound MD-H told R9 the wound had not improved since last week and R9 needed to change positions to relieve the pressure to that area. LPN-C reiterated to R9 that R9 needed to not sit in the wheelchair all day and lay down in bed to relieve the pressure. R9 nodded to indicate understanding and then asked to get up in the wheelchair to go to activities. On 2/12/2020 at 3:00 PM, Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B to discuss the above findings: R9 developed an Unstageable pressure injury to the right buttock while in the facility on 1/18/2020 and an assessment wasn't completed until 1/22/2020. R9's At Risk for Skin Breakdown Care Plan had not been revised to incorporate the new pressure injury's cause and prevention of further breakdown. No further information was provided at that time. On 2/13/2020, the facility faxed a Skin Concern form dated 1/18/2020 with a revision date of 2/13/2020. The form indicated R9 had two open areas to the right posterior inner upper thigh; the first area was caused by an abrasion, and the second area was circular measuring 1 cm x 1 cm with redness around it. The wound bed was not described and a cause of the wound was not given. An additional entry on the form dated 1/20/2020 stated DON-B assessed R9's open areas: a Stage 2 open area to the right upper posterior buttocks measuring 1 cm x 1.8 cm and a right lower posterior buttocks wound measuring 2 cm x 1.5 cm with 90% slough. The documentation does not denote which area was an abrasion or if both areas were pressure injuries at a Stage 2. (A pressure injury with slough is a Stage 3 or higher and cannot be a Stage 2.) On 2/17/2020 at 1:53 PM, DON-B stated over the phone R9's wounds were assessed on 1/20/2020 by DON-B. Review of the faxed information showed R9's wound developed 1/18/2020 and was not assessed comprehensively until 1/22/2020. The initial discovery of the wounds on 1/18/2020 were not complete and the assessment of the wounds on 1/20/2020 were inconclusive as to what the actual wounds were and how they developed with inaccurate staging of the pressure wound. The form was revised 2/13/2020 after being brought to the facility's attention by Surveyor. 3.) On 02/11/20 Surveyor reviewed R2's Annual Minimum Data Sheet ((MDS) dated [DATE] which indicated R2 needed extensive assist of 1 with toileting and personal hygiene. The MDS also indicated R2 needed extensive assist of 2 with bed mobility. R2's MDS indicated R2 was totally dependent during transfers. MDS indicated R2 was at risk for the pressure injury but R2's skin was intact. Surveyor noted R2's Brief interview for mental status was not completed by the facility as the facility indicated on the MDS R2 was severely cognitively impaired, had a short term and long term memory loss. On 02/11/20 Surveyor reviewed R2's plan of care revised on 04/26/19 which indicated R2 was at risk for developing a skin breakdown related to history of pressure injury,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), poor nutrition and incontinence. Interventions included: apply protective ointments after incontinent episode revised 05/15/19, blue boots to prevent skin breakdown on R2's heels as allowed revised 05/23/20, offload heels when in bed to prevent skin breakdown dated 08/15/17, skin protectant to left heel to prevent development of impaired skin integrity to the area barrier cream, turn and reposition at regular intervals revised 05/23/19 (Surveyor noted the care plan did not have specific intervals for R2's repositioning schedule), assist with keeping lower extremities from being crossed long period of time, use a pillow or wedge for support in minimizing opportunity for legs to remain crossed, recline the Broda chair when resident is sitting in it. On 02/11/20 Surveyor reviewed R2's Certified Nursing Assistant (CNA) Kardex dated 02/04/20 which indicated R2 needed protective ointment after incontinence episode, blue boots to prevent skin breakdown on R2's heels as allowed, offload heels when in bed to prevent skin breakdown, pressure reducing mattress to bed, skin protectant to left heel to prevent development of impaired skin integrity to the area-barrier cream, tubi grips to hands, turn and reposition at regular intervals (not specified), assist with keeping lower extremities from being crossed long period of time and use a pillow or wedge for support in minimizing opportunity for legs to remain crossed. On 02/11/20, Surveyor reviewed R2's skin assessments dated 01/16/20 which indicated R2 had a new skin issue noted. Surveyor noted no further information was provided on the form. Surveyor reviewed R2's medical notes for 01/16/20 which indicated R2 did not have any new skin related issues. The information was contradicting. On 02/11/20 at 9:45 am, Surveyor observed R2 sitting in the Broda chair on his back. R2 was receiving activities at the activity room. R2's heels were not offloaded as per R2's plan of care dated 05/23/19 and were resting directly on the Broda heel rest. R2 had gripper socks on and did not have blue boots on his feet. R2 had his legs crossed and did not have a pillow between his legs to keep R2's legs separated as per R2's plan of care. R2 was sitting straight in the chair and not reclined as per care plan. On 02/11/20 at 10:25 am, R2 continued to sit in the Broda chair on his back, without heels offloaded and without blue boots on. R2 had his legs crossed and did not have a pillow between his legs to keep R2's legs separated as per R2's plan of care. R2 was sitting in the same position as observed on 02/11/20 at 9:45. On 02/11/20 at 11:26 am, R2 continued to sit in the Broda chair on his back without heels offloaded, R2's feet and heels were pressing directly onto foot rest and without blue boots on. R2 had his legs crossed and did not have a pillow between his legs to keep R2's legs separated as per R2's plan of care. R2 was sitting in the same sitting position. R2 was not repositioned. On 02/11/20 at 12:16 pm, R2 continued to sit in the Broda chair without heels offloaded, without blue boots and without pillow between his legs. On 02/11/20 at 12:50 pm, R2 was in the dining room sitting in the Broda chair. R2 continued to be without heels offloaded, heels directly on the foot rest, pressing on the foot rest of the Broda chair, without blue boots, without pillow between his legs and continued to sit straight in the Broda chair. On 02/11/20 at 1:22 pm, R2 continued to sit in the Broda chair without heels offloaded, heels directly on the foot stand of the Broda chair, without blue boots, without pillow between his legs and continued to sit straight in the Broda chair. On 02/11/20 at 1:55 pm, R2 continued to sit in the Broda chair. R2's feet continue to press on the foot rests of the Broda chair. R2 was sitting in the same position. R2 was sitting on his back and sitting straight in the chair. R2's legs were crossed, no blue boots on and R2 was not repositioned since Surveyor started to observe R2 at 9:45 am. On 02/11/20 at 2:20 pm, R2 was observed sleeping in the Broda chair by the nurse's station. R2's Broda chair was reclined. R2's heels were pressing on the foot rest of the Broda chair. R2's legs were crossed. R2 did not have a pillow between his legs and R2 was not repositioned. On 02/11/20 at 3:00 pm, Surveyor spoke with R2's family and they indicated they were pleased with the facility and the care R2 receives at the facility. On 02/11/20 at 3:00 PM, Surveyor interviewed R2's assigned Certified Nursing Assistant (CNA)-I for the day and asked about R2's daily routine. CNA-I stated R2 was assisted with ADLs in the morning, then assisted getting dressed, needed assist with toileting and then sometime after lunch R2 goes to bed. On 02/11/20 at 3:05 pm, CNA-J and CNA-K assisted R2 to his bed. Surveyor observed R2's buttocks and heels. R2's buttocks and coccyx area were red with one scab onto each buttock. R2's right heel was read. Areas were blanchable. CNA-K indicated R2 had redness to both buttocks for about 7 days. CNA-J indicated a barrier cream is applied to R2's buttocks but she doesn't have any cream at this time. R2's incontinence care was provided but R2 did not receive a barrier cream. Surveyor noted, upon completion of R2's cares, R2 was left to rest in his bed. R2 did not receive his blue boots on and heels were placed onto the pillow. Surveyor observed R2's heels were not floated. R2 did not have a pillow between his legs. On 02/11/20 at 3:20 pm, Surveyor interviewed CNA-I and she indicated the care for R2 is provided following the CNA Kardex. CNA-I also indicated she did not place blue boots onto R2's feet today because the blue boots were missing for sometime but could not provide a timeframe. CNA-I told Surveyor she does not place a pillow between R2's legs and R2's feet are floated when R2 is in bed. On 02/11/20 at 3:25 pm, Surveyor interviewed the Licensed Practical Nurse (LPN) Unit Manager-L who indicated CNAs are to follow the CNA Kardex plan of care and receive the daily report from nurse prior to taking care of the resident. LPN Unit Manager-L indicated CNA-I should have followed all of the interventions as indicated in the CNA Kardex plan of care. LPN Unit Manager-L indicated the blue boots are stored in the basement. On 02/11/20 at 3:40 pm, Director of Nursing (DON)-B indicated CNAs are to follow CNA Kardex plan of care for each resident. DON-B also indicated she was not sure if interventions written in the Kardex, dated 02/04/20, were appropriate for R2 at this time. Surveyor informed DON-B R2 had redness on his buttocks and right heel. DON-B indicated she will assess R2's redness areas. DON-B was not aware of CNA-K's observations of R2's redness to the buttocks over the past 7 days. On 02/12/20 at 12:31 pm, DON-B indicated R2 had blue boots today and a pillow between his legs. DON-B also indicated [MEDICATION NAME] barrier cream has been provided to R2, skin prep onto both heels was ordered to be placed 2 times per day and R2 will be repositioned every 2 to 3 hours. On 02/12/20 at 1:05 pm, DON-B provided R2's skin assessments dated 02/12/20 to the Surveyor. DON-B indicated she assessed R2's buttocks. Surveyor reviewed the skin assessments DON-B provided. R2's skin assessments were dated 02/12/20 which indicated there was an area on R2's right buttock which measured 3 x 1.5 cm and the area was pink and related to the moisture, per DON-B's assessment. Surveyor also reviewed R2's skin assessment for R2's left buttock, dated 02/12/20 and performed by DON-B which indicated R2 had a pink area to the right buttock which measured 1.5 x 1.5 cm. On 02/12/20 at 1:30 pm R2 was assisted into bed with foam boots on R2's feet and no pillow between his legs. On 02/12/20 at 2:00 pm, Administrator-A and DON-B were made aware R2's prevention of pressure injury plan of care was not followed on 02/11/20. On 02/13/20, the facility faxed additional information related to R2. The information faxed was related to R2's care plan. This is the same care plan Surveyor reviewed while on site indicating R2 is to wear blue boots to prevent skin breakdown, offload heels when in bed to prevent skin breakdown and turn, reposition at regular intervals (time frames for the intervals are not specific) and continue to use a pillow or wedge between the legs.

Based on observation, interview, and record review the facility failed to prevent pressure injury development, promote the healing of existing pressure injuries, prevent the development of additional pressure injuries, define and implement interventions for residents with pressure injuries or at risk for the development of pressure injuries, or revise interventions as appropriate for 8 (R88, R318, R113, R86, R39, R22, R59, R106) of 11 residents either with pressure injuries or at risk for the development of pressure injuries. - R88 returned to the facility on [DATE] following a hospitalization , and was documented as being at risk for the development of pressure injuries. On 1/18/19 an LPN (licensed practical nurse) noted a 2 cm x 1 cm x 0.1 cm 50% yellow and 50% pink wound to R88's coccyx. There is no documentation of a RN assessment of the wound on 1/18/19, and no updates to R88's care plan with the development of a wound on a point of pressure. There is no documented treatment to the wound until 1/21/19. The facility informed the surveyor when R88 returned from the hospital, he would refuse repositioning and interventions such as prevalon boots and pillows. The facility did not develop a plan of care related to R88's refusal of care until 4/24/19. On 1/24/19 R88 is documented as having moisture associated skin damage to his right and left buttock, with wound documentation stating [MEDICATION NAME] paste to buttocks during dressing changes. There is no documentation that the [MEDICATION NAME] paste was completed to R88's wounds in Janauary. From 1/18/19-2/3/19 there is no documentation of an assessment completed in R88's medical record of R88's coccyx wound despite documentation in R88's TAR that the treatment for [REDACTED]. on 2/3/19. On 2/3/19 R3 was hospitalized with a stage 3 pressure injury to the sacrum/coccyx with [MEDICAL CONDITION] that was present upon admission to the hospital. On 2/11/19 R88 returned from the hospital, the coccyx wound was not staged and did not document what tissue types were noted in the wound bed. R88's care plan was not updated with the development of the resident now having a stage 3 pressure injury. This wound was noted to have developed into a stage 4 pressure injury on 5/8/19. On 2/28/19 R88 developed 3 new pressure injuries, a left elbow unstageable pressure injury with slough tissue present, a right heel deep tissue injury, a right elbow deep tissue injury and the existing area on his coccyx. R88 was hospitalized later that day. On 3/11/19 R88 returned with 7 areas of skin impairment noted by an LPN. There is no documentation of an RN assessment of R88's wounds upon return from the hospital on [DATE]. R88's care plan related to skin impairment was not updated upon return from the hospital with 7 wounds. On 3/14/19 R88's coccyx wound is documented as worsening. There is no documentation of MD notification of the wound worsening. On 3/14/19 R88 was noted to have two pressure injuries to his left lower leg, with necrotic tissue present in the wounds. There is no documentation of MD notification or change in treatments to the wounds. The wounds were not assessed again until 3/31/19. R88's plan of care was not updated related to the development of two pressure injuries with necrotic tissue to R88's lower legs. The facility's failure to provide necessary treatment and care to prevent R88's pressure injuries from worsening created a finding of Immediate Jeopardy that started on 1/18/19. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 5/15/19 at approximately 2:30 pm. The Immediate Jeopardy was removed on 5/15/19 when the facility implemented an action plan. However, the deficient practice continues at a scope and severity level of G (actual harm/isolated) for the examples R86 and R113. -R86 did not have consistent assessment and monitoring of their pressure injury. R86's care plan was not updated upon worsening of a stage 4 pressure injury. -R113 had a stage 3 wound worsen to an unstageable pressure injury. The facility did not define and implement interventions consistent with her needs. -R319 did not have a comprehensive wound assessment upon admission and did not have appropriate treatment for [REDACTED]. -R39, R22, R59, and R106, who were at risk for the development of pressure injuries, heels were not offloaded of pressure. Findings include: The facility's Prevention of Pressure Ulcers/Injuries policy and procedure, revised (MONTH) (YEAR), states Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .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 two hours, reposition residents who are reclining and dependent on staff for repositioning. 3. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort .Monitoring 1. Evaluate report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 1.) R88 has [DIAGNOSES REDACTED]. R88 was admitted to the facility on [DATE]. An admission summary noted on 12/15/18 documents There are no skin abnormalities noted. An Admit/Readmit Screen on 12/15/18 documented Skin intact (no abnormalities). On 12/17/18 a care plan was developed for I have a pressure ulcer/stasis ulcer to my buttocks. Interventions initiated on 12/17/18 included: apply barrier cream to buttocks with incontinence care, assess/record/monitor wound healing (FREQ) (frequency). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, Report improvements and declines to the MD, encourage me to reposition Q (every) 2 hours and PRN (as needed), encourage me to turn side to side when in bed as tolerated, I required supplemental protein, amino acids, vitamins, minerals, as ordered to promote wound healing, measure wounds weekly and notify MD of any s/s (signs/symptoms) of worsening if not improving, offer to assist me with toileting routinely and PRN. Assist with incontinence care as needed to keep skin warm and dry. Provide barrier cream after incontinence care and PRN, pressure relieving cushion to chair, pressure relieving mattress to bed, and provide treatments as ordered. IDT (interdisciplinary team) notes on 12/18/18 documents Risk Management: Resident has a stage I on his coccyx and as (sic) a poor appetite. Progress notes on 12/18/18 documents He currently has a Stage 1 on his buttocks. The surveyor noted no documentation of an assessment of the stage I pressure injury on his coccyx. R88's TAR (Treatment Administration Record) Documents Bedside Creams: Moisture Barrier cream after each incontinence episode, STNA may apply to intact skin every shift for prevention. This treatment is documented as being started on 2/16/18 (prior to the documented development of a stage 1 pressure injury) and as being discontinued on 12/21/18. Progress notes on 12/19/19 document Res (resident) has had a decline in mental and function status. Res has not been eating or drinking the (sic) evening. Daughter is aware of transfers. NOR (new order received to sent (sic) to ST Lukes main. R88 was hospitalized [DATE]-12/31/18. R88 returned to the facility on [DATE] with a new PEG (percutaneous endoscopic gastrostomy, commonly known as a feeding tube) tube. An admission summary note on 12/31/18 documents There are skin abnormalities noted. An Admit/Readmit screen, signed 1/1/19 documents An impaired skin condition is noted (discoloration, redness or open area). Comments state seen skin. Documentation for 12/31/18 states abrasion to R hand, R knee and dry abraided area to R buttock. Multiple arm bruised (sic). New PEG tube insertion site to abdomen. There is no documentation of assessment to include description of the wound beds or the measurements of the wounds. R88's TAR documents Bedside Creams: Moisture Barrier cream after each incontinence episode. STNA may apply to intact skin every shift for prevention. This treatment is documented as being started on 1/1/19 and discontinued 1/8/19. There is no documented treatment specified for the dry abraided area to the right buttock noted in the TAR. A dietitian assessment note on 1/2/19 documents He was readmitted with abrasion to right hand, abraded area to right buttock & a new PEG. The facility provided the surveyor with a list of non-pressure wounds dated 1/3/19 that document R88's right hand, right knee, and right buttock as healed. The surveyor noted this was not part of R88's medical record and had no time stamp on it to include the date it was developed. The list provided does not document who completed the list. R88's admission Minimum Data Set Assessment, with an assessment reference date of 1/7/19, documents rejection of care behavior not exhibited, required extensive assistance of two plus persons physical assistance for bed mobility and toileting, total dependence of two plus persons for transfers, and was at risk for the development of pressure injuries. On 1/9/19 R88's care plan was updated to include a focus area of I am at risk for skin breakdown d/t (due to) immobility. Interventions include: Administer medications as ordered. Monitor/document for side effects and effectiveness, Administer treatments as ordered and monitor for effectiveness, Educate me/my family/my caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, Encourage me/assist me with repositioning routinely and PRN, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. An IDT note on 1/16/19 documents Risk Meeting: abrasion to right buttock is healed, continues NPO (nothing by mouth) diet [MEDICATION NAME] 1.2 @ 75cc/hr (milliliters per hour), continues air mattress. A progress note on 1/18/19 by LPN-G documents Resident noted to have a small open area to coccyx area. No s/s (signs/symptoms) of infection noted to wound. DON (Director of Nursing) made aware. (Nurse Practitioner) also made aware. New orders received for NSW (normal saline wash) f/b (followed by) [MEDICATION NAME] then cover with [MEDICATION NAME] drsg (dressing)/ Drsg to be changed 3x/wk (three times a week) and PRN (as needed). Will continue to monitor. There is no documentation of a RN assessment of the area. R88's TAR does not document this treatment being completed until 1/21/19. The Skin & Wound Weekly Documentation -V2 by LPN-G on 1/18/19 documents Coccyx 2cm L (length) x 1cm W (Width) x 0.1cm D (Depth) 50% yellow and 50% pink. The form documents the Sacrum as 2.2 cm L x 1.1 cm W x 0.1cm D Wound bed 50% yellow and 50% pink. Under condition was present on admission is checked No. The form documents slough tissue present as a visible tissue. The form documents treatment as NSW f/b [MEDICATION NAME] then cover with [MEDICATION NAME]. Change 3x/wk (Mon-Wed-Fri). R88's TAR does not document this treatment being completed until 1/21/19. R88's care plan was not updated to include new interventions to prevent further skin impairment when the pressure injury to the coccyx was noted on 1/18/19. There is no documentation of a RN assessment of the area. On 5/15/19 at 7:44 AM the surveyor interviewed DON-B. The surveyor asked when a wound is first noted is an RN assessment completed. DON-B stated the unit manager should have gone into the room and assessed it as well. DON-B stated that is why they have switched to the PM supervisor or herself to go look at them. On 1/24/19 a Skin & Wound Weekly Documentation-V2 documents right and left buttock MASD (moisture associated skin damage). The Overall impression is documented as First Observation, no reference. The form documents [MEDICATION NAME] paste to buttocks during dressing changes. R88's (MONTH) TAR does not document a treatment with [MEDICATION NAME] paste being completed or as an ordered treatment in January. There is no documentation of a barrier cream product being applied from 1/8/19-1/31/19. A progress note on 1/29/19 documents Resident discussed in risk meeting held this date. Resident remains NPO, continuous tube feeding remains. MASD (moisture associated skin damage) noted to buttocks. Calzinc tx (treatment) in place. Wound team will continue to follow. R88's (MONTH) TAR does not document a treatment with Calzinc as being completed or as an ordered treatment in January. The facility provided the surveyor with a Non-pressure wounds list dated 5/14/19. The surveyor noted this was not part of the resident's medical record and was not time stamped to verify the date it was created. The list includes R88 and states MASD-Bilateral Buttocks with an initial date of 1/18/19, and a current date/description of 1/24/19 as MASD. Under measurements is documented Multiple scattered denuded unable to measure. The treatment is documented as [MEDICATION NAME], and the MD is documented as being updated on 1/24/19. R88's TAR does not document [MEDICATION NAME] as being ordered. R88's medical record does not contain documentation of MD notification. A progress note on 1/31/19 by LPN-G documents New order received for [MEDICATION NAME] for btx (buttocks) yeast wound. Resident made aware of new order and has no questions at this time. There is no documentation of RN assessment of the yeast wound. A verification of investigation provided by the facility states .Resident's coccyx was noted to have red, moist skin appearing as a yeasty skin infection as resident would not allow staff to reposition him or turn him in bed. Resident had a large amount of loose stools during the initiation of tube feeding with the use [MEDICATION NAME] cream for skin protectant. The surveyor noted R88's care plan did not address refusals of care until 4/24/19. The surveyor noted no changes in R88's incontinence care plan related to increased loose stools. The surveyor noted no documentation from 1/8/19-2/3/19 of a [MEDICATION NAME] or barrier cream product being applied. On 5/14/19 at 12:54 PM the surveyor interviewed DON (Director of Nursing)-B. The surveyor asked what the process is when a new skin impairment is noted. DON-B stated a Braden assessment is completed, pain assessment is completed, risk management is done, get a treatment, basic wound information in note, wound team will discuss origin and stage if necessary, and management should be updating careplan when new area developed. The surveyor informed DON-B of no documentation of assessment of the coccyx wound from 1/18/19-2/3/19. On 5/15/19 the surveyor received a written response stating 1/18/19- wound documented as sacral and coccyx. 1/24/19 documented as right and left buttock MASD. Wounds were MASD not pressure at this time. Antifungal implemented. Scattered area and unable to measure. Weekly wound log provided for 1/24/19 showing initial wound found on 1/18/19 and classified as a MASD. On 5/15/19 at 7:44 AM the surveyor interviewed DON-B. The surveyor informed DON-B of the coccyx wound having documented treatment throughout January, and unable to find documentation of any treatment to the MASD. From 1/18/19-2/3/19 there is no documentation of an assessment completed in R88's medical record of R88's coccyx wound despite documentation in R88's TAR that the treatment for [REDACTED]. on 2/3/19. On 5/15/19 the facility provided a list of non-pressure wounds dated 5/14/19. The list is not part of R88's medical record and is not time stamped when the information was entered. The document states MASD-Bilateral Buttocks with an initial date of 1/20/19. The current date/description is documented as 1/31/19: MASD @ hospital this date 2/7/19. The measurement is documented as Multiple scattered denuded. The treatment is documented as [MEDICATION NAME]. The surveyor noted the initial date is different from the 1/24/19 non-pressure wound list which listed 1/18/19 as the initial date. On 5/14/19 at 12: 54 PM the surveyor interviewed DON-B. The surveyor asked who monitors wounds. DON-B stated daily when the treatment is done by the treatment nurse, and weekly is the wound team. A progress note on 2/3/19 at 10:16 am documents Paratech ambulance present to transport resident to SLSS ED (hospital emergency department) for GTube (feeding tube) replacement. Report called in to (RN at hospital). Resident changed and dressing to coccyx changed prior to ambulance arriving. A progress note on 2/3/19 at 2:47 pm documents Writer spoke with SLSS (hospital): patient being admitted to their facility Dx (diagnoses): [MEDICAL CONDITION] of sacrum, pneumonia . R88 was hospitalized from [DATE]-2/11/19. Admitting hospital [DIAGNOSES REDACTED]. The hospital documents a stage 3 pressure injury present on admission with [MEDICAL CONDITION]. The hospital document indication for admission states .In the ER patient is noted to have a fever and was [MEDICAL CONDITION] There was an area in his lower back with concerns of [MEDICAL CONDITION]. The hospital course documents .Patient has a stage 3 sacral/coccyx pressure injury that was present on admission. Hospital documentation documents the wound as being left and right buttock/coccyx one entire unstageable wound measuring 6.5 cm x 7cm on 2/3/19. Hospital documentation indicates Offload heels and elbows as well .Patient stable to dc (discharge) back to SNF (skilled nursing facility) with close follow up. An Admit/Readmit screen on 2/11/19 documents skin integrity as skin intact despite also documenting the right elbow as 1 x 1 with [MEDICATION NAME] gentle in place and the coccyx as 9 x 7.5 areas of dark red, beefy red and yellow within area. Areas measured as one. The surveyor noted the assessment did not stage the pressure injuries and did not document the amount of tissue types noted in the wound. On 5/14/19 at 12:54 PM the surveyor interviewed DON-B. The surveyor asked when a resident returns from the hospital who assesses the wounds. DON-B stated the nurse when the resident comes back. The surveyor asked if the nurse is expected to stage pressure injuries. DON-B stated no. The surveyor asked if it is the expectation for a wound to be staged and assessed including percentage of tissue types (upon return from the hospital). DON-B stated someone should. DON-B stated it is now set up herself or the PM Supervisor will. DON-B confirmed this should be done on the day of admission. DON-B informed the surveyor the previous process was the unit manager who is no longer at the facility would do it. The Skin & Wound Weekly Documentation-V2 on 2/14/19 documents the coccyx wound as Stage 3. old dressing removed. Wound measured as one. The wound is documented as being 9.5 cm x 5.0 cm with [MEDICATION NAME], granulation, slough, and necrotic tissue present. Necrotic tissue is documented as being 10% present in wound. On 2/21/19 the Skin & Wound Weekly Documentation-V2 documents the coccyx wound as Stage 3. Measured as one area. Old dressing removed. The wound is documented as being 9 cm x 5.0 cm with no documented depth. [MEDICATION NAME], granulation, slough, and necrotic tissue is documented as present. Necrotic tissue is documented as being 10% present in wound. On 2/28/19 R88 was noted to have 3 new pressure injuries and the coccyx wound was documented as worsening. On 2/28/19 the Skin & Wound Weekly Documentation- V2 documents the coccyx wound as Unstageable, old dressing removed. 50% slough, 40% granulation, 10% eschar. The wound is documented as being 12.7 x 9.5 x 0.3 and is documented as worsening. The assessment documents Clinitron bed recommended. A Clinitron bed was never implemented. On 2/28/19 the Skin & Wound Weekly Documentation-V2 documents the left elbow pressure injury as being Unstageable, 90% slough, 10% pink measuring 1.0 x 1.5. This wound is documented as being healed on 3/14/19. On 2/28/19 the Skin & Wound Weekly Documentation-V2 documents a right heel deep tissue injury, measuring 4.3 x 4.0. On 2/28/19 the Skin & Wound Weekly Documentation-V2 document the right elbow pressure injury as stage 2 100% pink measuring 1.6 x 1.5. R88 was hospitalized from [DATE]-3/11/19 with admission [DIAGNOSES REDACTED].He had multiple wounds and was seen by hyperbaric he was put on the sand bed and was ruled out for underlying osteo[DIAGNOSES REDACTED] .I have instructed nursing to discharge him if cleared by wound care only. An Admit/Readmit Screen assessment on 3/11/19 documents an impaired skin condition is noted as discoloration, redness or open area. The assessment documents the right elbow as pressure injury covered with Allevyn dressing the left elbow as pressure injury covered with dressing, the left lower leg as Scabbed area lateral side covered with dressing, the right ankle Scabbing, the sacrum pressure ulcer with slough and necrosis present. excoriation to periwound, the left heel is documented as Left heel blanchable pressure ulcer and Right lateral foot scab. The assessment is documented as completed by an LPN. There is no documentation of an RN assessment of the wounds until 3/14/19. The wounds are not documented as measured, staged, or the amount of tissue types present described. On 5/15/19 at 7:44 AM the surveyor interviewed DON-B. The surveyor informed DON-B about the concern that a complete assessment of R88's wound was not completed upon return from this hospital on [DATE]. DON-B stated a complete assessment was not completed, but appropriate treatments were in place for them. DON-B stated the problem was identified and on 4/4 switched to PM supervisor or herself doing wound assessments. R88's care plan related to skin impairment was not updated upon return from the hospital with 7 wounds. Progress notes on 3/12/19 document Resident discussed in Risk Mtg held this date. Resident remains NPO with tube feeding. Multiple wounds noted. Dietician to monitor tube feeding. Progress notes on 3/12/19 document Care plan meeting held this date with daughter and daughter's friend. Family requests increased therapy and turning. Nursing and therapy explained that resident refused to be turned and screams when staff touches resident and refuses. Therapy since admission with little progress. Explained that pain is his limiting factor. Resident is tube fed at this time and is NPO. Nursing to request orders for behavioral Solutions and referral for chaplain visits. On 3/14/19 the Skin & Wound Weekly Documentation- V2 documents the coccyx wound as Unstageable wound. Old dressing removed. The wound is documented as being 12.3 x 7.2 x 1.5. [MEDICATION NAME], slough, and necrotic tissue are documented as present with 50% of necrotic tissue present in wound. The wound is documented as worsening. There is no documentation of MD notification. The form documents continue same treatment plan. There is no documentation of re-assessment of this wound until 3/31/19. The surveyor reviewed R88's (MONTH) TAR. The surveyor noted from R88's re-admission on 3/11/19- 3/19/19 the only documented and ordered treatment in place is Barrier Cream to buttocks every after incontinent as needed every shift for open wound. This treatment is documented as being continued until 5/10/19. The surveyor noted no treatment in place to the coccyx wound related to the presence of slough. On 3/19/19 the treatment was changed to Cleanse coccyx wound with Dakins solution and apply santyl to wound bed, skin prep peri wound f/b [MEDICATION NAME] change daily and PRN one time a day for wound care. On 3/14/19 the right heel wound is documented as being 4.5 x 4.5 with 100% necrotic tissue present. On 3/14/19 a right elbow pressure injury is documented unstageable, 100% slough measuring 0.2 x 0.4. The area is documented as being healed on 3/31/19. On 3/14/19 a left lower leg (front) pressure injury is documented as later lower left leg DTI measuring 12.5 x 1.8. [MEDICATION NAME], slough, and necrotic tissue are documented as present with 50% necrotic tissue present in the wound. There is no assessment of the wound again until 3/31/19. On 3/14/19 the left lower leg (front) pressure is documented as proximal to lateral leg wound. DTI measuring 2.2 x 1.5. Necrotic tissue is documented a present, with 100% necrotic tissue present in wound. There is no assessment of the wound again until 3/31/19 at which point the wound had developed slough. On 5/15/19 at 11:45 AM the surveyor interviewed DON-B related to R88's legs wounds. DON-B stated they suspected the prevalon boots, but were unable to prove it. The surveyor informed DON-B of the concern of the lack of new interventions/update to R88's plan of care when the deep tissue injuries were noted to the legs on 3/14/19. Progress notes on 3/29/19 document Writer spoke with (family). Discussed TF regimen, wound deteriorization (sic), new wound care orders for coccyx wound from this past week, specialty air mattress in place, pain control with [MEDICATION NAME], loose stools secondary to TF . The Skin & Wound Weekly Documentation-V2 on 3/31/19 documents the coccyx wound as Unstageable wound. Wound base in combination of slought (sic) 40%, granulation 50% and DTI (deep tissue injury) 10% noted to bilateral lower gluteal edges. Superficial granulation at bilateral edges. Slough directly over coccyx. Undermining of 3.5 cm @ 12 o'clock. The wound is documented as being 10.5 x 8 x 1.5. The wound is documented as being unchanged, despite the new presence of undermining documented. The progress note document the MD aware as of previous wound care orders received for dakins and santyl. The form also states Dtr (daughter) was present in facility on 3/29/19. Updated that wound had previously declined and new orders for dakins and santyl received . The surveyor noted no documentation of assessment of the wound between 3/14/19 and 3/31/19. On 3/31/19 the right heel wound is documented as DTI. Eschar cap noted 100%. The wound is documented as being 4.3 cm x 3.9 cm with 100% necrotic tissue. The surveyor noted no documentation of assessment of the wound between 3/14/19 and 3/31/19. On 3/31/19 the right lateral foot wound is documented as measuring 1.2 x 1.1 with 100% necrotic tissue. On 3/31/19 the left lower leg (front) wound is documented as Lateral lower left leg DTI measuring 5.0 x 2.5 with slough tissue documented as present and 50% necrotic tissue present in wound. On 3/31/19 the left lower leg (front) wound is documented as proximal to lateral leg wound. DTI measuring 2.2 x 1.5. Slough tissue is documented as present. The assessment does not document the amount of slough noted. The MD was notified and Santyl was ordered to address presence of slough. On 5/15/19 at 7:44 AM DON-B informed the surveyor the wounds were measure on 3/28 but were not entered into the wound documentation until 3/31. The surveyor noted if the wound were measured on 3/28/19 there was no change in treatments to R88's left lower leg wounds until 4/1/19, despite the wound notes stating the MD was notified and Santyl was ordered. On 4/1/19 a new treatment was started to Wounds to L posterior and L medial calf; cleanse with wound cleanser, pay dry. Skin prep periphery. Apply Santyl to slough. Cover with opti-foam gentle once daily. The Skin & Wound Weekly Documentation-V2 on 4/4/19 documents the coccyx wound as Unstageable wound. Wound base in combination of slought (sic) 40%, granulation 40% and [MEDICATION NAME] 20% noted to bilateral lower gluteal edges. Superficial granulation at bilateral edges. Slough directly over coccyx. Undermining of 1.5 cm @ 12 o'clock. The wound is documented as being 10.5 x 6 x 1.5. On 4/4/19 the right heel wound is documented as DTI. Eschar cap noted 100%. The wound is documented as measuring 4.0 x 3.5 with 100% necrotic tissue. On 4/4/19 the right lateral foot wound is documented as measuring 1.0 x 1.1 with 100% necrotic tissue. On 4/4/19 the left lower leg (front) wound is documented as Lateral lower left leg Dti. Lesser degree of slough, some [MEDICATION NAME] growth at wound edges measuring 5.5 x 2. Slough tissue is documented as present. The assessment does not document the amount of slough tissue present in the wound. On 4/4/19 the left lower leg (front) wound is documented as proximal to lateral leg wound. DTI. Lesser degree of slough, some [MEDICATION NAME] growth at edges measuring 2.0 x 1.0. [MEDICATION NAME] and slough tissue are documented as present. The assessment does not document the amount of slough noted in the wound bed. The Skin & Wound Weekly Documentation-V2 on 4/11/19 documents the coccyx wound as Unstageable wound. Wound base in combination of slough 40%, granulation 50% and [MEDICATION NAME] 10% noted to bilateral lower gluteal edges. 2.1 center depth, Slough directly over coccyx. Undermining of 3 cm @ 12 o'clock, and 2.1 undermining at 3 o'clock. [MEDICATION NAME] tissue and bilateral lower edges (buttocks). Increased granulation tissue noted and upper and and upper lateral wound edges and area of current undermining .previously slough. The wound is documented as being 10.5 x 6. On 4/11/19 the right heel is documented as DTI. Eschar cap noted 100% the wound is documented as measuring 3.5 x 3.5 with 100% necrotic tissue. On 4/11/19 the right later foot wound is documented as 1.0 x 1.1 with 100% necrotic tissue. On 4/11/19 the left lower leg (front) wound is documented as Lateral lower left leg DTI. Lesser degree of slough (40%), some [MEDICATION NAME] growth at wound edges measuring 5.2 x 2.2. On 4/11/91 the left lower leg (front) wound is documented as proximal to lateral leg wound. DTI. Lesser degree of slough, some [MEDICATION NAME] growth at edges 90% slough, maceration of wound edges included in measurement and amount of increase. The wound is documented as measuring 2.4 x 1.9, and documented as worsening. The Skin & Wound Weekly Documentation -V2 on 4/18/19 documents the coccyx wound as Unstageable wound. Wound base in combination of slough 30-40%, granulation 60-70%. Slough directly over coccyx (right). Undermining of 2.5cm @ 12 o'clock, and 2.0 undermining at 3 o'clock. The wound is documented as being 8.5 x 4.2. On 4/18/19 the right heel wound is documented as 80% eschar cap in place. Lower (towards bottom of food edge) no open 1.0*3.5 with tan colored draining. When cleansed, beefy red tissue noted. The wound is documented as being 3.0 x 3.5 with 80% necrotic tissue present in the wound bed and granulation tissue. On 4/18/19 the right later foot wound is documented as 1.0 x 1.1 with 100% necrotic tissue. On 4/18/19 the left lower leg (front) wound is documented as Lateral lower left leg DTI. 60% granulation/40% slough. Small bridge of skin between two areas measured as one. The wound is documented as measuring 4.5 x 2.2 On 4/18/19 the left lower leg (front) wound is documented as lateral leg wound. DTI. Wound bed 100% slough, with slight purple discoloration to edges. Purple d

Based on a complaint received by the State Agency, interviews, record reviews, review of the facility's self-report investigation and observations, the facility did not ensure that 2 of 6 sampled residents (R1, R2) received adequate supervision and assistive devices to prevent an accident during Hoyer lift transfers. On [DATE], R2 fell forwarding hitting her head on the short swinging bar of the Hoyer lift. No injury was noted. The facility re-inserviced the two certified nursing assistants (CNAs) involved, but did not provide training to other nursing assistants because the facility was conducting ongoing skills validation. On [DATE], R1 fell during a transfer with the Hoyer lift. R1 hit her head on the floor as the upper part of her body hit the floor. R1 was sent to the hospital where it was determined R1 had bleeding in the brain. R1's condition deteriorated over the next several days and R1 died on [DATE]. R1's care plan did not identify the type of sling to be used to transfer R1 using the Hoyer lift. R1's care plan did not instruct the CNAs to cross the straps on the sling when using the sling for transfers. The 2 CNAs involved with this Hoyer lift transfer did not cross the straps to the half sling used during this transfer. The 2 CNAs involved in this transfer had not received the inservice training regarding the safe use of lift equipment the facility provided to staff in February and April of 2017, nor had recent skills evaluations been completed for CNAs F and G. The facility's failure to provide the needed supervision and the correct utilization of assistive devices to safely transfer R1 created a finding of Immedate Jeopary beginning on [DATE]. Surveyor notified the Nursing Home Administrator (NHA) - A of the Immediate Jeopardy on [DATE] at 2:00 p.m. The Immediate Jeopardy was removed on [DATE] and the deficient practice corrected on [DATE]. Findings include; Per interview with the DON on [DATE], the facility presently has 53 residents who require the use of a lift when transferred. To help ensure that the lift transfers were done safely, the facility provided training/skills validation to staff on the use of the facility's lifts in February and [DATE]. 1. On [DATE] at 6:00 p.m., (R2) was being transferred from chair to bed by CNA-C (certified nurse aide) and CNA-D. During the transfer, (R2) fell forward hitting the right side of her head on the Hoyer lift. This was reported by the nurse aides to LPN-E (licensed practical nurse) who assessed (R1) and found no evidence of injury to the resident. This incident was reported to the NHA and the Director of Nursing (DON) and an investigation was started including a re-enactment of what occurred. On completion of the investigation, CNA-C and CNA-D received re-training on proper transfer techniques while using a Hoyer lift. It was noted that the re-training involved input from the rehab therapies department. There was no evidence that additional nurse aides received re-training on Hoyer lift transfers. Per interview with the DON on [DATE] at 8:54 a.m., the DON stated, We only did education for those two CNAs; our training and education is ongoing and did not see a trend, so not all CNAs received education. 2. Per clinical record, (R1) has been residing in the facility since [DATE]. (R1) experienced Heart Failure, Chronic Kidney Disease, Chronic Pain and Rheumatoid arthritis. The resident also was on Coumadin therapy related to her [DIAGNOSES REDACTED]. Per clinical record review, R1 is identified to be alert and oriented times three, with a BIMS score of 15 and able to make her needs known. Based on the last annual Minumum Date Set (MDS) assessment of [DATE], R1 was totally dependent on staff for transfers. The care plan [DATE] stated, has been evaluated by rehab therapy for safe transfer ability, nursing staff should transfer with two person total lift Hoyer. The facility self report indicates on [DATE] at 6:30 a.m. (R1) was being transferred per her care plan with the assistance of CNA-F and CNA-G from the bed to her wheelchair. Per the DON both CNAs F and G typically worked the night shift and typically did not have to transfer residents. The facility self report indicates during this transfer (R1) fell from the Hoyer sling onto the floor hitting the back of her head to the floor. CNA-F notified RN-I (Registered Nurse) that the resident had fallen to which RN-I went to assess the resident and determined that (R1) had sustained a hematoma to the back of her head. Per documented assessment in progress notes dated [DATE] by RN-I (R1) had no other obvious injuries, alert and oriented per baseline, vitals stable, pupils reactive and equal and able to move all extremities. The resident was removed from the floor via Hoyer lift at the direction of RN-I. Per the facility investigation and self report, R1 requested to be sent out to the hospital for evaluation. R1 was sent to the hospital on [DATE] at 7:25 a.m. per ambulance. Per hospital record review, (R1) was assessed and found to have experienced a Scalp Abrasion and Nontraumatic Subarachnoid Hemorrhage (bleeding in the brain). Per Surveyor telephone interview with the family of (R1), the resident was transferred from the first hospital to a second hospital for further Neurosurgery consultation. The resident was admitted to the second hospital for further evaluation. As the days progressed, R1's condition deteriorated as the resident also experienced Respiratory Failure with Hypoxia. This was confirmed per hospital record review conducted by Surveyor. On [DATE], five days later, (R1) died as a result of her injury sustained from the fall from the Hoyer lift. The State of Wisconsin original certificate of death identifies the immediate cause of death as CLOSED HEAD INJURY WITH SUBARACHNOID HEMORRHAGE as a result of the fall from the Hoyer lift. A review of the facility immediate investigation related to this fall noted that the transfer of (R1) from the bed to the wheelchair was re-enacted by using the same sling and involving both CNA-F and CNA-G. The facility investigation indicates both CNAs were also interviewed and from that interview it was discovered that the resident fell from the sling as the result of the sling not being crossed at the legs. The facilty's investigation noted that the facility utilizes two types of slings on the Hoyer lift device, Half slings and Whole slings. Per Surveyor interview with RD-(Rehab Director)-H and DON (Director of Nursing)- B on [DATE] at 2:30 p.m. it was noted that the half slings are made to be removed from under the resident therefore they do not cover the buttocks. It was also referenced the the half slings have to be crossed at the legs and per RD-H and DON-B all staff know this from their training . staff know this information. This interview noted that the full slings do not have to be crossed at the legs. Surveyor's review of the skills validation inservice training on safe lift transfers provided to the staff in February and [DATE] did not include CNA-F and CNA-G attending these inservces or having recent skills evaluations completed. Surveyor's investigation noted that the type of sling to be utilized and the need to cross the straps of the half sling were not identified in R1's care plan or nurse aide care card. The facility's investigation interviews conducted with CNA-F and CNA-G revealed that R1 was positioned in a half sling that required the straps it to be crossed at the legs and it was not crossed at the legs per CNA-F and CNA-G statements. Both CNAs acknowledged that the straps were not crossed at the legs. Per Surveyor interview with RD-H and review of the Hoyer lift manufacturer's information, the use of a half sling vs. whole sling is at the discretion of the facility. The failure to provide the needed supervison and the correct utilization of an assistive device to safely transfer R1 created a finding of Immediate Jeopardy. The facility removed the Immediate Jeopardy on [DATE], and the deficient practice was corrected when the facility completed the following: -Resident (R1) was assessed after the fall, with the completion of fall assessment on [DATE]. -Investigation initiated, re-enactment of fall, with the retraining of two CNAs involved on [DATE]. -Competency check of all caregivers/nurses on mechanical lift transfers was completed on [DATE]. -Evaluation of all residents requiring a mechanical lift transfer for appropriate type of sling used-was completed on [DATE]. -Therapy recommendations were incorporated into resident plan of care, for existing and new residents was completed on [DATE] and is ongoing. -Staff educated on policy: proper handling of malfunctioning equipment or equipment that has been involved in an accident was completed on [DATE]. -Policy: Transfer, Mechanical lift, reviewed, revised, education to staff completed on [DATE]. -Mechanical lift-Hoyer/sling. Audit revised based on policy revision completed on [DATE]. -LEARN module developed for training purposes. Education initiated with nursing staff and therapy was completed on [DATE]. -On going auditing of mechanical lift transfers was completed on [DATE] and ongoing. -Report to QAA committee on [DATE]. -Both nurse aides were assigned to the second shift tour of duty for more exposure to resident care and closer supervision per the DON. -Surveyor observed 4 Hoyer lift transfers using the half sling and whole sling - with no problems noted - and interviewed 6 nurse aides who were able to verify what slings to use and the mechanical lift process and procedure.

Based on interview and record review the facility did not immediately consult with 1 (R1) of 4 sampled resident's physician when there was a change in the resident's physical condition. R1 experienced a change in condition when he was exhibiting symptoms of a stroke which included verbalizing the inability to move his left side, and experiencing numbness and tingling on his left side. The facility did not complete a thorough assessment and did not report the new left sided weakness, numbness, and tingling to the physician. R1 experienced a stroke and was unable to receive treatment due to the delay in hospitalization . R1 has experienced a decline in the power of his left arm and leg. The facility's failure to notify the physician when R1 reported symptoms of a possible stroke created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. Nursing Home Administrator-A was notified of the immediate jeopardy on [DATE] at 2:30 p.m. The facility removed the jeopardy on [DATE], however, the deficient practice continued at a severity/scope level of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. Findings include: According to the American Medical Directors Association, Stroke Management in the Long-Term Care Setting Clinical Practice Guideline, Columbia, MD: AMDA 2011. Early identification and treatment can help to decrease stroke-related disability and death for appropriately selected patients. For this reason, the signs of acute stroke must be recognized and addressed promptly. Common presentations of an acute stroke include: Sudden confusion, difficulty speaking, or difficulty understanding speech. Sudden difficulty walking, severe dizziness or loss of balance or coordination. Sudden numbness or weakness of the face or in and arm or leg, especially if confined to one side of the body. Sudden severe headache with no other readily identifiable cause. If at any time a patient displays any of these acute neurological symptoms go to step four. Step four: Confirm that the patient is suffering an acute stroke. Clarify and describe the patient's signs and symptoms. Summary: Patients who have a stroke should be assessed promptly. It is up to the facility and interdisciplinary team leaders to ensure that mechanisms are in place to rapidly identify the patient who is experiencing an acute stroke and to determine-taking into consideration factors, including the patient's preferences-whether to treat the patient in the facility or transfer him or her to an acute care setting. The FAST guideline put out by the American Heart Association and the American Stroke Association direct individuals to call 911 immediately if someone shows any of these symptoms, even if the symptoms go away .to help get the person to the hospital immediately. Time is important! Don't delay . The A in FAST represents ARM WEAKNESS - Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? http://www.strokeassociation.org/STROKEORG/WarningSigns/Stroke-Warning-Signs-and-Symptoms_UCM_ 8_SubHomePage.jsp 1.) The facility's RESIDENT CHANGE OF CONDITION & REPORTING RESPOINSIBILITIES policy with an effective fate of [DATE] and which references the Clinical Practice Guidelines. Acute Change of Condition in the Long-Term Care Setting. American Medical Directors Association (AMDA) states in part that .A change of condition is defined as a change in the resident's physician, mental or psychosocial status that includes but is not limited to: .Decline in ADL (activities of daily living) functioning .Emergence of a condition or disease which is unstable or new, Change in baselines behaviors .NOTIFICATION OF PHYSICIAN. When a change of condition occurs the attending physician should be notified by the nurse. R1 has [DIAGNOSES REDACTED]. R1 preferred to have CPR. R1's admission minimum data set assessment with an assessment reference date of [DATE], and quarterly minimum data set assessment with assessment reference dates of [DATE] and [DATE] documents that R1 had no impairment for functional limitation in range of motion in his upper or lower extremities. R1's most recent minimum data set assessment with an assessment reference date of [DATE] documents that R1 usually makes self understood, and usually understands others. The assessment documents that R1 had an impairment for functional limitation in range of motion in his upper extremity and no impairment in his lower extremities. On [DATE] at 3:34 p.m. the surveyor interviewed RN MDS Coordinator-J who is documented as completing R1's minimum data set assessment of [DATE]. The surveyor asked RN MDS Coordinator-J how she collects information related to a resident's range of motion for the minimum data set assessment. RN MDS Coordinator-J stated mostly through observations, and sometimes documentation. RN MDS Coordinator-J stated that she will have residents move their arms and legs, and that she physically sees that they can do it. The surveyor asked RN MDS Coordinator-J if she recalled R1. RN MDS Coordinator-J stated a little bit. The surveyor asked RN MDS Coordinator-J if she recalled anything related to her February assessment of R1's upper extremity range of motion. RN MDS Coordinator-J stated not that she could recall. The surveyor asked RN MDS Coordinator-J if an impairment to range of motion is new if there was any follow-up. RN MDS Coordinator-J stated it depends, such as it may just be that someone is stiff or has pain at the time of the assessment. The surveyor asked RN MDS Coordinator if there was any follow-up related to R1's new documented impairment to range of motion to 1 side of his upper extremity. RN MDS Coordinator-J could not recall what side the impairment was on. The surveyor asked for any additional information regarding the new impairment documented in the minimum data set assessment. No additional information was provided. On [DATE] at 9:49 a.m. the surveyor interviewed CNA-I. CNA-I informed the surveyor that she worked with R1 frequently. The surveyor asked CNA-I if she recalled anything different about R1 between ,[DATE]-,[DATE]. CNA-I informed the surveyor that she was not sure what day it was, that R1 had reported he could not move his arm or his leg and that she reported to the nurse, and that she was working as an aide that day (CNA-I also works at the facility as a medication technician.) The surveyor asked if she recalled who she reported that too. CNA-I stated LPN-H. CNA-I stated that she observed LPN-H look at R1, take his temperature, his blood pressure, had him squeeze her hands. CNA-I stated that later in the day he was still complaining, so she went and told LPN-H again, that it was near the end of the shift, and that she was not sure what LPN-H did then. CNA-I stated that she had off the next day (CNA-I is not on the schedule [DATE]th, 2017), and then the following day she worked with him he was still complaining and that was when DON (Director of Nursing)-B came in and that she told DON-B that R1 is still complaining about his arm, so that is when she (DON-B) looked at him and then sent him out (R1 was sent to the hospital on [DATE]th, 2017). On [DATE] at 7:34 a.m. the surveyor interviewed LPN (licensed practical nurse)-H. LPN-H is documented as administering R1 his medications on [DATE] and [DATE]. On [DATE] at 1:37 p.m. LPN-H had written the following entry in R1's interdisciplinary notes Late entry from [DATE]. CNA (certified nursing assistant) stated resident states he has some tingling in his hands. Writer assessed resident who was alert. Verbalizing appropriately. Skin warm and dry no [MEDICAL CONDITION]. Hand grasps strong and equal. Good ROM (range of motion). Denies any pain. Lungs clear pulse Ox 95% at room air. TPR (temperature, pulse respirations) 98XXX[DATE]. B/P (blood pressure)-,[DATE]. Resting comfortably. Above assessment in later morning. Again rechecked resident in afternoon and again denied any pain. No further verbalization of tingling. Hand grasps remain strong and equal. Good ROM in all extremities. Updated next shift that resident had earlier tingling but was now resolved and vitals were stable. The surveyor asked LPN-H if she recalled R1 acting differently on [DATE]th or 7th. LPN-H stated she did not recall anything out of the ordinary. The surveyor asked why the above entry was written as a late entry. LPN-H stated that CNA (certified nursing assistant)-I had told her he was complaining of tingling in his hands, did not see anything different, that she did an assessment and checked his hand grasps. LPN-H recalled that it was late morning, and that later in the afternoon she checked on R1 again and he did not say anything, hand not tingling, was talking like he always does, that she did not notice any swelling in his hand, that he had good range of motion, and had noticed nothing out of the ordinary. The surveyor asked LPN-H how she was able to recall R1's vitals on [DATE] to chart on [DATE]. LPN-H stated that she saves her worksheets on her clipboard and was able to look her notes from ,[DATE]. The surveyor asked LPN-H if she had informed a RN that R1 was experiencing tingling. LPN-H stated that no she did not because did not think anything was going on after assessing him, and R1 didn't complain further. LPN-H stated that she thought perhaps R1 laid on it, or that circulation in the elderly is not good. LPN-H stated that if he would have continued complaining she would have called an RN, but he didn't show any signs and had no further complaints. LPN-H confirmed that she did not notify a physician of R1 having tingling. The surveyor asked how the next shift was updated. LPN-H stated verbally. On [DATE] at 1:27 p.m. the surveyor re-interviewed LPN-H. The surveyor reviewed the schedule with LPN-H and informed her that CNA-I believed she was working as an aide, and then had off and then he was sent out the next day. LPN-H stated after reviewing the schedule that, although not 100% sure, CNA-I came to her on ,[DATE] and not ,[DATE] perhaps. LPN-H confirmed that CNA-I came to her a second time about R1, that she could not recall what CNA-I had said, but that she had been checking on the resident throughout the shift, and that he seemed fine. There is no documentation that staff consulted with the physician regarding R1's complaints. On [DATE] at 1:19 p.m. the surveyor spoke with Family Member-D, R1's daughter. Family Member-D informed the surveyor that the week that her father had been sent out (,[DATE]-,[DATE]) there had been a care conference that her son (R1's grandson) had attended as she had been unable to attend. Family Member-D stated that her son had informed her that R1 had complained of numbness and tingling in his leg at the care conference. Interdisciplinary notes on [DATE] document Resident, grandson, Ombudsman, business office, administrator and ID team met with resident on today's date . On [DATE] at 11:01 a.m. the surveyor interviewed Ombudsman-E. Ombudsman-E confirmed that she had been at the care conference on [DATE]. The surveyor asked Ombudsman-E if R1 had any complaints. Ombudsman-E recalled that she was sitting outside of the room where the care conference was held with R1, R1's grandson, and his grandson's fiancé prior to the meeting starting. Ombudsman-E recalled that R1 stated he felt like his leg was stuck in the mud, that he couldn't move it. Ombusman-E also recalled R1 stating he couldn't move his arm. Ombudsman-E stated it was the left side. Ombudsman-E stated she recalled telling the nurse who was on the floor adjusting R1's foot pedals. Ombudsman-E stated that she recalled repeating herself as she wasn't sure if she had heard her. Ombudsman-E stated there were other people in the room including NHA (nursing home administrator)-E. Ombudsman-E confirmed that the nurse was RN Unit Manager-G. On [DATE] at 11:40 a.m. the surveyor interviewed Dietitian-F. Dietitian-F confirmed that she had attended R1's [DATE] care conference. The surveyor asked Dietitian-F if she recalled R1 having any complaints. Dietitian-F asked surveyor like what. The surveyor stated numbness, tingling, or pain. Dietitian-F stated she recalled the ombudsman said something, that he should be assessed after the care conference, can't recall why, and that R1 seemed like his usual self that he had no slurring or anything. On [DATE] at approximately 1:40 p.m. the surveyor interviewed NHA-H. NHA-A confirmed that he had attended a care conference with Ombudsman-E and R1's grandson whose mother was R1's power of attorney, Family Member-D. The surveyor asked NHA-A if he recalled R1 having any complaints of pain, numbness, tingling, or being unable to move an extremity during the meeting. NHA-A stated that he believed he recalled R1 having a complaint of pain, and that he believed RN Unit Manager-G was going to look into it. An Interdisciplinary Note written by RN Unit Manager-G on [DATE] documents Late entry; assessed resident on [DATE] for complaints of pain on lower left leg during careplan meeting after W/C (wheelchair) foot pedal was applied. RN UM (unit manager) lowered foot pedal and inquired whether resident had continued pain with the adjustment to the foot pedal. Resident communicated relief of pain, and made no other further complaints. On [DATE] a correction/addendum was completed on this note to correct date of assessment during care plan meeting to [DATE]. On [DATE] at 3:06 p.m. the surveyor interviewed RN Unit Manager-G. The surveyor reviewed the late entry with RN Unit Manager-G. RN Unit Manager-G stated that the grandson had wheeled R1 in without foot pedals, that when she had put the foot pedals on R1 had expressed pain, which she believed the foot pedal was too high, and that when it was lowered he expressed no pain. RN Unit Manager-G confirmed she had attended the care conference meeting. Surveyor asked if she recalled any concerns about numbness or tingling. RN Unit Manager-G stated she did not recall anything about numbness or tingling, that she really just recalled discussion about a clock. On [DATE] at 2:12 p.m. the surveyor interviewed RN Unit Manager-G again. The surveyor informed RN Unit Manager-G of the interview with Ombudsmen-E. The surveyor asked RN Unit Manager-G if she recalled being informed of R1 stating that his leg felt like it was stuck in the mud, of not being able to move his arm, or of a need for an assessment. RN Unit Manager-G stated that she did not recall hearing any of that and that if she had she would have done an assessment. On [DATE] at 1:19 p.m. Surveyor spoke with Family Member-D, daughter of R1. Family Member-D informed Surveyor that she had talked with R1's nurse on the night of [DATE] and was assured her father was fine. Family Member-D informed the surveyor that she had informed the nurse that her father was complaining of numbness and tingling. Family Member-D stated that the nurse informed her that R1's vitals were fine and that R1 was fine. Family Member-D did not recall the name of the nurse she spoke with. On [DATE] at approximately 2:05 p.m. the surveyor spoke with RN (registered nurse)-C over the phone. According to the facility's schedule RN-C worked on R1's unit [DATE] and [DATE]. The surveyor asked RN-C if she recalled R1 complaining of pain or anything unusual on [DATE]. RN-C stated she recalled that R1 would sometimes complain of stomach pain that would be relieved with repositioning, or would often have a bowel movement in the evening and have relief with a bowel movement. The surveyor asked RN-C if she recalled R1 complaining of numbness or tingling that night. RN-C stated that she could not recall the specific date or time, but sometime this month R1 stated he was having a weird feeling in his arm, that he couldn't move it. RN-C stated that she asked R1 if he was having numbness in his face and that R1 moved his hand to his face, and then stated that he wanted to go home. RN-C stated she believes that she assessed R1, took his vitals, and everything was okay/at his baseline. RN-C stated she believes that she re-oriented R1 to the building, that R1 had confusion from time to time, and that she didn't really see anything different from baseline. Surveyor asked if RN-C could recall the date this interaction occurred. RN-C stated that she not sure, that it was this month, but not sure when. The surveyor informed RN-C that she was documented as giving R1 his medications on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. RN-C stated that it would have either been [DATE] or [DATE]. Surveyor asked RN-C if she would usually chart that. RN-C stated that if something was off would have, but if normal no change in condition, may not have. RN-C stated that ever since caring for him, R1 has had time-to-time confusion, that she did not recall any real change based on her assessment. Surveyor asked if she recalled Family Member-D calling her that day. RN-C stated that she was not 100% sure but believes that it was the same date. RN-C stated that Family Member-D had spoken to her stating that her father had called about his hearing aid. RN-C stated she recalled Family Member-D asking if her father had had any change in condition. RN-C stated she informed Family Member-D that she had not been endorsed (informed in report) of anything by the previous shift. RN-C stated that Family Member-D informed her that her father had told her he was feeling weird, and that she recalled telling Family Member-D that if he had any change in condition she would be updated, and that her main concern was the hearing aid. The surveyor asked RN-C what she did when she assessed R1. RN-C stated she asked how R1 was he was feeling. He stated he was feeling weird, that he needs to go home. RN-C stated she reoriented R1, and when she asked him about weirdness, he stated he could not move his left arm. RN-C stated she checked his vitals, did not see anything out of baseline, checked the strength in his arms, that neuro check was intact, had no drooping, clear speech, and that he then moved his left hand to his face when she asked about numbness in his face. RN-C stated that she checked on the resident later in the night and he was fine. The surveyor reviewed R1's medical record and noted there was no doucmentaiton that a physician was notified of R1's change of condition until [DATE]. Interdisciplinary notes on [DATE] written by DON-B document, Write into assess IAD (incontinence associated [MEDICAL CONDITION]) to buttocks. Caregiver stated that (R1) c/o (complained of) tingling in left arm and leg. Handgrasps left weaker than right. Left leg strength weaker than right. BP ,[DATE] HR (heartrate) 60 RR (respiratory rate) 22 T94.6 poximetry (pulse ox) 95% room air. When repositioned on side is able to grasp positioning bar weakly with left hand. Speech clear no facial drooping. Dx. (diagnoses) hypertension. (Physician-L) called, given update and orders to send to (name of hospital) ER (emergency room ) for evaluation. Write contacted POA (family member-D) via telephone. Notified her that (R1) will be sent to (name of hospital) via ambulance for evaluation of left sided weakness. Bell ambulance called to transport to ER. R9 was admitted to the hospital on [DATE] with an admission [DIAGNOSES REDACTED]. Emergency department provider notes on [DATE] document that .c/o (complained of) left-sided weakness that began six days ago. He states, 'my left leg is completely dead, I told the facility about it and they laughed. They told me I just needed to rest.' He initially developed the LLE (left lower extremity weakness, and then the next day developed LUE (left upper extremity) weakness. He reports inability to move the LLE and LUE. He additionally has transient diplopia. He denies speech difficulty, fever, vomiting, or cough. He has no other sx (symptoms) or complaints at this time. Per the RN: The patient's son reports that he was having these symptoms two days ago, and had reported they started three days ago. The patient's last known well time is between three and six days ago. Emergency department provider notes documented on [DATE] assessment notes that include the following There is ,[DATE] strength of the RUE (right upper extremity) and RLE (right lower extremity). There is ,[DATE] strength of the LLE. The patient can grasp with the LUE, but cannot hold it against gravity. Sensation is intact throughout the BLE (bilateral lower extremity) and BUE (bilateral upper extremity). Emergency department course notes document that R1's National Institute of Health stroke scale score is 7 indicating a moderate stroke. The course notes document, The patient initially presents with several days of left-sided weakness. His head CT today reveals that he has had a subsequent stroke. The patient had said that he alerted the nursing home staff about his complaints, but was ignored by the staff .The patient presents with six days of left-sided weakness, which the nursing home staff was not taking seriously. He has paralysis of the LLE and Minimal movement of the LUE. The head CT revealed a 10 mm area to right periventricular region that is concerning for new ischemia. He is not a tPA (used to breakdown clots) candidate given the duration of sx (symptoms). The patient is allergic to ASA (aspirin), so he has not received any. His NIH (National Institute of Health stroke scale score) is 7 . MDM (medical decision making) pt (patient) with [MEDICAL CONDITION](stroke). No aspirin due to allergy per pt. No indication for tpa or intervention based on LKWT (last known well time). Neurology Consultation notes on [DATE] document that .The exact time frame of the onset of symptoms is somewhat unclear, but it was somewhere between ,[DATE] days. Due to this timing he was not considered a candidate for IV alteplase. Apparently he had been telling the staff that my left leg is totally dead' for several days and they continually ignored it, thinking he was confabulating secondary to his dementia . Neurology examination progress notes on [DATE] document that .Power in the left upper extremity is unchanged and is about ,[DATE] proximally and ,[DATE] distally. Power in the left lower extremity is about ,[DATE]. The facility's failure to immediately consult with R1's physician when he had signs and symptoms of stroke, created a finding of Immediate Jeopardy for R1 beginning on [DATE]. The Immediate Jeopardy was removed on [DATE] when: -The facility provided education to available licensed nursing staff or Resident Change of Condition and Reporting Responsibilities and the 24 hour Nursing Change of Condition Report. This education will be provided for all new licensed nursing staff upon hire. Education will be provided to licensed nursing staff on LOA or otherwise not available prior to working his or her shift. -An audit was conducted of all resident in the facility on [DATE] for significant Change of Condition to include proper documentation of the notification of the physician, notify the resident's' legal representative or an interested family member, and documentation of the assessment. -The Director of Nursing or designee will audit identified significant change of condition during the Daily Stand up/Stand down meeting. On days where the Daily Standup/Stand down meetings do not occur, the licensed nurses will report any significant change of condition to the Charge RN. This information will be reviewed and appropriate action will be taken immediately upon discovery of any non-compliance with the policy and will be reported at the facility QA&A meetings. Cross-reference F309

Based on interview and record review the facility did not ensure each resident received the necessary care and services to attain or maintain the highest practicable physician, mental and psychosocial well-being for 1 (R1) of 4 sampled residents. R1 experienced a change in condition indicating symptoms of a stroke which included verbalizing the inability to move his left side, and experiencing numbness and tingling on his left side. The facility did not complete a thorough assessment, including notifying a RN of new complaints of numbness, tingling, and verbalizing that he could not move left extremities, and did not report the new left sided weakness, numbness, and tingling to the physician. R1 experienced a stroke and was unable to receive treatment due to the delay in hospitalization . R1 has lost strength in both his left arm and leg. The facility's failure to provide the necessary care and services when R1 reported symptoms of a stroke created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. Nursing Home Administrator-A was notified of the immediate jeopardy on [DATE] at 2:30 p.m. The facility removed the jeopardy on [DATE], however, the deficient practice continues at a severity/scope level of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. Findings include: The FAST guideline put out by the American Heart Association and the American Stroke Association direct individuals to call 911 immediately if someone shows any of these symptoms, even if the symptoms go away .to help get the person to the hospital immediately. Time is important! Don't delay . The A in FAST represents ARM WEAKNESS - Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? http://www.strokeassociation.org/STROKEORG/WarningSigns/Stroke-Warning-Signs-and-Symptoms_UCM_ 8_SubHomePage.jsp 1.) The facility's RESIDENT CHANGE OF CONDITION & REPORTING RESPONSIBILITIES policy with an effective date of [DATE] and which references the Clinical Practice Guidelines. Acute Change of Condition in the Long-Term Care Setting. American Medical Directors Association (AMDA) states in part that 1.When a member of the health care team notices a change of condition, the nurse on duty shall be notified promptly. The nurse will gather required data and report findings to the RN Clinical Coordinator or member of nursing leadership team. 2. The RN Clinical Coordinator will assess the resident related to the reported data. An RN member of the nursing leadership team or a charge RN will assess and document on residents in the absence of the RN Clinical coordinator .DOCUMENTATION Documentation of findings and assessment regarding the change of condition in the resident's medical record by the individual nurse who discovered change and the RN who followed up on concern if the discovery was made by a L.P.N. This includes documentation symptoms, assessment, subjective and objective information, of attempts to notify and notification of physician, resident, PAO-HC (power of attorney-health care) and/or emergency contact. Resident will be placed on 24 hour Report for monitoring. R1 has [DIAGNOSES REDACTED]. R1 preferred to have CPR. R1's admission minimum data set assessment with an assessment reference date of [DATE], and quarterly minimum data set assessment with assessment reference dates of [DATE] and [DATE] documents that R1 had no impairment for functional limitation in range of motion in his upper or lower extremities. R1's most recent minimum data set assessment with an assessment reference date of [DATE] documents that R1 usually makes self understood, and usually understands others. The assessment documents that R1 had an impairment for functional limitation in range of motion in his upper extremity and no impairment in his lower extremities. On [DATE] at 3:34 p.m. the surveyor interviewed RN MDS Coordinator-J who is documented as completing R1's minimum data set assessment of [DATE]. The surveyor asked RN MDS Coordinator-J how she collects information related to a resident's range of motion for the minimum data set assessment. RN MDS Coordinator-J stated mostly through observations, and sometimes documentation. RN MDS Coordinator-J stated that she will have residents move their arms and legs, and that she physically sees that they can do it. The surveyor asked RN MDS Coordinator-J if she recalled R1. RN MDS Coordinator-J stated a little bit. The surveyor asked RN MDS Coordinator-J if she recalled anything related to her February assessment of R1's upper extremity range of motion. RN MDS Coordinator-J stated not that she could recall. The surveyor asked RN MDS Coordinator-J if an impairment to range of motion is new if there was any follow-up. RN MDS Coordinator-J stated it depends, such as it may just be that someone is stiff or has pain at the time of the assessment. The surveyor asked RN MDS Coordinator if there was any follow-up related to R1's new documented impairment to range of motion to 1 side of his upper extremity. RN MDS Coordinator-J could not recall what side the impairment was on. The surveyor asked for any additional information regarding the new impairment documented in the minimum data set assessment. No additional information was provided. On [DATE] at 9:49 a.m. the surveyor interviewed CNA-I. CNA-I informed the surveyor that she worked with R1 frequently. The surveyor asked CNA-I if she recalled anything different about R1 between ,[DATE]-,[DATE]. CNA-I informed the surveyor that she was not sure what day it was, that R1 had reported he could not move his arm or his leg and that she reported to the nurse, and that she was working as an aide that day (CNA-I also works at the facility as a medication technician.) The surveyor asked if she recalled who she reported that too. CNA-I stated LPN-H. CNA-I stated that she observed LPN-H look at R1, take his temperature, his blood pressure, had him squeeze her hands. CNA-I stated that later in the day he was still complaining, so she went and told LPN-H again, that it was near the end of the shift, and that she was not sure what LPN-H did then. CNA-I stated that she had off the next day (CNA-I is not on the schedule [DATE]th, 2017), and then the following day she worked with him he was still complaining and that was when DON (Director of Nursing)-B came in and that she told DON-B that R1 is still complaining about his arm, so that is when she (DON-B) looked at him and then sent him out (R1 was sent to the hospital on [DATE]th, 2017). On [DATE] at 7:34 a.m. the surveyor interviewed LPN (licensed practical nurse)-H. LPN-H is documented as administering R1 his medications on [DATE] and [DATE]. On [DATE] at 1:37 p.m. LPN-H had written the following entry in R1's interdisciplinary notes Late entry from [DATE]. CNA (certified nursing assistant) stated resident states he has some tingling in his hands. Writer assessed resident who was alert. Verbalizing appropriately. Skin warm and dry no [MEDICAL CONDITION]. Hand grasps strong and equal. Good ROM (range of motion). Denies any pain. Lungs clear pulse Ox 95% at room air. TPR (temperature, pulse respirations) 98XXX[DATE]. B/P (blood pressure)-,[DATE]. Resting comfortably. Above assessment in later morning. Again rechecked resident in afternoon and again denied any pain. No further verbalization of tingling. Hand grasps remain strong and equal. Good ROM in all extremities. Updated next shift that resident had earlier tingling but was now resolved and vitals were stable. The surveyor asked LPN-H if she recalled R1 acting differently on [DATE]th or 7th. LPN-H stated she did not recall anything out of the ordinary. The surveyor asked why the above entry was written as a late entry. LPN-H stated that CNA (certified nursing assistant)-I had told her he was complaining of tingling in his hands, did not see anything different, that she did an assessment and checked his hand grasps. LPN-H recalled that it was late morning, and that later in the afternoon she checked on R1 again and he did not say anything, hand not tingling, was talking like he always does, that she did not notice any swelling in his hand, that he had good range of motion, and had noticed nothing out of the ordinary. The surveyor asked LPN-H how she was able to recall R1's vitals on [DATE] to chart on [DATE]. LPN-H stated that she saves her worksheets on her clipboard and was able to look her notes from ,[DATE]. The surveyor asked LPN-H if she had informed a RN that R1 was experiencing tingling. LPN-H stated that no she did not because did not think anything was going on after assessing him, and R1 didn't complain further. LPN-H stated that she thought perhaps R1 laid on it, or that circulation in the elderly is not good. LPN-H stated that if he would have continued complaining she would have called an RN, but he didn't show any signs and had no further complaints. LPN-H confirmed that she did not notify a physician of R1 having tingling. The surveyor asked how the next shift was updated. LPN-H stated verbally. On [DATE] at 1:27 p.m. the surveyor re-interviewed LPN-H. The surveyor reviewed the schedule with LPN-H and informed her that CNA-I believed she was working as an aide, and then had off and then he was sent out the next day. LPN-H stated after reviewing the schedule that, although not 100% sure, CNA-I came to her on ,[DATE] and not ,[DATE] perhaps. LPN-H confirmed that CNA-I came to her a second time about R1, that she could not recall what CNA-I had said, but that she had been checking on the resident throughout the shift, and that he seemed fine. According to N6, Nurse Practice Act, while an LPN can assist in the collection of data, only an RN can assess, plan, intervene and evaluate a patient. On [DATE] at 2:12 p.m. the surveyor interviewed RN Unit Manager-G. The surveyor informed RN Unit Manager-G of the above interviews with LPN-H. The surveyor asked RN Unit Manager-G if she would have expected LPN-H to inform her of the above information. RN Unit Manager-G stated yes, and that staff are usually really good. Not sure what happened here. On [DATE] at 2 p.m. the surveyor interviewed DON-B. The surveyor informed DON-B of the above interviews with LPN-H and CNA-I. The surveyor asked DON-B if she would have expected LPN-H to have contacted an RN. DON-B stated that in hindsight, yes, but that she was familiar with R1 and she knows that he would make unfounded statements, that he had confusion, and that he is cognitively impaired. DON-B stated that LPN-H had assessed R1 and noted no change in condition. On [DATE] at 1:19 p.m. the surveyor spoke with Family Member-D, R1's daughter. Family Member-D informed the surveyor that the week that her father had been sent out (,[DATE]-,[DATE]) there had been a care conference that her son (R1's grandson) had attended as she had been unable to attend. Family Member-D stated that her son had informed her that R1 had complained of numbness and tingling in his leg at the care conference. Interdisciplinary notes on [DATE] document Resident, grandson, Ombudsman, business office, administrator and ID team met with resident on today's date . On [DATE] at 11:01 a.m. the surveyor interviewed Ombudsman-E. Ombudsman-E confirmed that she had been at the care conference on [DATE]. The surveyor asked Ombudsman-E if R1 had any complaints. Ombudsman-E recalled that she was sitting outside of the room where the care conference was held with R1, R1's grandson, and his grandson's fiancé prior to the meeting starting. Ombudsman-E recalled that R1 stated he felt like his leg was stuck in the mud, that he couldn't move it. Ombusman-E also recalled R1 stating he couldn't move his arm. Ombudsman-E stated it was the left side. Ombudsman-E stated she recalled telling the nurse who was on the floor adjusting R1's foot pedals. Ombudsman-E stated that she recalled repeating herself as she wasn't sure if she had heard her. Ombudsman-E stated there were other people in the room including NHA (nursing home administrator)-E. Ombudsman-E confirmed that the nurse was RN Unit Manager-G. On [DATE] at 11:40 a.m. the surveyor interviewed Dietitian-F. Dietitian-F confirmed that she had attended R1's [DATE] care conference. The surveyor asked Dietitian-F if she recalled R1 having any complaints. Dietitian-F asked surveyor like what. The surveyor stated numbness, tingling, or pain. Dietitian-F stated she recalled the ombudsman said something, that he should be assessed after the care conference, can't recall why, and that R1 seemed like his usual self that he had no slurring or anything. On [DATE] at approximately 1:40 p.m. the surveyor interviewed NHA-H. NHA-A confirmed that he had attended a care conference with Ombudsman-E and R1's grandson whose mother was R1's power of attorney, Family Member-D. The surveyor asked NHA-A if he recalled R1 having any complaints of pain, numbness, tingling, or being unable to move an extremity during the meeting. NHA-A stated that he believed he recalled R1 having a complaint of pain, and that he believed RN Unit Manager-G was going to look into it. An Interdisciplinary Note written by RN Unit Manager-G on [DATE] documents Late entry; assessed resident on [DATE] for complaints of pain on lower left leg during careplan meeting after W/C (wheelchair) foot pedal was applied. RN UM (unit manager) lowered foot pedal and inquired whether resident had continued pain with the adjustment to the foot pedal. Resident communicated relief of pain, and made no other further complaints. On [DATE] a correction/addendum was completed on this note to correct date of assessment during care plan meeting to [DATE]. On [DATE] at 3:06 p.m. the surveyor interviewed RN Unit Manager-G. The surveyor reviewed the late entry with RN Unit Manager-G. RN Unit Manager-G stated that the grandson had wheeled R1 in without foot pedals, that when she had put the foot pedals on R1 had expressed pain, which she believed the foot pedal was too high, and that when it was lowered he expressed no pain. RN Unit Manager-G confirmed she had attended the care conference meeting. Surveyor asked if she recalled any concerns about numbness or tingling. RN Unit Manager-G stated she did not recall anything about numbness or tingling, that she really just recalled discussion about a clock. On [DATE] at 2:12 p.m. the surveyor interviewed RN Unit Manager-G again. The surveyor informed RN Unit Manager-G of the interview with Ombudsmen-E. The surveyor asked RN Unit Manager-G if she recalled being informed of R1 stating that his leg felt like it was stuck in the mud, of not being able to move his arm, or of a need for an assessment. RN Unit Manager-G stated that she did not recall hearing any of that and that if she had she would have done an assessment. On [DATE] at 1:19 p.m. Surveyor spoke with Family Member-D, daughter of R1. Family Member-D informed Surveyor that she had talked with R1's nurse on the night of [DATE] and was assured her father was fine. Family Member-D informed the surveyor that she had informed the nurse that her father was complaining of numbness and tingling. Family Member-D stated that the nurse informed her that R1's vitals were fine and that R1 was fine. Family Member-D did not recall the name of the nurse she spoke with. On [DATE] at approximately 2:05 p.m. the surveyor spoke with RN (registered nurse)-C over the phone. According to the facility's schedule RN-C worked on R1's unit [DATE] and [DATE]. The surveyor asked RN-C if she recalled R1 complaining of pain or anything unusual on [DATE]. RN-C stated she recalled that R1 would sometimes complain of stomach pain that would be relieved with repositioning, or would often have a bowel movement in the evening and have relief with a bowel movement. The surveyor asked RN-C if she recalled R1 complaining of numbness or tingling that night. RN-C stated that she could not recall the specific date or time, but sometime this month R1 stated he was having a weird feeling in his arm, that he couldn't move it. RN-C stated that she asked R1 if he was having numbness in his face and that R1 moved his hand to his face, and then stated that he wanted to go home. RN-C stated she believes that she assessed R1, took his vitals, and everything was okay/at his baseline. RN-C stated she believes that she re-oriented R1 to the building, that R1 had confusion from time to time, and that she didn't really see anything different from baseline. Surveyor asked if RN-C could recall the date this interaction occurred. RN-C stated that she not sure, that it was this month, but not sure when. The surveyor informed RN-C that she was documented as giving R1 his medications on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. RN-C stated that it would have either been [DATE] or [DATE]. Surveyor asked RN-C if she would usually chart that. RN-C stated that if something was off would have, but if normal no change in condition, may not have. RN-C stated that ever since caring for him, R1 has had time-to-time confusion, that she did not recall any real change based on her assessment. Surveyor asked if she recalled Family Member-D calling her that day. RN-C stated that she was not 100% sure but believes that it was the same date. RN-C stated that Family Member-D had spoken to her stating that her father had called about his hearing aid. RN-C stated she recalled Family Member-D asking if her father had had any change in condition. RN-C stated she informed Family Member-D that she had not been endorsed (informed in report) of anything by the previous shift. RN-C stated that Family Member-D informed her that her father had told her he was feeling weird, and that she recalled telling Family Member-D that if he had any change in condition she would be updated, and that her main concern was the hearing aid. The surveyor asked RN-C what she did when she assessed R1. RN-C stated she asked how R1 was he was feeling. He stated he was feeling weird, that he needs to go home. RN-C stated she reoriented R1, and when she asked him about weirdness, he stated he could not move his left arm. RN-C stated she checked his vitals, did not see anything out of baseline, checked the strength in his arms, that neuro check was intact, had no drooping, clear speech, and that he then moved his left hand to his face when she asked about numbness in his face. RN-C stated that she checked on the resident later in the night and he was fine. Interdisciplinary notes on [DATE] written by DON-B document, Write into assess IAD (incontinence associated [MEDICAL CONDITION]) to buttocks. Caregiver stated that (R1) c/o (complained of) tingling in left arm and leg. Handgrasps left weaker than right. Left leg strength weaker than right. BP ,[DATE] HR (heartrate) 60 RR (respiratory rate) 22 T94.6 poximetry (pulse ox) 95% room air. When repositioned on side is able to grasp positioning bar weakly with left hand. Speech clear no facial drooping. Dx. (diagnoses) hypertension. (Physician-L) called, given update and orders to send to (name of hospital) ER (emergency room ) for evaluation. Write contacted POA (family member-D) via telephone. Notified her that (R1) will be sent to (name of hospital) via ambulance for evaluation of left sided weakness. Bell ambulance called to transport to ER. R9 was admitted to the hospital on [DATE] with an admission [DIAGNOSES REDACTED]. Emergency department provider notes on [DATE] document that .c/o (complained of) left-sided weakness that began six days ago. He states, 'my left leg is completely dead, I told the facility about it and they laughed. They told me I just needed to rest.' He initially developed the LLE (left lower extremity weakness, and then the next day developed LUE (left upper extremity) weakness. He reports inability to move the LLE and LUE. He additionally has transient diplopia. He denies speech difficulty, fever, vomiting, or cough. He has no other sx (symptoms) or complaints at this time. Per the RN: The patient's son reports that he was having these symptoms two days ago, and had reported they started three days ago. The patient's last known well time is between three and six days ago. Emergency department provider notes documented on [DATE] assessment notes that include the following There is ,[DATE] strength of the RUE (right upper extremity) and RLE (right lower extremity). There is ,[DATE] strength of the LLE. The patient can grasp with the LUE, but cannot hold it against gravity. Sensation is intact throughout the BLE (bilateral lower extremity) and BUE (bilateral upper extremity). Emergency department course notes document that R1's National Institute of Health stroke scale score is 7 indicating a moderate stroke. The course notes document, The patient initially presents with several days of left-sided weakness. His head CT today reveals that he has had a subsequent stroke. The patient had said that he alerted the nursing home staff about his complaints, but was ignored by the staff .The patient presents with six days of left-sided weakness, which the nursing home staff was not taking seriously. He has paralysis of the LLE and Minimal movement of the LUE. The head CT revealed a 10 mm area to right periventricular region that is concerning for new ischemia. He is not a tPA (used to breakdown clots) candidate given the duration of sx (symptoms). The patient is allergic to ASA (aspirin), so he has not received any. His NIH (National Institute of Health stroke scale score) is 7 . MDM (medical decision making) pt (patient) with [MEDICAL CONDITION](stroke). No aspirin due to allergy per pt. No indication for tpa or intervention based on LKWT (last known well time). Neurology Consultation notes on [DATE] document that .The exact time frame of the onset of symptoms is somewhat unclear, but it was somewhere between ,[DATE] days. Due to this timing he was not considered a candidate for IV alteplase. Apparently he had been telling the staff that my left leg is totally dead' for several days and they continually ignored it, thinking he was confabulating secondary to his dementia . Neurology examination progress notes on [DATE] document that .Power in the left upper extremity is unchanged and is about ,[DATE] proximally and ,[DATE] distally. Power in the left lower extremity is about ,[DATE]. According to a Scientific statement from the American Heart Association in 2006 in an article titled Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke, More than 50% of the 1.2 million people who suffer an acute [MEDICAL CONDITION] infarction (AMI) or coronary death each year in the United States die in an emergency department (ED) or before reaching a hospital within an hour of symptom onset. About 700 000 individuals will have a stroke each year, 167 000 of those who have [MEDICAL CONDITION] will die, and more will suffer a major disability. Of the stroke deaths that occur each year, almost half occur before the patient reaches the hospital. Many of these deaths and significant disability could be prevented if patients received earlier treatment. Although the benefits of early treatment of [REDACTED].Delay to treatment for [REDACTED]. The disability associated with stroke and with heart failure after AMI is largely a consequence of infarct size, and lack of timely treatment is a major determinant of increased infarct size in both AMI and stroke. Unfortunately, most individuals who experience symptoms delay substantially before seeking treatment . Stroke trials demonstrated that treatment within 3 hours of symptom onset is beneficial for intravenous [MEDICATION NAME] corroborated these findings and indicated that the optimal administration time is within 90 minutes patients with acute ischemic stroke. Even within the 3-hour window, benefit from [MEDICATION NAME] decreases as time from symptom onset increases. http://circ.ahajournals.org/content/[DATE].full The facility's failure to provide the necessary care and services when R1 had signs and symptoms of stroke, created a finding of Immediate Jeopardy for R1 beginning on [DATE]. The Immediate Jeopardy was removed on [DATE] when: -An audit was conducted on all residents in the facility on [DATE] for Significant Change of Condition to include proper documentation of the notification of the physician, notify the resident's legal representative or an interested family member, and documentation of the assessment. - The nursing leadership team reviews all electronic nursing documents, physician orders, and the unit specific 24 hour board for identified significant change of condition. The nursing leadership team reviews the residents assigned to a specific unit with the nurse and caregivers assigned to that area at a minimum of once per day during regular business hours to identify potential significant change of condition. Any change of condition on off shifts will be communicated to the RN on-call. This information is shared during the Daily Stand Up and Stand Down meeting to include the multidisciplinary team. -The facility provided education to available licensed nursing staff on Resident Change of Condition and Reporting Responsibilities and the 24 hour Nursing Change of Condition Report. This education will be provided for all new licensed nursing staff upon hire. Education will be provided to licensed nursing staff on LOA or otherwise not available prior to working his or her next shift. -The Director or Nursing or designee will audit identified significant change of condition during the Daily Stand up/Stand down meeting. On days where the Daily Standup/Stand down meetings do not occur, the licensed nurses will report any significant change of condition to the Charge RN. This information will be reviewed and appropriate action will be taken immediately upon discovery of any non-compliance with the policy and will be reported at the facility QA&A meetings. Cross-reference F157

Based on observations, interviews and record reviews, multiple facility staff did not adhere to current accepted infection prevention and control standards of practice as well as facility policy while providing care for 5 of 21 sampled residents (#7, #8, #10, #13 and #14). · Resident #10 had signage on the outside of his door alerting staff / visitors to see nurse for instructions. Staff did not know Resident #10 had a Clostridium difficile infection (CDI). · Facility staff did not follow accepted infection prevention and control standards of practice and facility policy while caring for Resident #10. The facility did not: o Initiate contact precautions when Resident #10 was suspected of having CDI on multiple occasions o Update Resident #10's care plan or CNA care card to indicate he was on contact precautions o Follow contact precautions and appropriately utilize personal protective equipment (gowns and gloves) o Perform hand hygiene when indicated o Maintain resident in contact precautions until diarrhea ceases o Communicate information about Resident #10's infection to the facility housekeeping department, therapy department and physician office so appropriate precautions could be instituted to prevent transmission of infection o Utilize an appropriate disinfectant that was effective against Clostridium difficile to clean the resident's room and shared bathroom The facility's failure to initiate appropriate precautions when a resident is suspected of having CDI (Clostridium Difficile Infection), communicate the infection status to all departments caring for a resident with CDI, follow and maintain contact precautions, appropriately utilize personal protective equipment, perform hand hygiene when indicated and appropriately clean and disinfect the resident's environment and shared bathroom with an appropriate disinfectant created a finding of Immediate Jeopardy beginning 5/23/16. This had the potential to affect all residents who came in contact with Resident #10 or with staff who had cared for Resident #10 who had not used proper precautions. Administrator-A, Director of Nursing (DON)-B and President-TT were notified of the Immediate Jeopardy on 6/1/16 at 10:42 am. The Immediate Jeopardy was removed on 6/3/16 when the facility implemented an action plan related to infection prevention and control. The deficient practice continues at a scope and severity (s/s) of an E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan and as evidenced by the following: * During a gastrointestinal outbreak in March 2016, five staff were ill but there was no line list indicating who the staff were, when they were symptom free and when those ill staff returned to work or if they stayed away until they had been symptom free for 48 hours. Additionally, five ill residents (#40, #41, #32, #39, and #42) were not on the GI line list, * Seven staff (CNA-X, CNA-G, RN-C, CNA-ZZ, LPN-K, CNA-H, and CNA-J) did not follow proper handwashing procedures when providing personal cares, wound care, or insulin injection for Residents #13, #14, #7, and *8. Findings include: According to information on the Advancing Excellence Campaign in America's Nursing Homes website, Gastrointestinal infections from Clostridium difficile (C. diff) are a major problem in US healthcare facilities. Although at one time most of these infections occurred in hospitals, now over 75% of [DIAGNOSES REDACTED] infections are first identified outside of the hospital setting. Nursing homes are among the most common places where [DIAGNOSES REDACTED] infections can happen. <https://www.nhqualitycampaign.org/goalDetail.aspx?g=inf#tab1> The Centers for Disease Control (CDC) Frequently Asked Questions about Clostridium difficile for Healthcare Providers website indicates how CDI can be prevented in hospitals and other healthcare settings. http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a10 <http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html> Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium spores. These spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. The information on this website includes but is not limited to the following interventions that healthcare providers can implement to prevent Clostridium difficile: · Use antibiotics judiciously · Use Contact Precautions: for patients with known or suspected CDI: o Place these patients in private rooms. If private rooms are not available, these patients may be placed in rooms (cohorted) with other patients with CDI. o Use gloves when entering patient's rooms and during patient care. o Perform Hand Hygiene after removing gloves § Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of [DIAGNOSES REDACTED]icile spores is more challenging than the removal or inactivation of other common pathogens. § Preventing contamination of the hands via glove use remains the cornerstone for preventing [DIAGNOSES REDACTED]icile transmission via the hands of healthcare workers . o Use gowns when entering patient's rooms and during patient care. o Dedicate or perform cleaning of any shared medical equipment. o Continue these precautions until diarrhea ceases. § Because [DIAGNOSES REDACTED]icile - infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending on the type of setting and average length of stay. · Implement an environmental cleaning and disinfection strategy: o Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. o Consider using an Environmental Protection Agency (EPA) - registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants and not effective against [DIAGNOSES REDACTED]icile spores.) Hypochlorite-based disinfectants may be most effective in preventing [DIAGNOSES REDACTED]icile transmission in units with high endemic rates of CDI. o Follow the manufacturer's instructions for disinfection of endoscopes and other devices. On 5/25/16, Surveyor # reviewed the facility's Clostridium Difficile Protocol revised on 10/9/13. The protocol includes but is not limited to the following: 1. If Clostridium difficile is suspected, the nurse will: · Assess resident for constipation/fecal impaction · Review medications · Review laxative use both scheduled and prn · Assess abdomen . · Vital signs A. Update physician of findings and request order for Stool for[DIAGNOSES REDACTED] Toxin. B. Initiate Contact Precautions for patients with known or suspected[DIAGNOSES REDACTED] associated disease and document in Nurses Notes 1) Complete Isolation Precautions Memo and have unit secretary distribute memo 2) If resident is continent and shares a bathroom, place a commode at bedside 3) Initiate care plan 4) Put on 24 Hour Report that contact isolation was initiated. · Perform hand hygiene using soap and water · Use gloves when entering patients' room and during patient care · Use gowns if soiling of clothes is likely. (NOTE: This intervention is not consistent with the Association for Professionals in Infection Control (APIC) and CDC C- difficile recommendations as well as the Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). All three of these organizations recommend use of a gown upon entry to the room.) · Dedicate equipment whenever possible. · Continue these precautions until diarrhea ceases. Implement an environmental cleaning and disinfection strategy: · Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. · Use an Environmental Protection Agency (EPA) - registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants and not effective against [DIAGNOSES REDACTED]icile spores.) Hypochlorite-based disinfectants may be most effective in preventing [DIAGNOSES REDACTED]icile transmission in units with high endemic rates of CDI. · Follow the manufacturer's instructions for disinfection of endoscopes and other devices. C. Update responsible party/resident of orders/contact precautions. Surveyors and reviewed Resident #10's record on 5/25-5/26 and 5/31- 6/1/16. Interdisciplinary (IDT) Notes noted the following: 2/12/16 -18:38 - Resident #10 was started on Bactrim DS twice daily for 5 days for a UTI (urinary tract infection). 2/15/16 - 10:52:08 - Writer received an update this morning that resident had 2 loose stools during therapy session .Writer updated NP (Nurse Practitioner) on report from therapy . New order received to obtain stool sample for [DIAGNOSES REDACTED] and to start Lactobacillus: 2 capsules by mouth daily x 14 days. 2/15/16 - 16:52:39 - .Assist of 1 with gait belt and walker for transfers. Attends therapy per orders 2-3 loose stool during am shift. Unable to obtain sample for [DIAGNOSES REDACTED] culture. 2/17/16 - 16:00:12 - .Unable to obtain stool sample for [DIAGNOSES REDACTED] . Assist of 1 with gait belt and walker for transfers. Attends therapies per orders. Moved to room [ROOM NUMBER]-2 late this morning. 2/19/16 - 13:50:42 - Resident positive for[DIAGNOSES REDACTED] (sic). Nor'd (new order) for abt (antibiotic) treatment from NP. Contact isolation initiated . Infection Tracking information in the electronic health record noted the following: 2/19/16 -[DIAGNOSES REDACTED] - Gastrointestinal - facility acquired - contact precautions Facility staff suspected Resident #10 of having[DIAGNOSES REDACTED]icile on 2/15/16 but didn't institute contact precautions according to facility policy and current standards of practice until 2/19/16 and continued to allow Resident #10 to attend therapy. IDT Notes noted the following: 2/21/16 - 12:26:28 - .Resident remains on ABT (antibiotic) related to[DIAGNOSES REDACTED] no loose stools reported at this time. Resident ate breakfast in room this morning and ate lunch in the dining room with no issues noted will monitor. The IDT Note does not indicate if Resident #10 had any stools. IDT Notes dated 2/22/16 through 2/25/16 identified no loose stools noted or no loose stools reported and IDT Notes 2/24/16 and 2/25/16 indicate contact precautions maintained even though the facility policy indicates that contact precautions will be maintained until diarrhea ceases. It should be noted that facility staff use the term loose stool while the facility policy uses the term diarrhea. IDT Note - 2/29/15 @ 13:15:42 - No adverse reaction to ABT for c.diff. No loose stools noted. Remains on contact isolation. IDT Note - 3/1/16 @ 3:32:56 - .Completed ABT/C-diff, no loose stool noted . 3/4/16 @ 10:33:21 - Resident received orders to d/c (discharge) to Gardens with PT (physical therapy) and OT (occupational therapy). IDT Note - 3/6/16 @ 15:21:03 - Resident admitted to facility today 3/6/16 at 1414 by Bell ambulance, after he fell prone from hois (sic) W/C (wheelchair) at the assisted living facility, came from ER . IDT Note - 3/8/16 @ 13:35:16 - .Resident is alert and oriented, able to make needs known .U/A (urinalysis) pending .Nor'd (new order) for PT and OT to eval and treat. IDT Note - 3/11/16 @ 13:56:34 - .Resident was started on antibiotics for UTI today . IDT Note - 3/13/16 @ 19:21:30 - MD updated @ 1810 with U/A (urinalysis) C&S (culture & sensitivity) results. NOR (new order) to D/C (discontinue) [MEDICATION NAME], Start [MEDICATION NAME] 100 mg BID (twice daily) x 7 days . IDT Note - 3/14/16 @ 14:17:45 - No adverse reaction noted ATB (sic) for UTI and cellulitis. Stools becoming loose, had explosion of loose stool this AM but did not smell like cdiff (sic). Surveyor reviewed documents titled Resident Bowel and Bladder by Shift Chart completed by nurse aides dated 3/15/16 that noted Resident #10 was incontinent of bowel three times between 7 am - 1500 pm. One small, one medium and one large episode of bowel incontinence was recorded with no consistency recorded however the category of diarrhea was not checked and there is no category for loose stool. IDT Note - 3/17/16 @ 17:03:36 - .NP (nurse practitioner) updated with PT/INR (Pro-time/International normalized ratio) results and loose stools. NOR (new order received). The 3/17/16 Resident Bowl and Bladder by Shift Chart noted Resident had two extra large episodes of bowel incontinence between 7am - 1500pm. IDT Note - 3/18/16 @ 10:57:09 - .1x loose stool noted so far this shift, sample obtained, mucous present . Infection Tracking information in the electronic health record noted the following: 3/18/16 -[DIAGNOSES REDACTED] - acquired at facility, contact precautions. The facility 24 hour report for 3/18/16 noted: Day shift - Loose stools with mucous,[DIAGNOSES REDACTED] being tested PM Shift - Was not able to defecate for this shift NOC (night) Shift - +[DIAGNOSES REDACTED] Resident #10's room number is listed under the Isolation category on the 24 hour report. IDT Note - 3/19/16 @ 13:44:26 - .One large loose stool this am shift. IDT Note - 3/19/16 @ 22:14:50 - Stool culture positive for[DIAGNOSES REDACTED] infection, results communicated to MD, who gave order to start resident on [MEDICATION NAME] 500 mg po (oral) 3x/day (three times a day) for 10 days. IDT Note - 3/22/16 @ 11:15:16 - Abt for[DIAGNOSES REDACTED] given as ordered. No current signs of adverse reaction. Contact precautions maintained. No report of loose stools as of yet this shift. IDT Note - 3/22/16 @ 21:57:34 - .Md (moderate) loose stool noted . IDT Note - 3/23/16 @ 16:25:53 - Care plan meeting this date with resident and niece's participation and MD's knowledge .Resident is up daily in wheelchair and propels self about the facility and attends programs of choice . IDT Notes continue to record the presence of loose stools on the following dates and times; 3/24/19 @ 22:50, 3/25/16 @ 02:42 and 14:16, 3/26/16 @ 10:32 and 21:26, 3/27/16 @ 20:25 and 3/28/16 04:04. On 3/28/16, the facility obtained an order to re-test for[DIAGNOSES REDACTED]. On 3/29/16, the stool specimen was negative for[DIAGNOSES REDACTED] but facility staff continued to document that Resident #10 continued to have at least one loose stool on 3/30, and 3/31/16. There is no documentation in the IDT notes as to if and when contact precautions were discontinued. On 3/14/16, a facility staff member ruled out suspicion for[DIAGNOSES REDACTED]icile associated diarrhea based on the resident's stool not smelling like[DIAGNOSES REDACTED]icile even though Resident #10 developed loose stools after starting an antibiotic and has a prior history of[DIAGNOSES REDACTED]icile infection. Consequently, the facility did not initiate contact precautions until 3/18/16. Once contact precautions were initiated, an IDT Note dated 3/23/16 indicated that Resident #10 was allowed to propel himself about the facility and attend programs of choice despite having loose stools. IDT Notes noted the following: 4/14/16 @ 23:38 - Alert and Oriented x 2 . Eats in dining room .Loose stools x 2 noted .Assist x 1 with transfers and ADL's (activities of daily living). Propels self in hallways. 4/15/16 @ 23:29 - . Loose stools x2 noted. Foul smelling. Scant amt of blood noted . (The 4/15/16 Resident Bowel and Bladder by Shift Chart completed by nurse aides notes that Resident #10 had 2 X-Large episodes of bowel incontinence between 7 am and 1500 pm. The diarrhea category was not checked and there is no category for loose stool.) 4/16/16 @ 13:56 - . Resident on alert for loose stools with blood . 4/17/16 @ 02:03 - . CNA reports orange colored soft stool x 1. 4/17/16 @ 21:36 - . No loose stools reported this pm shift . (The 4/17/16 Resident Bowel and Bladder by Shift Chart completed by nurse aides notes that Resident #10 had 1 Large episode of bowel incontinence between 1500 - 2300. The diarrhea category was not checked and there is no loose category.) 4/18/16 @ 14:07 and 23:02 indicate no reported loose stools and zero loose stools noted. (The 4/18/16 Resident Bowel & Bladder by Shift Chart notes that Resident #10 had 1 large episode of bowel incontinence between 0700-1500.) 4/19/16 @ 11:24 - .Resident is alert and verbally responsive .1x reported loose stool so far this shift. no blood noted . 4/19/16 @ 23:53 - Alert and oriented x 2 . Loose stools x 2 noted. Bleeding noted from buttocks wound. Tx (treatment applied). Up in w/c (wheelchair) propelling self in hallways. 4/20/16 @ 17:51 - Md (medium) loose stool noted at the start of shift. Nurse Practitioner updated with Cont (continued) loose stools. NOr (new order) for lactose free diet, Stool spec (specimen) for[DIAGNOSES REDACTED], [MEDICATION NAME] PRN (as needed) and GI Consult. 4/21/16 @ 20:04 - Alert and Oriented x 2, .Tolerated lactose free diet. Sm (small) amt of stool in brief. Not able to obtain sample. Noted taking soda from the dining room. Reminded he was on a fluid restriction 4/22/16 @ 14:42 - Stool was called in and faxed to pharmacy this AM at 0645, waiting results. Had small stool today but was more like mucous . 4/22/16 @ 20:53 - Resident was in small dining room after other residents left out and was seen sitting by juice machine drinking cup after cup of juice . 4/23/16 @ 21:50 - Md loose stool noted x 1. Sm (amount) of blood noted from excoriated areas . 4/24/16 @ 03:29 - Per lab order for stool sample was canceled. Will reobtain stool spec for[DIAGNOSES REDACTED]. 4/24/16 @ 13:36 - Resident has bowel movement x 1 in am. loose and hard to collect. 4/24/16 @ 22:54 - alb (sic) (lab) never picked up stool sample. New specimen obtained. Lab notified. awaiting pickup. 4/25/16 @ 14:01 - Resident had 1 medium formed stool and 1 small loose stool this shift. Awaiting results from lab for stool specimen. 4/25/16 @ 14:05 - Resident went to appointment at 1315, picked up by bell (Bell Ambulance) and stretcher. 4/25/16 @ 14:37 - Returned from appointment on stretcher via Bell ambulance. Also positive for[DIAGNOSES REDACTED] and NOR (new order received) from Nurse Practitioner and Administrator A informed. Isolation precautions will be placed. IDT Note dated 5/9/16 @ 22:09 noted Resident #10 was hospitalized due to jaundice and cholecystolithiasis. Resident #10 began having loose stools on 4/14/16 and staff did suspect reoccurrence of[DIAGNOSES REDACTED]icile and did not initiate contact precautions even though Resident #10 had two previous occurrences of[DIAGNOSES REDACTED]icile infection and had taken antibiotics. In the interim, Resident #10 was allowed to propel himself around the facility. On 4/20/16, facility staff obtained an order to test Resident #10's stool for[DIAGNOSES REDACTED]icile and the facility did not initiate contact precautions until 4/25/16 when the facility received laboratory results confirming[DIAGNOSES REDACTED]icile infection. IDT Notes dated 5/20/16 @ 20:16 noted that Resident #10 was readmitted to the facility. He was noted to be alert and oriented x 3 with periods of mental wandering, Foley catheter present and briefs used for bowel incontinence. Medications included [MEDICATION NAME] for C.diff and contact iso (isolation) precautions. IDT Notes noted the following: 5/21/16 @ 14:12 - . remain on Abt (antibiotic) Vanco([MEDICATION NAME]) for[DIAGNOSES REDACTED] with no adverse reaction noted. resident has x2 loose stool. remain on contact precaution . 5/22/16 @ 22:51 - Alert and oriented x 2, . Loose stool x 2 noted .Stayed in bed all shift per request . 5/23/16 @ 23:48 - Alert and oriented x 2 . Loose stool x 1 noted. Up in w/c propelling self through the hallways . 5/25/16 @ 22:02 - Alert and oriented x 2 Loose stool x1 noted. Up in w/c propelling self through the hallways. On 5/23/16 at approximately 8:52 am Surveyor # and Surveyor # were completing the survey tour task with Administrator-A when they arrived at Resident #10's room. Surveyors # and # observed a cart outside Resident #10's room and a sign posted on the frame of the door stating Stop See Nurse. Surveyors # and # asked Administrator-A about the cart and sign. She indicated it meant that Resident #10 is in isolation for[DIAGNOSES REDACTED]. Administrator-A then entered the room without donning any personal protective equipment (PPE) to speak with Resident #34 who is Resident #10's roommate and resides in the bed closest to the door. Resident #34 complained that he couldn't get into the bathroom as it was blocked. Surveyor # and Surveyor # observed a linen cart and two wheelchairs at the foot of Resident #10's bed. On 5/23/16 @ 10:55 a.m., Surveyor # and # spoke with Resident #34 who reported he uses the bathroom to shave and dump my urinal but he couldn't get into it because it was blocked by the commode. On 5/23/16 at 10:38 am, Surveyor # and Surveyor entered Resident #10's room to speak with his roommate. Resident #10 was not in his bed or in his room. At approximately 12:45 pm Surveyor # and # observed Resident #10 wheeling himself in his wheelchair in the corridor of the facility. On 5/24/16 at 4:31 am, Certified Nursing Assistant (CNA)-BB told Surveyor that Resident #10 has[DIAGNOSES REDACTED] and staff should use gown, mask and gloves. On 5/24/16 at approximately 9:19 am Surveyors # and # observed Certified Nursing Assistant (CNA)-NN enter Resident #10's room. CNA-NN did not don a gown or gloves. Surveyor # observed CNA-NN touch Resident #10's tray table and the bed remote. CNA-NN then left the room. Surveyor # observed CNA-NN use alcohol gel hand rub from the wall dispenser before obtaining Resident #10's food tray off of the meal cart. CNA-NN returned to Resident #10's room with the tray. Surveyor # observed CNA-NN still does not have gloves or a gown on. CNA-NN was observed going into Resident #10's bathroom to get gloves. Following this CNA-NN pulled up the white sheet to cover Resident #10's legs. CNA-NN removed her gloves and washed her hands. Surveyor # noted CNA-NN rinsed her hands for approximately 30 seconds and then washed her hands for 45 seconds with soap and water. CNA-NN indicated to Surveyor # she was just waiting for someone to help her boost the resident. On 5/24/16 at approximately 9:22 am Director of Nursing (DON)-B entered Resident #10's room. Surveyor # observed DON-B did not put on a gown. CNA-NN asked DON-B if she could help boost Resident #10. DON-B grabbed Resident #10's pillows from behind his head and greeted Resident #10 and told Resident #10 she needed to grab gloves and then she would help boost Resident #10. On 5/24/16 at approximately 9:23 am CNA-YY entered Resident #10's room. CNA-YY did not don a gown upon entering, just gloves. DON-B asked CNA-NN and CNA-YY if they were good and CNA-YY indicated yes. CNA-NN and CNA-YY proceeded to boost Resident #10 in bed by grabbing the sides of the bath sheet and pulling Resident #10 upward. CNA-NN then removed her gloves and washed her hands. CNA-NN did not don new gloves. CNA-NN then opened Resident #10's milk on his breakfast tray and then left Resident #10's room. Surveyor # observed CNA-NN use hand sanitizer upon exiting Resident #10's room. On 5/24/16 at approximately 10:04 am Surveyor # interviewed CNA-YY about cares provided that day to Resident #10. CNA-YY indicated that she had placed Resident #10 on the commode. Surveyor # asked what consistency was of Resident #10's stool. CNA-YY indicated Resident #10's stool was not watery but it was not formed. On 5/24/16 at approximately 10:22 am Surveyor # and # observed Resident #10 in the therapy department in the lower level of the facility. Surveyor # observed Resident #10 had a walker positioned in front of him with a wheelchair behind him. Resident #10 was observed lifting one leg at a time while holding onto the walker while Therapist-EEE held onto a gait belt around Resident #10's waist. Resident #10 finished his exercises and sat back down. Therapist-EEE asked Surveyor # and # if there was anything he could help with. Surveyor # asked Therapist-EEE if made him aware of anything special regarding Resident #10's condition. Therapist-EEE indicated Resident #10 had just recently returned from the hospital and Resident #10 has issues with falls and other issues and they are working on balance and overall strengthening on therapy. Surveyor # asked Therapist-EEE if nursing had communicated to him anything about infection control issues and his condition. Therapist-EEE indicated no. Therapist-EEE indicated he has worked with Resident #10 for a while. Therapist-EEE checked the black tablet he had in his hand and indicated to Surveyor # and # that he now sees that Resident #10 does have precautions for[DIAGNOSES REDACTED] (clostridium difficile). Therapist-EEE indicated that by having precautions for[DIAGNOSES REDACTED] that means Resident #10 cannot use the public bathroom and if Resident #10 uses equipment it needs to be wiped down after use. On 5/25/16 at approximately 8:36 am Resident #10 activated his call light. Surveyor # and # observed CNA-AAA enter Resident #10's room. Surveyor # observed CNA-AAA did not don personal protective equipment to include a gown or gloves. CNA-AAA proceeded to touch Resident #10's privacy curtain and stated to Resident #10, Let me go get your aide okay? CNA-AAA left Resident #10's room and applied gel hand sanitizer. At approximately 8:38 am Licensed Practical Nurse (LPN)-FFF entered Resident #10's room with Resident #10's medication. Surveyor # observed LPN-FFF did not put on a gown but did don gloves on her hands and she was holding Resident #10's medications. LPN-FFF approached Resident #10 and said, Let me lift the head of your bed up. LPN-FFF used the remote control to raise the head of the bed up then gave Resident #10 the medication and water and asked if they went down okay. LPN-FFF then went to the resident bathroom and washed her hands and upon exiting the bathroom she used the right side of her body to close the bathroom door. On 5/26/16 at 12:50 pm Surveyor # interviewed Environmental Services Tech (EST)-GGG about the facility. EST-GGG indicated they work on the unit where Resident #10 resides approximately 2 times a week. Surveyor # asked EST-GGG if she knew why there was an isolation cart outside Resident #10's room. EST-GGG indicated they did not know why and they only knew they were in isolation. Surveyor # asked EST-GGG to explain the process for cleaning Resident #10's room and if there is any difference with cleaning a room with an isolation cart versus other Resident rooms. EST-GGG stated just gown. EST-GGG indicated they put on a gown and gloves on and clean wipe off table. When asked what product does EST-GGG use to clean surfaces EST-GGG stated, I'm using orange, it's like an orange disinfectant. Once in a while I will use bleach wipes, like Clorox wipes for the counter, the handles, the dresser or bed remote .I use orange cleaner for the floor. Surveyor # asked if EST-GGG had received any special training for isolation. EST-GGG said, At my old job .here my boss told me to clean anything at reach. EST-GGG was asked if there was anything else about the cleaning process that she could share and EST-GGG stated, Oh the bathroom, I clean the sink first then the handles, then the toilet handles, the toilet, the mirror - I think that's it. Surveyor # asked EST-GGG what product she uses to clean the bathroom and EST-GGG replied I use orange. On 5/26/16 at approximately 12:58 pm Surveyor # interviewed Environmental Services Manager (ESM)-HHH regarding isolation and cleaning. ESM-HHH indicated it is her understanding a cart is used when a person is in isolation to hold gowns, gloves etc. depending upon what they need. Surveyor # asked if she knew about the different Resident conditions when placed in isolation/precautions. ESM-HHH indicated she does not know what condition just that they are in isolation and follow standard precautions and policies and procedures. Surveyor # asked about cleaning agents used. ESM-HHH indicated they use the chemical H2Orange and that it kills about everything because it's a disinfectant. ESM-HHH indicated they clean the room in isolation last because they cannot go room to room with a wet mop after using it in that room. ESM-HHH indicated they clean all resident rooms the same, the only difference is after cleaning the isolation rooms they do not go room to room to clean without cleaning the bucket after. Surveyor # asked ESM-HHH about personal protective equipment that housekeeping staff are to use when cleaning a room in isolation. ESM-HHH indicated they only gown up if they are close to the resident but usually the staff just wear gloves and nursing will tell them if it is something serious where we have to gown up. Surveyor # asked ESM-HHH if she had been told anything specific about Resident #10 and why he was in isolation. ESM-HHH indicated no, she had not been told there is anything serious with Resident #10. On 5/31/16 Surveyor # reviewed the Material Safety Data Sheet (MSDS) for the H2Orange used by the facility to clean resident rooms and mop floors. Surveyor # noted the information for sanitizing indicates: Kills 99% of common bacteria (Staphylococcus aureus, Salmonella chloleraesuis, [DIAGNOSES REDACTED] pneumonia, Pseudomonas aeruginosa, Streptococcus faecalis, and Escherichia coli. The information related to effectiveness against viruses indicates: Kills 99% specified viruses (Herpes Simplex Virus Type 2, Influenza A2/Japan, HBV and HIV-1). Surveyor # noted this cleaning product was not effective against[DIAGNOSES REDACTED]icile. On 5/31/16 at approximately 1:17 pm Surveyors # and # met with Administrator-A to share concerns regarding Resident #10. During this time Surveyors # and # shared with Administrator-A that surveyors were unable to find information that facility staff followed their policy regarding instituting contact precautions when a resident has suspected or confirmed[DIAGNOSES REDACTED]. Administrator-A confirmed that Resident #10 should be in isolation. Surveyors # and # shared observations of Resident #10 being out of isolation despite having symptoms of[DIAGNOSES REDACTED]. NHA-A indicated Resident #10 is in contact isolation for the[DIAGNOSES REDACTED]. Administrator-A was asked if the policy and procedure indicates to continue precautions until diarrhea ceases. Administrator-A indicated she would need to research this a little more. Surveyors # and # shared their multiple observations of staff not donning personal protective equipment including gloves and gowns and staff brushing up against potentially contaminated equipment in Resident #10's room. Surveyors # a

Based on a complaint received at the Southeastern Regional Office, interview, and record review, the Facility did not consult with 1 (Resident #24) of 24 sampled Residents' physician when indicated. Resident #24's physician was not consulted multiple times when Resident #24's pressure injury presented with an odor, which could signify the development of an infection and result in deterioration of the pressure injury. Additionally, Resident #24's family member was not provided with notification related to changes in care and treatment. Resident #24 was admitted to the facility on [DATE] from an assisted living facility for rehab without any pressure injuries. On [DATE] a ruptured blister was observed on Resident #24's left heel when his shoe was removed. On [DATE] Resident #24's unstageable pressure injury measured 4.6 x 7.6 cm with no odor. Five days later on [DATE] the scab appeared to be coming off and the treatment was not done. The Facility did not consult with the physician that the treatment was not done. On [DATE] Facility staff called the physician but did not speak with the physician. There was no follow up with consulting with the physician. On [DATE], [DATE], [DATE] & [DATE] Resident #24's pressure injury presented with an odor but the Facility did not consult with the physician. On [DATE] Resident #24 saw the Physician-LLL, a podiatrist at a wound clinic. Physician-LLL noted a 4 x 5 necrotic heel with obvious signs of infection. The ulcer was gangrenous and Physician-LLL could feel the bone. Resident #24 was transferred to the hospital and was started on IV [MEDICATION NAME] for a stage 4 pressure injury with osteo[DIAGNOSES REDACTED]. Resident #24 was placed on hospice and died a week later on [DATE]. The failure to promptly consult with the physician to obtain guidance and orders for treatment created a finding of Immediate Jeopardy for Resident #24 beginning on [DATE]. Administrator-A, DON (Director of Nursing)-B and President-TT were informed of the Immediate Jeopardy and substandard quality of care on [DATE] at 10:42 a.m. The Immediate Jeopardy was removed on [DATE] when the facility implemented their action plan; however, the deficient practice continues at a scope and severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the Facility has not fully implemented its plan for ongoing monitoring. Findings include: 1. Surveyor # reviewed Resident #24's closed medical record from [DATE] to [DATE]. Resident #24 was admitted on [DATE] from an assisted living facility for rehabilitation with [DIAGNOSES REDACTED]. Resident #24 was not admitted with any pressure injuries. The at risk for skin integrity care plan, not dated, has approaches dated [DATE] of: Reposition in bed and in wheelchair, educate resident to reposition self frequently when in bed or w/c (wheelchair)/ Skin assessment on shower/bath days/ Monitor for s/sx (signs/symptoms) of skin breakdown, redness or irritation/ and Update MD (medical doctor) and family with changes in skin appearance. Approaches dated [DATE] are Blue boots on. and Air Matt in place. Surveyor # noted there is not an approach to float Resident #24's heels. The admission MDS (minimum data set) with an assessment reference date of [DATE] and signed as complete on [DATE] documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. Resident #24 requires extensive assistance with bed mobility, transfers, does not ambulate, is frequently incontinent of urine and continent of bowel. Resident #24 is at risk for developing pressure injuries and currently does not have any pressure injuries. Under skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, and application of ointments/medications other than to feet are checked. The pressure ulcer CAA (care area assessment) dated [DATE] under care plan reasons documents, care plan to be in place to reduce risk factors associated with potential pressure ulcers/skin concerns, and monitor. Under description of problem documents, no skin concerns/pressure ulcers noted, but resident is at risk for area. Under causes and contributing factors documents, Dx (diagnosis) in place, MEDs in use, Inc. (incontinent) episodes, decreased mobility .see review of indicators. The nurses note dated [DATE] documents, @ (at) 2000 (8:00 p.m.), resident assisted to bed per CNA (Certified Nursing Assistant) and HS (hour sleep) cares were started. Upon removing resident's L (left) shoe and sock, an open area was noted. Team leader and writer notified. Area is a ruptured blister. Physician-JJJ not on call. Physician-NNN covering and was consulted. New orders received. Resident updated and aware. Writer did phone son and updated on the above. No concerns voiced. Heel boot and treatment performed. The skin assessment form dated [DATE] documents under description, ruptured blister, surrounding skin WNL (within normal limits). Measurements are documented as Length: 5.0 cm (centimeters) Width: 7.0 cm. The nurses note dated [DATE] documents, Late entry for [DATE]: 3.5 cm (centimeter) x (by) 8.0 cm x 0.1 cm wound to left posterior heel assessed. Wound bed is 100% deep purple, dry. Scant amount of sanguineous drainage noted to old bandage. Mild odor Surrounding skin is loose and macerated from 0300 to 0800. Some [MEDICATION NAME] tissue growth noted from ,[DATE]. Wound was cleaned and dressed. Resident tolerated treatment well with mild discomfort noted. Will continue treatment for one week, then wound team to assess. The nurses note dated [DATE] documents, Wound team reassessed wound to left posterior heel on this date. Wound worsening with development of large area of hardened black eschar to posterior heel surface, and deep tissue injury to proximal posterior heel area. Small amount of red/brown serosanguineous drainage noted to old dressing with mild odor. Resident noted pressing heel to mattress and pulling toward head of bed. Blue boots already in place. Wound team recommends treatment change: Wash with normal saline and pat dry daily, apply Marathon to hardened eschar area every 3 days, leave open to air. Also recommended wedge to lift heels higher off of bed to prevent shearing against mattress along with continuation of blue boot placement. Wound team to reassess in one week. Surveyor # noted that FM-OOO and Resident #24's physician was not notified of the change in Resident #24's pressure injury and change of treatment. The pressure ulcer care plan not dated has a goal of No s/s (signs symptoms) of infection will develop and wound to left heel will show evidence of healing with a goal date of [DATE]. Approaches dated [DATE] are Clean left heel with 0.9% sodium chloride. Pat dry. Apply [MEDICATION NAME] to eschar and leave open to air., Preventative skin care measures to decrease pressure/irritation to skin: Air mattress, float heels, frequent repositioning., Weekly RN (Registered Nurse) assessment and documentation to include: wound status, size and depth of wound., Provide diet and snacks as recommended by dietician and per resident choice., Monitor for signs symptoms of infection (odor, drainage, redness of surrounding tissue)., Monitor reports of pain/discomfort--provide pain meds; monitor effectiveness. Offer and provide pain med prior to treatment., and Provide supplements as ordered. Assess need for increase of protein and/or carbohydrate intake. Monitor & encourage food/fluid intake. Surveyor # noted there were no further revisions of Resident #24's care plan after the initial approaches dated [DATE]. The nurses note dated [DATE] documents, Wound to left posterior heel assessed by wound team on this date. No drainage noted. Moist tissue surrounding eschar has dried out 10.8 cm (centimeter) x (times) 13.2 cm area of deep tissue injury to proximal posterior heel and large area of black eschar covering surface of heel remain. Resident tolerated procedure. Wound team recommends changing treatment to wash with NS (normal saline), pat dry, and apply [MEDICATION NAME] daily. Will reassess in one week. Surveyor # noted that FM-OOO was not notified of the change of treatment. The quarterly MDS with an assessment reference date of [DATE] and signed as complete on [DATE] has a BIMS score of 15 which indicates cognitively intact. Resident #24 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, does not ambulate, is frequently incontinent of urine and always incontinent of bowel. Resident #24 is at risk for developing pressure ulcer and is coded as having one unstageable pressure injury. Under skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, and application of ointments/medications other than to feet are checked. The nurses note dated [DATE] documents, Wound team assessed pressure area to left posterior heel. Unstageable pressure area remains with hard black eschar cap securely attached to wound bed. No drainage, redness, or odor. Surrounding skin intact, but dry. Recommend continuation of [MEDICATION NAME] treatment. Heels floated on pillow when in bed. Float heels when in Broda chair. Air mattress in place and functional. Wound to right buttock also assessed. Wound is incontinence associated [MEDICAL CONDITION]. Wound area is very moist at this time. Recommend change from Duoderm treatment to Calazinc cream after good pericare following episodes of incontinence. Resident tolerated treatment. The nurses note dated [DATE] documents, Unstageable pressure wound to left posterior heel was assessed by interdisciplinary wound team. Current measurement is 4.6 cm x 7.6 cm. Hard, black eschar cap remains. Cap is lifting from 1000 to 0200. Yellow slough visible under eschar cap. Maceration to periwound form 1000 to 0200. [MEDICATION NAME] treatment remains appropriate at this time. Right heel boggy. No open areas. Blanchable skin. Air mattress in place for pressure relief. Heels floated when in bed/chair. Resident receives supplemental nutrition for wound healing. Growth noted to right shoulder during assessment with sanguineous drainage. Area cleaned and staff nurse notified. The nurses note dated [DATE] documents, Black scab cap to left heel appears to be separating from wound edge, [MEDICATION NAME] not administered. Wound nurse aware, will update MD when wound treatment recommendation for fingers received from wound nurse. Pillow placed behind calves while in Broda chair, towel under feet per order. Surveyor # noted this is the first note documenting Resident #24's heel was being floated.The nurses note dated [DATE] documents, Black scab cap to left heel appears to be separating from wound edge, [MEDICATION NAME] not administered. Wound nurse aware, will update MD when wound treatment recommendation for fingers received from wound nurse. Pillow placed behind calves while in Broda chair, towel under feet per order. Surveyor # noted this is the first note documenting Resident #24's heel was being floated. On [DATE] at 7:36 a.m. and at 10:13 a.m. Surveyor # interviewed RN (Registered Nurse)-MMM about his [DATE] nurses note and asked why he didn't call the physician when the edges of wound were separating and he didn't complete the treatment as ordered. RN-MMM informed Surveyor # that typically they would get the recommendation from the wound nurse. RN-MMM indicated that he guessed he was waiting for the wound nurse to make her recommendation about Resident #24's fingers (refer to nurses note) and then would let the physician know to see if the recommendation was ok with the physician. Surveyor # asked RN-MMM if he recalled any odor. RN-MMM replied I don't know if I charted that. I honestly don't remember. The nurses note dated [DATE] documents, Resident is alert and oriented, able to make needs known. Pleasant and cooperative with staff. skin warm and dry, resp. (respirations) are even and unlabored. No c/o (complaint of) increase pain or disc (discomfort) to fingers. Areas appear free of s/s (signs/symptoms) infection. Indent still present, areas are dry. Wound nurse assessed fingers and felt it was best to leave them open to air. Fingers cleansed. Paged MD at 1400 (2:00 p.m.) to update. Awaiting call back. On [DATE] at 7:36 a.m. and at 10:13 a.m. Surveyor # asked RN (Registered Nurse)-MMM if Resident #24's physician called back after the call at 2:00 p.m. on [DATE]. RN-MMM informed Surveyor # that he would have made a note if the doctor had called back. Surveyor # inquired if there was any follow up. RN-MMM explained that his shift is over at 2:30 p.m. and wasn't sure if there anyone followed up. The skin assessment form dated [DATE] documents under description, Black eschar remains to left heel, firmly attached, no maceration noted to surrounding tissue. Area is starting to lift at the edges some odor is noted while assessing the wound. The measurements are documented as Length: 4.6 cm Width 7.6 cm. Under nurses notes documents, Area remains with attached dry eschar, lifting on the top of the wound slightly, no drainage noted, had a mild odor when sock was removed, no sign of infection. Recommend changing treatment from [MEDICATION NAME] to marathon due to lifting of the cap. Will continue all other intervention. The date physician notified is documented as [DATE]. The Facility did not consult with Resident #24's physician about the odor which could signify the development of an infection. Surveyor # asked RN-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. if he notified Resident #24's physician about the odor as documented on [DATE]. RN-MMM reviewed this form and informed Surveyor # that Administrator-A wrote the note so she would have contacted the physician. The skin assessment form dated [DATE] documents under treatment, Wash with NS (normal saline), apply [MEDICATION NAME] to eschar daily. Under description documents, Black eschar remains to left heel, firmly attached, no maceration noted to surrounding tissue. Area is starting to lift at the edges some odor is noted while assessing the wound. The measurements are documented as Length 4.8 cm Width: 8.0 cm. Under nurses note documents, Black dry eschar remains on the left heel, edges area staring to lift at 12 o'clock to about 3 o'clock. Noted some bloody, brown small amount of drainage on dressing. Palpation of the wound noted some boggy feeling of the wound suspect that wound is not healing under the eschar tissue. Recommend sharp debridement of the wound to aid in wound healing. Surveyor # noted the treatment is incorrect on this skin assessment as the treatment was changed [DATE] to Marathon. The nurses note dated [DATE] documents, Resident alert and verbally responsive. Able to make simple needs known. Pleasant and cooperative with staff. Skin is warm and dry, resp (respirations) are even and unlabored. No noted increase confusion. Fluids encouraged and accepted. 1 x (times) loose stool, kept clean and dry, abd. (abdomen) is soft, non-tender with bowel sounds active in all 4 quad. (quadrants). Consulted Physician-JJJ re: black eschar heel. Order received for podiatrist Physician-LLL. There is no evidence that Physician-JJJ was informed about the odor. Surveyor # asked RN-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. if he informed Physician-JJJ about the odor on [DATE]. RN-MMM informed Surveyor # that he didn't recall and that he would have documented if he did. The skin assessment form dated [DATE] documents under treatment documents, Wash area, pat dry and apply Marathon. Under description Black eschar remains to left heel, detaching from upper part, no maceration noted to surrounding tissue. Area is starting to lift at the edges some odor is noted while assessing the wound. Order received for wound consult. The measurements are documented as Length: 4.8 cm Width: 8.0 cm. The date physician notified is documented as [DATE]. The nurses notes on the skin assessment form is blank. The nurses note dated [DATE] documents, Resident is alert and verbally responsive. Able to make simple needs known Skin is warm and dry, resp. are even and unlabored. INR (international normalized ratio) elevated, two old scabs/scars to left forearm appeared with small amount of serious drainage. Areas cleansed and skin care provided. No c/o (complaint of) increased pain or disc. Updated MD and new orders received to d/c (discontinue) [MEDICATION NAME] and repeat INR on [DATE]. Son updated via telephone, thankful for update. There is no evidence that Physician-JJJ was informed about the odor. Surveyor # asked RN-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. when he updated the physician on [DATE] if he informed the physician about the odor. RN-MMM informed Surveyor # that he doesn't recall if he spoke to the doctor about the odor and probably made an assumption that Administrator-A did because she was the one that was documenting odor. The skin assessment form dated [DATE] documents under treatment, Marathon to heel every 3 days. Under measurements documents, Length: 4.7 cm Width: 7.8 cm. Under description documents, Black eschar remains to left heel, firmly attached, no maceration noted to surrounding tissue. Area is starting to lift at the edges at 3 o'clock with intact skin under it. Under nurses notes document Area in the left heel remains, noted that the eschar is lifting at 3 o'clock with intact tissue showing under lifted area. Resident has an appointment with the wound clinic to see if area can be surgically debrided. Changed treatment to marathon due to lifting of the eschar and [MEDICATION NAME] no longer appropriate treatment. Resident does have an alternating air mattress in place as well as provolon boots to keep pressure of the heel. Resident does not wear shoes due to the area but wears the boots at all time. Plan of care reviewed and still appropriate will continue with current plan of care. Surveyor # noted the Marathon treatment started on [DATE]. The nurses note dated [DATE] documents, MD updated on left heel drainage and two old scabs to left forearm. NOR'd (new order received) for treatments prn (as needed). Resident is alert and verbally responsive. Skin is warm and dry, lotion applied to bilat. forearms. No current c/o increased pain or disc. (discomfort). The physician telephone order dated [DATE] documents, [MEDICATION NAME] heel to (L) heel change (triangle sign) PRN (as needed) Polymembrane #3 to (L) forearm scabs. Review of the February 2016 TAR (treatment administration record) documents, Apply marathon to left heel every 3 days Start Date [DATE]. Surveyor # noted initials on the TAR indicating that the treatment was done on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. On [DATE] treatment order was reprogrammed in the MAR (medication administration record) with a starting date of [DATE] and Apply Marathon to left heel every 3 days with X on the days the treatment should not be done. Review of the [DATE] TAR reveals that the treatment is not initialed on [DATE] as being done. On [DATE] at 7:36 a.m. and at 10:13 a.m. Surveyor # asked RN-MMM why the treatment for Marathon was rewritten on the February TAR. RN-MMM informed Surveyor # that it was initially programmed and that they were doing the treatment every day when it should have been every three days. RN-MMM informed Surveyor # that on [DATE] he noted that it was entered wrong and corrected it. The nurses note dated [DATE] documents, Resident out to wound clinic re: left heel scab cap. The nurses note dated [DATE] documents, Resident was transferred from SLMC (St. Luke's Medical Center) from the wound clinic. Resident admitted to SLMC for infected ulcer @ (at) 1815 (6:15 p.m.) Son _____ aware and was at the hospital with the resident. The social service note dated [DATE] documents, Son___ called this worker stating that resident was admitted to Zilber Hospice and will not be returning to this facility. On [DATE] at 11:08 a.m. Surveyor # spoke with FM (Family Member)-OOO on the telephone regarding Resident #24 and the complaint that was called into the Southeastern Regional Office. FM-OOO informed Surveyor # that they were not aware of the severity of the wound and that his sister had seen it and it looked like the heel of a piece of bread. FM-OOO stated that one day a nurse came in and felt the pressure injury and said it looks like it's all healed and then a week or so later there was an appointment to see a doctor. FM-OOO stated Resident #24 went to the Podiatrist and as soon as the Podiatrist saw it, he could feel the bone, said it was the worst pressure ulcer he had seen and that Resident #24 needed to go to the hospital. FM-OOO stated Resident #24 went to St. Luke's. FM-OOO stated that Resident #24 complained of soreness and staff said they were going to put a boot on. Surveyor # inquired if Resident #24 had a pressure relieving boot on before the pressure ulcer was identified. FM-OOO replied no and stated that the boot was kept on and that it never went away, they never took it off. FM-OOO informed Surveyor # that Resident #24 mention that his heel was very sore. FM-OOO stated that they would relay this to the nurse and caregiver. FM-OOO informed Surveyor # that he thought the issue was there wasn't enough follow through. FM-OOO stated My dad was old I get that. His comfort level could have been a lot different things fell through the cracks. He went to the hospital and passed away a week after, his comfort level is what bothers me. We were relying on opinions of someone that had the knowledge. On [DATE] at 12:55 p.m. Surveyor # spoke with Physician-LLL via the telephone regarding Resident #24. Physician-LLL informed Surveyor # that [DATE] was the first time that he had seen Resident #24 and that Resident #24 came from the nursing home with a CNA who had no idea what was going on. The CNA informed him that Resident #24 was here for his foot. Physician-LLL said he had no history to go on as the nursing home did not send anything and he couldn't get any information from Resident #24. Physician-LLL informed Surveyor # that when he examined Resident #24's left heel there was a pressure ulcer that was approximately 4 cm times 5 cm. It was necrotic, gangrenous, smelled really bad, the eschar was loose, there was an obvious infection and it was down to the bone. Physician-LLL informed Surveyor # that there was no real blood flow and it hurt Resident #24 when direct pressure was applied. Physician-LLL indicated that once the wound is infected it progressed very quickly. Physician-LLL stated that this was terrible and something had to be done right away so sent (sic) Resident #24 to the hospital. Surveyor # asked Physician-LLL if he followed Resident #24 in the hospital. Physician-LLL replied no and explained that Resident #24's primary physician informed him that Resident #24 was going hospice and there was nothing more for him to do. On [DATE] at 7:36 a.m. and at 10:13 a.m. Surveyor # interviewed RN (Registered Nurse)-MMM regarding Resident #24. Surveyor # asked RN-MMM if he took care of Resident #24 when he was at the Facility and if he did Resident #24's treatment. RN-MMM informed Surveyor # that he did. Surveyor # asked RN-MMM how he thought Resident #24 developed the pressure injury on his left heel. RN-MMM informed Surveyor # that Resident #24 came to the Facility with the heel scabbed over. Surveyor # informed RN-MMM that Resident #24 was admitted [DATE] and the pressure injury was identified on [DATE]. RN-MMM informed Surveyor # that the whole heel was scabbed over and the wound nurse told him to get a consult at one point because the scab was separating from the edges. Surveyor # asked RN-MMM when he speaks to a Resident's family member about a change in condition or treatment for a Resident does he document this in his nurses note. RN-MMM replied oh yes. Surveyor # asked RN-MMM if he would notify FM-OOO about Resident #24. RN-MMM informed Surveyor # that after he received an order from the doctor he would notify FM-OOO and that he had a good relationship with the family. Surveyor # informed RN-MMM that Surveyor # was investigating a complaint that FM-OOO was aware of the pressure injury but didn't know how bad it was. Surveyor # informed RN-MMM that while reviewing Resident #24's medical record when there was a change of treatment Surveyor # did not see that FM-OOO was always notified. Surveyor # informed RN-MMM that although Resident #24 had been his own person it was evident that the Facility was to contact FM-OOO as an identified interested party by the Resident. On [DATE] at 2:24 p.m. Surveyor # met with Administrator-A to discuss Resident #24's pressure injury. Surveyor # informed Administrator-A that Resident #24's interested family member was not notified when there was a change of treatment on [DATE], [DATE], & [DATE]. Administrator-A replied there seems to be a pattern. Surveyor # informed Administrator-A on [DATE] the nurse telephoned the doctor and left a message but does not know if the doctor called back or if there was any follow up. On [DATE], [DATE], [DATE], & [DATE] Resident #24's pressure injury presented with an odor but the Facility did not consult with the physician. Surveyor # asked Administrator-A when the nurses do a treatment do they also assess the pressure injury. Administrator-A informed Surveyor # that if there is a decline then they would tell the wound team and the wound team would look at it. Surveyor # informed Administrator-A that when the treatment was changed to Marathon on [DATE] every three days, staff was doing the treatment not according to physician order's as they were doing the treatment daily. Surveyor # asked Administrator-A for any information regarding Resident #24's physician being consulted and what the Facility did to prevent the pressure injury from declining. Surveyor # was not provided with any additional information from Administrator-A. On [DATE] Surveyor # reviewed Resident #24's hospital medical record. Physician-LLL's progress note dated [DATE] documents under objective: Gen. (general) appearance: This is a well developed [AGE] year old male. Integument (skin): There is a large open lesion on the posterior aspect of the left heel measuring approximately 4 cm x 5 cm. This is necrotic/gangrenous in nature. It is loose and the surrounding rim and there (sic)significant fibrotic tissue as well as necrosis and purulence. There is positive probe posterior calcaneal bone. There is significant malodor. There is pain on palpation to this area. Under assessment documents, 1. Decubitus ulcer of left heel, stage 4. 2. Acute osteo[DIAGNOSES REDACTED] of left foot. Under plan documents, Discussed in depth in detail with the patient condition as well as treatment options. At this time no debridement was performed in the office. The area was dressed utilizing [MEDICATION NAME] and gauze. At this time I am recommending admission to St. Luke's Hospital. At that point I would recommend IV (intravenous) antibiotics. I expect order x-rays, vascular studies, possible MRI (magnetic resonance imaging). Pending results of the testing I feel the patient will most likely benefit from a partial calcanectomy and debridement of this would. I expect to perform this procedure over the weekend or by Monday. I also feel the patient will most likely need a long inpatient stay and possible subacute rehabilitation. I did contact the hospitalist who initially accepted admission. I did then received a call stating that Physician-PPP would be the primary admitting physician as he is covering for Physician-JJJ and Physician-KKK. Contact St. Luke's for bed and was advised that all beds are currently full. Patient to be transferred to the ER (emergency room ) for evaluation and beginning of IV antibiotics. To be admitted via the ER. The facility's failure to consult with Resident #24's physician when changes in Resident #24's pressure injury developed created a situation of Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE] when the Facility provided education to the nursing staff on proper notification of physician and family with any significant change of condition, the Facility audited all resident with pressure injuries to validate that the proper notification was given to physicians and resident legal representatives or interested family members of those resident with change of condition related to pressure injury and DON (Director of Nursing) or designee will monitor compliance by reviewing the 24 hour board and nursing notes for 5 residents a week for 1 month and monthly for 3 months to assure that change of condition notifications are being done timely.

Based on observation, a complaint received at the Southeastern Regional Office, interview, and record review, the Facility did not provide the necessary care and services to promote healing of a pressure injury and preventing a pressure injury from developing for 8 (Resident #24, #13, #14, #2, #11, #6, #1 and #10) of 24 sampled Residents at risk for pressure injuries and 1 (Resident #35) of 30 supplemental sampled Residents. * Resident #24 was admitted to the facility on [DATE] from an assisted living facility for rehab without any pressure injuries. On [DATE] a ruptured blister was observed on Resident #24's left heel when his shoe was removed. Staff updated the care plan on [DATE] to include blue boots and air mattress. On [DATE] the Facility updated the care plan to include float heels, provide supplement & snacks, RN assessment weekly. This was the last change to the care plan regarding Resident #24's pressure injuries despite the fact that the pressure injury got larger, deteriorated in appearance, and developed an odor. . On [DATE] Resident #24's unstageable pressure injury measured 4.6 x 7.6 cm with no odor. Five days later on [DATE] the scab appeared to be coming off and the treatment was not done. The Facility did not consult with the physician that the treatment was not done. On [DATE], [DATE], [DATE] & [DATE] Resident #24's pressure injury presented with an odor but the Facility did not timely consult with the physician to obtain guidance for future care/treatment. On [DATE] Resident #24 saw the Physician-LLL, a podiatrist at a wound clinic. Physician-LLL noted a 4 x 5 necrotic heel with obvious signs of infection. The ulcer was gangrenous and Physician-LLL could feel the bone. Resident #24 was transferred to the hospital and was started on IV [MEDICATION NAME] for a stage 4 pressure injury with osteo[DIAGNOSES REDACTED]. Resident #24 was placed on hospice and died a week later on [DATE]. This created a finding of Immediate Jeopardy for Resident #24 beginning on [DATE]. Administrator-A, DON (Director of Nursing)-B and President-TT were informed of the Immediate Jeopardy and substandard level of care on [DATE] at 10:42 a.m. The Immediate Jeopardy was removed on [DATE] when the Facility implemented their action plan. The deficient practice continues at a scope and severity (s/s) of a G (actual harm/isolated) as evidenced by the following example for Resident #13. The additional 9 examples regarding Residents #14, #2, #11, #6, #1, #10, #31, #35, and #36 are examples at a scope/severity level 2: (potential for harm/pattern). * Resident #13 developed an avoidable, unstageable pressure area to the left posterior heel measuring 2.7 cm (centimeters) x (by) 2.2 cm x 0.2 cm, with a depressed center with 100% yellow slough and macerated yellow tissue to wound edge, noted foul odor and moderate amount of yellow serous drainage. Resident #13 was observed multiple days with his heels resting directly on the mattress, not wearing pressure relieving boots while in bed, and wearing shoes when Resident #13's care plan documents that Resident #13 should not wear shoes. Barrier cream was not applied after an incontinence episode and treatment observed was not completed according to physician's orders [REDACTED]. * Resident #14 was observed on [DATE] without a dressing on the left outer foot pressure injury, was not reposition for approximately five and a half hours on [DATE], and the treatment observed on [DATE] was not completed according to physician orders. * Resident #2 did not have barrier cream applied after an incontinence episode, heels were not floated, and was not repositioned. * Resident #11 was observed with his heels not being floated. * Resident #6 did not have barrier cream applied after an incontinence episode. * Resident #1 was observed with her heels not being floated and was not wearing blue pressure relieving boots. * Resident #10 was not repositioned for an extended period of time and was observed with his heels not being floated. * Resident #35 heels were not being floated. Findings include: 1.) Surveyor # reviewed Resident #24's closed medical record on [DATE] to [DATE]. Resident #24 was admitted on [DATE] from an assisted living facility for rehabilitation with [DIAGNOSES REDACTED]. Resident #24 was not admitted with pressure injuries. The Braden assessment dated [DATE] has a total score of 16. A score of 12 or less is high risk. The at risk for skin integrity care plan, not dated, has approaches dated [DATE] of Reposition in bed and in wheelchair, educate resident to reposition self frequently when in bed or w/c (wheelchair)., Skin assessment on shower/bath days., Monitor for s/sx (signs/symptoms) of skin breakdown, redness or irritation., and Update MD (medical doctor) and family with changes in skin appearance. Approaches dated [DATE] are Blue boots on. and Air Matt in place. Surveyor # noted there is not an approach to float Resident #24's heels. The admission MDS (minimum data set) with an assessment reference date of [DATE] and signed as complete on [DATE] documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. Resident #24 requires extensive assistance with bed mobility, transfers, does not ambulate, is frequently incontinent of urine and continent of bowel. Resident #24 is at risk for developing pressure injuries and currently does not have any pressure injuries. Under skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, and application of ointments/medications other than to feet are checked. The pressure ulcer CAA (care area assessment) dated [DATE] under care plan reasons documents, care plan to be in place to reduce risk factors associated with potential pressure ulcers/skin concerns, and monitor. Under description of problem documents, no skin concerns/pressure ulcers noted, but resident is at risk for area. Under causes and contributing factors documents, Dx (diagnosis) in place, MEDs in use, Inc. (incontinent) episodes, decreased mobility .see review of indicators. The nurses note dated [DATE] documents, @ (at) 2000 (8:00 p.m.), resident assisted to bed per CNA (Certified Nursing Assistant) and HS (hour sleep) cares were started. Upon removing resident's L (left) shoe and sock, an open area was noted. Team leader and writer notified. Area is a ruptured blister. Physician-JJJ not on call. Physician-NNN covering and was consulted. New orders received. Resident updated and aware. Writer did phone son and updated on the above. No concerns voiced. Heel boot and treatment performed. The skin assessment form dated [DATE] documents under description, ruptured blister, surrounding skin WNL (within normal limits). Measurements are documented as Length: 5.0 cm (centimeters) Width: 7.0 cm. The Braden assessment dated [DATE] has a total score of 17. A score of 12 or less is high risk. The nurses note dated [DATE] documents, Late entry for [DATE]: 3.5 cm (centimeter) x (by) 8.0 cm x 0.1 cm wound to left posterior heel assessed. Wound bed is 100% deep purple, dry. Scant amount of sanguineous drainage noted to old bandage. Mild odor Surrounding skin is loose and macerated from 0300 to 0800. Some [MEDICATION NAME] tissue growth noted from ,[DATE]. Wound was cleaned and dressed. Resident tolerated treatment well with mild discomfort noted. Will continue treatment for one week, then wound team to assess. The pressure ulcer care plan not dated has a goal of No s/s (signs symptoms) of infection will develop and wound to left heel will show evidence of healing with a goal date of [DATE]. Approaches dated [DATE] are Clean left heel with 0.9% sodium chloride. Pat dry. Apply [MEDICATION NAME] to eschar and leave open to air/ Preventative skin care measures to decrease pressure/irritation to skin: Air mattress, float heels, frequent repositioning/ Weekly RN (Registered Nurse) assessment and documentation to include: wound status, size and depth of wound/ Provide diet and snacks as recommended by dietician and per resident choice/ Monitor for signs symptoms of infection (odor, drainage, redness of surrounding tissue)/ Monitor reports of pain/discomfort--provide pain meds; monitor effectiveness. Offer and provide pain med prior to treatment/ and Provide supplements as ordered. Assess need for increase of protein and/or carbohydrate intake. Monitor & encourage food/fluid intake. Surveyor # noted there were no further revisions of Resident #24's care plan after the initial approaches dated [DATE] despite the fact that the pressure injury got larger, changed in appearance, and developed an odor. The quarterly MDS with an assessment reference date of [DATE] and signed as complete on [DATE] has a BIMS score of 15 which indicates cognitively intact. Resident #24 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, does not ambulate, is frequently incontinent of urine and always incontinent of bowel. Resident #24 is at risk for developing pressure ulcer and is coded as having one unstageable pressure injury. Under skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, and application of ointments/medications other than to feet are checked. The Braden assessment dated [DATE] has a total score of 15. A score of 12 or less is high risk. The nurses note dated [DATE] documents, Wound team assessed pressure area to left posterior heel. Unstageable pressure area remains with hard black eschar cap securely attached to wound bed. No drainage, redness, or odor. Surrounding skin intact, but dry. Recommend continuation of [MEDICATION NAME] treatment. Heels floated on pillow when in bed. Float heels when in Broda chair. Air mattress in place and functional. Wound to right buttock also assessed. Wound is incontinence associated [MEDICAL CONDITION]. Wound area is very moist at this time. Recommend change from Duoderm treatment to Calazinc cream after good pericare following episodes of incontinence. Resident tolerated treatment. The nurses note dated [DATE] documents, Unstageable pressure wound to left posterior heel was assessed by interdisciplinary wound team. Current measurement is 4.6 cm x 7.6 cm. Hard, black eschar cap remains. Cap is lifting from 1000 to 0200. Yellow slough visible under eschar cap. Maceration to periwound form 1000 to 0200. [MEDICATION NAME] treatment remains appropriate at this time. Right heel boggy. No open areas. Blanchable skin. Air mattress in place for pressure relief. Heels floated when in bed/chair. Resident receives supplemental nutrition for wound healing. Growth noted to right shoulder during assessment with sanguineous drainage. Area cleaned and staff nurse notified. The nurses note dated [DATE] documents, Black scab cap to left heel appears to be separating from wound edge, [MEDICATION NAME] not administered. Wound nurse aware, will update MD when wound treatment recommendation for fingers received from wound nurse. Pillow placed behind calves while in Broda chair, towel under feet per order. Surveyor # noted this is the first note documenting Resident #24's heel was being floated. Surveyor # interviewed RN (Registered Nurse)-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. about his [DATE] nurses note and asked why he didn't call the physician when the edges of wound were separating and he didn't complete the treatment as ordered. RN-MMM informed Surveyor # that typically they would get the recommendation from the wound nurse. RN-MMM indicated that he guessed he was waiting for the wound nurse to make her recommendation about Resident #24's fingers (refer to nurses note) and then would let the physician know to see if the recommendation was ok with the physician. Surveyor # asked RN-MMM if he recalled any odor. RN-MMM replied I don't know if I charted that. I honestly don't remember. The nurses note dated [DATE] documents, Resident is alert and oriented, able to make needs known. Pleasant and cooperative with staff. skin warm and dry, resp. (respirations) are even and unlabored. No c/o (complaint of) increase pain or disc (discomfort) to fingers. Areas appear free of s/s (signs/symptoms) infection. Indent still present, areas are dry. Wound nurse assessed fingers and felt it was best to leave them open to air. Fingers cleansed. Paged MD at 1400 (2:00 p.m.) to update. Awaiting call back. Surveyor # interviewed RN (Registered Nurse)-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. and asked if Resident #24's physician called back after the call at 2:00 p.m. on [DATE]. RN-MMM informed Surveyor # that he would have made a note if the doctor had called back. Surveyor # inquired if there was any follow up. RN-MMM explained that his shift is over at 2:30 p.m. and wasn't sure if there anyone followed up. RN-MMM informed Surveyor # that the wound team would assess the Resident's pressure injury once a week. Surveyor # inquired who the wound nurse is. RN-MMM informed Surveyor # that it was Administrator-A at the time but now it's DON (Director of Nursing)-B. The skin assessment form dated [DATE] documents under description, Black eschar remains to left heel, firmly attached, no maceration noted to surrounding tissue. Area is starting to lift at the edges some odor is noted while assessing the wound. The measurements are documented as Length: 4.6 cm Width 7.6 cm. Under nurses notes documents, Area remains with attached dry eschar, lifting on the top of the wound slightly, no drainage noted, had a mild odor when sock was removed, no sign of infection. Recommend changing treatment from [MEDICATION NAME] to marathon due to lifting of the cap. Will continue all other intervention. The date physician notified is documented as [DATE]. The Facility did not consult with Resident #24's physician about the odor which could signify the development of an infection. Surveyor # asked RN-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. if he notified Resident #24's physician about the odor that was documented in the nurse's note on [DATE]. RN-MMM reviewed this form and informed Surveyor # that Administrator-A wrote the note so she would have contacted the physician. The skin assessment form dated [DATE] documents under treatment, Wash with NS (normal saline), apply [MEDICATION NAME] to eschar daily. Under description documents, Black eschar remains to left heel, firmly attached, no maceration noted to surrounding tissue. Area is starting to lift at the edges some odor is noted while assessing the wound. The measurements are documented as Length 4.8 cm Width: 8.0 cm. Under nurses note documents, Black dry eschar remains on the left heel, edges area staring to lift at 12 o'clock to about 3 o'clock. Noted some bloody, brown small amount of drainage on dressing. Palpation of the wound noted some boggy feeling of the wound suspect that wound is not healing under the eschar tissue. Recommend sharp debridement of the wound to aid in wound healing. Surveyor # noted the treatment is incorrect on this skin assessment as the treatment was changed [DATE] to Marathon. The nurses note dated [DATE] documents, Resident alert and verbally responsive. Able to make simple needs known. Pleasant and cooperative with staff. Skin is warm and dry, resp (respirations) are even and unlabored. No noted increase confusion. Fluids encouraged and accepted. 1 x (times) loose stool, kept clean and dry, abd. (abdomen) is soft, non-tender with bowel sounds active in all 4 quad. (quadrants). Consulted Physician-JJJ re: black eschar heel. Order received for podiatrist Physician-LLL. There is no evidence that Physician-JJJ was informed about the odor. Surveyor # asked RN-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. if he informed Physician-JJJ about the odor on [DATE]. RN-MMM informed Surveyor # that he didn't recall and that he would have documented if he did. The skin assessment form dated [DATE] documents under treatment documents, Wash area, pat dry and apply Marathon. Under description Black eschar remains to left heel, detaching from upper part, no maceration noted to surrounding tissue. Area is starting to lift at the edges some odor is noted while assessing the wound. Order received for wound consult. The measurements are documented as Length: 4.8 cm Width: 8.0 cm. The date physician notified is documented as [DATE]. The nurses notes on the skin assessment form is blank. The nurses note dated [DATE] documents, Resident is alert and verbally responsive. Able to make simple needs known Skin is warm and dry, resp. are even and unlabored. INR (international normalized ratio) elevated, two old scabs/scars to left forearm appeared with small amount of serious drainage. Areas cleansed and skin care provided. No c/o (complaint of) increased pain or disc. Updated MD and new orders received to d/c (discontinue) [MEDICATION NAME] and repeat INR on [DATE]. Son updated via telephone, thankful for update. There is no evidence that Physician-JJJ was informed about the odor. Surveyor # asked RN-MMM on [DATE] at 7:36 a.m. and at 10:13 a.m. if he informed the physician about the odor when he updated the physician on [DATE]. RN-MMM informed Surveyor # that he doesn't recall if he spoke to the doctor about the odor and probably made an assumption that Administrator-A did because she was the one that was documenting odor. The skin assessment form dated [DATE] documents under treatment, Marathon to heel every 3 days. Under measurements documents, Length: 4.7 cm Width: 7.8 cm. Under description documents, Black eschar remains to left heel, firmly attached, no maceration noted to surrounding tissue. Area is starting to lift at the edges at 3 o'clock with intact skin under it. Under nurses notes document Area in the left heel remains, noted that the eschar is lifting at 3 o'clock with intact tissue showing under lifted area. Resident has an appointment with the wound clinic to see if area can be surgically debrided. Changed treatment to marathon due to lifting of the eschar and [MEDICATION NAME] no longer appropriate treatment. Resident does have an alternating air mattress in place as well as provolon boots to keep pressure of the heel. Resident does not wear shoes due to the area but wears the boots at all time. Plan of care reviewed and still appropriate will continue with current plan of care. Surveyor # noted the Marathon treatment started on [DATE]. The nurses note dated [DATE] documents, MD updated on left heel drainage and two old scabs to left forearm. NOR'd (new order received) for treatments prn (as needed). Resident is alert and verbally responsive. Skin is warm and dry, lotion applied to bilat. forearms. No current c/o increased pain or disc. (discomfort). The physician telephone order dated [DATE] documents, [MEDICATION NAME] heel to (L) heel change (triangle sign) PRN (as needed) Polymembrane #3 to (L) forearm scabs. Review of the February 2016 TAR (treatment administration record) documents, Apply marathon to left heel every 3 days Start Date [DATE]. Surveyor # noted initials on the TAR indicating that the treatment was done on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. On [DATE] treatment order was reprogrammed in the MAR (medication administration record) with a starting date of [DATE] and Apply Marathon to left heel every 3 days with X on the days the treatment should not be done. Review of the [DATE] TAR reveals that the treatment is not initialed on [DATE] as being done. On [DATE] at 7:36 a.m. and at 10:13 a.m. Surveyor # asked RN-MMM why the treatment for Marathon was rewritten on the February TAR. RN-MMM informed Surveyor # that it was initially programmed and that they were doing the treatment every day when it should have been every three days. RN-MMM informed Surveyor # that on [DATE] he noted that it was entered wrong and corrected it. The nurses note dated [DATE] documents, Resident out to wound clinic re: left heel scab cap. The nurses note dated [DATE] documents, Resident was transferred from SLMC (St. Luke's Medical Center) from the wound clinic. Resident admitted to SLMC for infected ulcer @ (at) 1815 (6:15 p.m.) Son _____ aware and was at the hospital with the resident. The social service note dated [DATE] documents, Son___ called this worker stating that resident was admitted to Zilber Hospice and will not be returning to this facility. On [DATE] at 11:08 a.m. Surveyor # spoke with FM (Family Member)-OOO on the telephone regarding Resident #24 and the complaint that was called into the Southeastern Regional Office. FM-OOO informed Surveyor # that they were not aware of the severity of the wound and that his sister had seen it and it looked like the heel of a piece of bread. FM-OOO stated that one day a nurse came in and felt the pressure injury and said it looks like it's all healed and then a week or so later there was an appointment to see a doctor. FM-OOO stated Resident #24 went to the Podiatrist and as soon as the Podiatrist saw it, he could feel the bone, said it was the worst pressure ulcer he had seen and that Resident #24 needed to go to the hospital. FM-OOO stated Resident #24 went to St. Luke's. FM-OOO stated that Resident #24 complained of soreness and staff said they were going to put a boot on. Surveyor # inquired if Resident #24 had a pressure relieving boot on before the pressure ulcer was identified. FM-OOO replied no and stated that the boot was kept on and that it never went away, they never took it off. FM-OOO informed Surveyor # that Resident #24 mention that his heel was very sore. FM-OOO stated that they would relay this to the nurse and caregiver. FM-OOO informed Surveyor # that he thought the issue was there wasn't enough follow through. FM-OOO stated My dad was old I get that. His comfort level could have been a lot different, things fell through the cracks. He went to the hospital and passed away a week after, his comfort level is what bothers me. We were relying on opinions of someone that had the knowledge. On [DATE] at 12:55 p.m. Surveyor # spoke with Physician-LLL via the telephone regarding Resident #24. Physician-LLL informed Surveyor # that [DATE] was the first time that he had seen Resident #24 and that Resident #24 came from the nursing home with a CNA who had no idea what was going on. The CNA informed him that Resident #24 was here for his foot. Physician-LLL said he had no history to go on as the nursing home did not send anything and he couldn't get any information from Resident #24. Physician-LLL informed Surveyor # that when he examined Resident #24's left heel there was a pressure ulcer that was approximately 4 cm times 5 cm. It was necrotic, gangrenous, smelled really bad, the eschar was loose, there was an obvious infection and it was down to the bone. Physician-LLL informed Surveyor # that there was no real blood flow and it hurt Resident #24 when direct pressure was applied. Physician-LLL indicated that once the wound is infected it progresses very quickly. Physician-LLL stated that this was terrible and something had to be done right away so sent (sic) Resident #24 to the hospital. Surveyor # asked Physician-LLL if he followed Resident #24 in the hospital. Physician-LLL replied no and explained that Resident #24's primary physician informed him that Resident #24 was going hospice and there was nothing more for him to do. On [DATE] at 7:36 a.m. and at 10:13 a.m. Surveyor # interviewed RN (Registered Nurse)-MMM regarding Resident #24. Surveyor # asked RN-MMM if he took care of Resident #24 when he was at the Facility and if he did Resident #24's treatment. RN-MMM informed Surveyor # that he did. Surveyor # asked RN-MMM how he thought Resident #24 developed the pressure injury on his left heel. RN-MMM informed Surveyor # that Resident #24 came to the Facility with the heel scabbed over. Surveyor # informed RN-MMM that Resident #24 was admitted [DATE] and the pressure injury as identified on [DATE]. RN-MMM informed Surveyor # that the whole heel was scabbed over and the wound nurse told him to get a consult at one point because the scab was separating from the edges. Surveyor # asked RN-MMM when he speaks to a Resident's family member about a change in condition or treatment for a Resident does he document this in his nurses note. RN-MMM replied, Oh yes. Surveyor # asked RN-MMM if he would notify FM-OOO about Resident #24. RN-MMM informed Surveyor # that after he received an order from the doctor he would notify FM-OOO, and that he had a good relationship with the family. Surveyor # informed RN-MMM that Surveyor # was investigating a complaint that FM-OOO was aware of the pressure injury but didn't know how bad it was. Surveyor # informed RN-MMM that while reviewing Resident #24's medical record when there was a change of treatment Surveyor # did not see that FM-OOO was always notified. Surveyor # informed RN-MMM that although Resident #24 had been his own person it was evident that was to contact FM-OOO as an identified interested party by the Resident. On [DATE] at 2:24 p.m. Surveyor # met with Administrator-A to discuss Resident #24's pressure injury. Surveyor # informed Administrator-A on [DATE] the nurse telephoned the doctor and left a message but does not know if the doctor called back or if there was any follow up. On [DATE], [DATE], [DATE], & [DATE] Resident #24's pressure injury presented with an odor but the Facility did not consult with the physician. Surveyor # asked Administrator-A when the nurses do a treatment do they also assess the pressure injury. Administrator-A informed Surveyor # that if there is a decline then they would tell the wound team and the wound team would look at it. Surveyor # informed Administrator-A that when the treatment was changed to Marathon on [DATE] every three days, staff was doing the treatment not according to physician order's as they were doing the treatment daily. On [DATE] Surveyor # reviewed Resident #24's hospital medical record. Physician-LLL progress note dated [DATE] documents under objective: Gen. (general) appearance: This is a well developed [AGE] year old male. Integument: There is a large open lesion on the posterior aspect of the left heel measuring approximately 4 cm x 5 cm. This is necrotic/gangrenous in nature. It is loose and the surrounding rim and there significant fibrotic tissue as well as necrosis and purulence. There is positive probe posterior calcaneal bone. There is significant malodor. There is pain on palpation to this area. Under assessment documents, 1. Decubitus ulcer of left heel, stage 4. 2. Acute osteo[DIAGNOSES REDACTED] of left foot. Under plan documents, Discussed in depth in detail with the patient condition as well as treatment options. At this time no debridement was performed in the office. The area was dressed utilizing [MEDICATION NAME] and gauze. At this time I am recommending admission to St. Luke's Hospital. At that point I would recommend IV (intravenous) antibiotics. I expect order x-rays, vascular studies, possible MRI (magnetic resonance imaging). Pending results of the testing I feel the patient will most likely benefit from a partial calcanectomy and debridement of this would. I expect to perform this procedure over the weekend or by Monday. I also feel the patient will most likely need a long inpatient stay and possible subacute rehabilitation. I did contact the hospitalist who initially accepted admission. I did then received a call stating that Physician-PPP would be the primary admitting physician as he is covering for Physician-JJJ and Physician-KKK. Contact St. Luke's for bed and was advised that all beds are currently full. Patient to be transferred to the ER (emergency room ) for evaluation and beginning of IV antibiotics. To be admitted via the ER. The ED (emergency department) provider notes dated [DATE] under physical exam documents: Large eschar formation to the left heel, approximately 4 x 3 cm, which is malodorous with purulent drainage. Bandage is saturated. Medications started in the emergency department include [MEDICATION NAME] 1,250 mg (milligrams) in sodium chloride 0.9% 250 mg IVPB (intravenous piggy back); [MEDICATION NAME]-tazobactam ([MEDICATION NAME]) 3.375 g (grams) in sodium chloride 0.9% 100 ml (milliliter) IVPB. The facility's failure to provide proper care and treatment to Resident #24's pressure injuries created a situation of Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE] when the Facility implemented their action plan to include: education was provided to nursing staff identifying changes in condition related to pressure injuries such as foul smelling odors, changes in wound bed such as increasing size, depth, diameter, color to report changes to the physician, responsible party, Director of Nursing and report on the 24 hour board for further monitoring. Residents with pressure injuries were reviewed for changes in their current wound conditions. Audited care plans & Resident Information Sheets related to pressure relieving measures. Validated that all pressure relieving measure were in place per plan of care. DON or designee will complete 5 audits to validate that all pressure relieving measures are in place per plan of care twice a week for four weeks and then the audits will be monthly for three months. The deficient practice continues at a scope and severity of G (actual harm/isolated) as evidenced by the following example for Resident #13. 2.) Surveyor # reviewed Resident #13's medical record on [DATE] to [DATE]. Resident #13's [DIAGNOSES REDACTED]. The at risk for impaired skin integrity care plan not dated documents approaches all dated [DATE] of Reposition in bed and in wheelchair, educate resident to reposition self frequently when in bed or in w/c (wheelchair)., Skin assessment on shower/bath days., Monitor for s/sx (signs/symptoms) of skin breakdown, redness, or irritation., and Update MD (medical doctor) and family with changes in skin appearance. Surveyor # noted this care plan does not address floating Resident #13's heels. The admission MDS (minimum data set) with an assessment reference date of [DATE] documents Resident #13 has short and long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #13 requires extensive assistance with two plus person physical assist for bed mobility, transfer, and toilet use, does not ambulate, is always incontinent of urine and frequently incontinent of bowel. Resident #13 is at risk for developing pressure injuries but currently does not have any pressure injuries. Under skin and ulcer treatment pressure reducing device for chair and pressure reducing device for bed are checked. The pressure ulcer CAA (care area assessment) dated [DATE] documents under description of problem at risk for pressure ulcers/skin concerns. and under causes and contributing factors documents weakness, decreased ROM (range of motion) with decreased mobility, Dx (diagnosis) in place, MED in use, Inc. (incontinent) episodes see review of indicators. The nurses note dated [DATE] documents, Small open area noted to site with green/yellow discol

Based on observation, interview and record review the facility did not ensure 6 (Residents #22, #1, #16, #2, #18, #13) of 24 sample residents and 5 supplemental residents (#45, 47, #48, #49 and #50), had an environment that was as free from hazards as possible. * On 3/3/16 Resident #22 was noted to have a fall. The facility's investigation concluded that on 3/3/16, Certified Nursing Assistant (CNA) - DD did not follow Resident #22's potential for fall care plan intervention dated 2/22/16, by using bilateral body pillows in place for fall prevention. On 3/12/16, Resident #22 was diagnosed with [REDACTED]. The fracture was determined to be a result of the 3/3/16 fall. * On 5/26/16 on the Skylight South Unit, the water temperatures were noted to be high in 2 bathroom sinks which had the potential to affect 8 residents (#1, #47, #48, #49, #6, #15, #45 and #50.) * On 5/15/16, Resident #1 was hit in the face with a mechanical lift during a transfer and no follow up with the staff was noted to prevent future incidents. * On 5/7/16, Resident #16 obtained a hematoma as a result of a leg being pinched during a transfer with a mechanical lift. A thorough investigation was not completed which would include obtaining information from the staff involved regard the surrounding circumstances regarding this incident to prevent future occurrences. * On 3/28/16, Resident #2 was hit in the head with a mechanical lift during a transfer and no facility follow-up was noted. * On 1/26/16, Resident #18 obtained a skin tear and an abrasion. The facility's investigation does not identify the other resident involved, any information on why this incident may have occurred, or any statements from staff to gather more information for follow-up prevention. *Resident #13 is at risk for falls and observation were made that body pillows and fall mats were not in place. Example #1 involving Resident #22 rises to a scope & severity level of a G (harm/isolated.) Findings include: 1. Surveyor # reviewed the facility's self- report investigation of a fracture and Resident #22's closed medical record on 5/30/16-6/1/16 as part of a complaint investigation. Resident #22 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #22's quarterly MDS (Minimum Data Set) with an assessment reference date of 12/30/15 indicates that resident requires extensive assist of 2 staff members for transfers, dressing, hygiene/bathing, and toileting. The MDS indicates that Resident #22's cognition is severely impaired. The MDS indicates that Resident #22 had no falls since prior MDS. Resident #22's falls care plan dated 2/22/16 indicates that Resident #22 is at risk for falls related to impaired mobility. Goal is: Resident #22 will remain free from injury. Approaches dated 2/22/16 include: PT/OT (physical therapy/occupational therapy) evaluation and treat as ordered, provide activities that minimize the potential for falls while providing diversion and distraction, floors free from spills or clutter, provide adequate and glare free lighting, personal items within reach, assist to wear non-skid footwear, bilateral body pillows. Additional approach on 3/7/16 includes bowel and bladder monitoring initiated to determine need for adjustment of toileting schedule. According to the facility self-report on 3/12/16 at 10:25 am, Resident #22's left knee was noted to have pain, swelling, and bruising and a mobile x-ray was ordered indicating a fracture. On 3/12/16 at 3:39 pm, Resident #22 was sent to the emergency room . Resident #22 returned the same day at 9:15 pm with orders to wear an immobilizer at all times to the left leg due to a femur fracture. An investigation was initiated and reported concluding that the fracture was a result of a recent fall. On 3/3/16 at 0430 the Interdisciplinary notes state, called to resident room per team leader. Resident observed sitting on floor next to bed. Incontinent of B&B (bowel & bladder) . Denies pain. 'Just get me up.' No apparent injury noted. ROM WNL (range of motion within normal limits). Resident assisted off of floor, incontinent cares provided per CNA (Certified Nursing Assistant). Resident #22 was assisted to bed by RN-CC and CNA-DD. Resident had been incontinent and cares were provided by CNA-DD. On 3/3/16 at 4:30 am, Resident #22, according to the Incident Report, was found kneeling next to bed with her head facing the head of bed, incontinence product off, Resident incontinent of bowel and bladder. Actions at time of Incident: RN called to room to assess. ROM normal, no injury noted. On 3/7/16 at 11:36 am, under the Investigation/Notes section RN-C writes, (this is in reference to the 3/3/16 fall) Resident was found on the floor next to her bed by care staff at 0430. She was previously visualized in bed sleeping at 0215. At the time of the incident, resident was incontinent of bowel and bladder and had removed her incontinence brief. Her call light was in reach but was not sounding at the time of the incident. Resident was assessed by the RN and no obvious sign of injury was noted. Neuro checks were initiated and WNL (within normal limits). ROM (range of motion) WNL for resident. VS (vital signs) WNL for resident. Resident was assisted off the floor per facility protocol. MD (Medical Doctor) and POA (Power of Attorney) were notified by staff of incident. No new orders were received. Bowel and Bladder monitoring tool initiated to evaluate resident's toileting schedule and need for adjustments. On 3/13/16, per the facility self-report, CNA-DD was questioned by NHA (Nursing Home Administrator)-A whether the body pillows were in place and CNA-DD indicated that they had not been in place. On 3/18/16 NHA-A provided education to CNA-DD on ensuring that resident's fall interventions are in place. On 5/31/16 at 10:55 am, Surveyor # spoke with NHA-A regarding clarification of the fall. NHA-A confirmed that Resident #22 was found on her knees and that RN-CC performed the assessment. NHA-A indicated that further investigation into the fall noted that CNA-DD did not follow the care plan and place body pillows as were indicated. Surveyor # noted that CNA-DD did not follow the At risk for falls related to impaired mobility care plan approach dated 2/22/16 which included the use of bilateral body pillows at the time of the 3/3/16 fall. On 3/12/16, Resident #22 was diagnosed with [REDACTED]. The fracture was determined to be a result of the 3/3/16 fall. On 6/2/16 Surveyor # shared with NHA-A the concerns with the self-report relating to the fall. No new information was provided. 2.) On 5/26/16 at 4:35 p.m., Surveyor # conducted a Resident room review for Resident's #1, #47, #48 and #49. The bathroom for the Resident's is an adjoining bathroom; the one bathroom serves Residents #1, #47, #48 and #49. The hot water at the bathroom sink was tested and observed to register at 130 degrees and hot to the touch. This posed a safety hazard for Resident's #1, #47, #48, and #49. Resident #1 and #47: According to Resident #1's annual Minimum Data Set (MDS) 12/10/15) Resident #1 is severely cognitively impaired. Resident #47 admission MDS with a reference date of 3/17/16 indicates Resident #47 is severely cognitively impaired and requires extensive assistance with ambulation, toilet use and personal hygiene. Resident #47 was observed ambulating around her room independently. Resident's #48 and #49: Resident #48's quarterly MDS with a reference date of 4/19/16 indicates Resident #48 has dementia and is severely cognitively impaired. Resident #48 requires extensive assistance with toilet use, and personal hygiene. Resident #48 requires extensive assistance with ambulation. Resident #49's admission MDS with a reference date of 4/8/16 indicates Resident #49 is severely cognitively impaired and has dementia. Resident #49 ambulates with limited assistance with 1, and requires extensive assistance with 1 for toilet use and personal hygiene. On 5/26/16 at 4:41 p.m., Surveyor # checked the hot water at the bathroom sink in the adjoining bathroom for Resident's #6, #15, #45 and #50. The hot water at the bathroom sink was tested and observed to register at 130 degrees and hot to the touch. This posed a safety hazard for Resident's #6, #15, #45 and #50. Resident's #6 and #15: According to Resident #6's quarterly MDS with a reference date of 5/4/16, Resident #6 has dementia, is severely cognitively impaired, ambulation did not occur and needs extensive assistance with toilet use, and personal hygiene. Resident #15's quarterly MDS indicates Resident #15 is cognitively moderately impaired, has Alzheimer's, limited walking with assistance and extensive assistance with toilet use and personal hygiene. Resident's #45 and #50: Resident #45's annual MDS with a reference date of 3/9/16 indicates Resident is severely cognitively impaired, has dementia and Alzheimer's. Resident #45 does not ambulate, requires extensive assistance of 1 for toilet use and personal hygiene. Resident #50's annual MDS with a reference date of 5/3/16 indicates Resident #50 is severely cognitively impaired, has Alzheimer's, dementia, is totally dependent on staff with toilet use and personal hygiene. On 5/26/16 at 4:48 p.m., Surveyor # informed President TT, who informed Vice President of Plant Operations UU. Shortly there after, Vice President of Plant Operations UU informed Surveyor # he had checked the hot water temperatures in these 2 Resident bathrooms and was getting reading such as 114-117 degrees. On 5/26/16 at 5:12 p.m. Surveyor # and Vice President of Plant Operations UU went up to these 2 bathrooms and using Surveyor's and Vice President of Plant Operations UU's thermometer the hot water tested at 120 degrees and then started to decline going down to 117 degrees. The water was hot when at 120 degrees. Vice President of Plant Operations UU stated he routinely takes water temps and that they tend to keep the water temps at 115 degrees. 3.) On 5/24/16 at 6:40 p.m., Surveyor # spoke to Resident #1's family member with Resident #1 present. During this conversation, Resident #1's family member stated that the Sunday prior to last Sunday, Resident #1 was crying because the Hoyer lift bar hit her hard in the face, hitting Resident #1's right cheek. Family member stated that Resident #1 reported that when this happened, the staff members looked at Resident and then started to laugh. Family member stated that the area was black and blue. Family member stated, I called the police. On 5/24/16 at approximately 7:36 p.m., Surveyor # interviewed RN RR regarding Resident #1 getting hit with the Hoyer Lift. RN RR stated that this was unintentional and resident sustained [REDACTED]. RN RR stated the Physician and Power of Attorney were notified. Surveyor # reviewed Resident #1's medical record from 5/23/16 through 5/26/16. The annual Minimum Data Set (MDS) with a reference date of 12/10/16, indicates Resident #1 has severe cognitive impairment, with no behavioral symptoms notes. The MDS also indicates Resident #1 requires total dependence with two staff assistance for transfers. The CNA current care sheet not dated, received on 5/24/16 indicates Resident #1 requires the use of a Hoyer lift and two staff assistance for transfers. Resident #1's medical record indicates under skin assessments: 5/15/16 6:00 p.m., Right cheek, small red area. MD/physician notified . 5/15/16 Right cheek- small area on check, MD/physician notified. The Interdisciplinary Notes dated 5/15/16 18:53 (6:53 p.m.) states, Writer was called to resident's room by CNA. The Hoyer had bumped resident in the face. Very small mark on side of fact to right cheek area. No complaints of pain. Resident stated she was OK . The Interdisciplinary Notes dated 5/16/16 11:28:22 (11:22 a.m.) states, R (right) cheek has non raised discolored area. The Interdisciplinary Notes dated 5/16/16 1:21 (1:21 p.m.) states, . Abrasion to right cheek with redness to bluish discoloration remained visible, no swelling noted. According to a witnessed incident report, on 5/15/16 at 1800 (6:00 p.m.) Resident #1 was bumped in the cheek with the Hoyer lift. Resident #1 did not complain of any pain. Resident #1 indicated she was O.K. Vital signs were taken and the supervisor notified. The resident's family member was notified as well as the primary care provider. CNA DD wrote a witness statement indicating that when putting Resident back into her wheelchair, the wheel was stuck on the Hoyer. As CNA DD was trying to get the wheel off of the Hoyer, it hit Resident in the face. I immediately got . to come and look at it. CNA QQ indicated that the wheelchair got stuck to the Hoyer .and bumped resident in the face .got nurse right away. The Skin Assessment Form dated 5/15/16 indicates that Resident #1 sustained a small read area on her cheek. While the incident was immediately reported and documented on, there is no indication as to any follow up on how CNA DD and CNA QQ used the Hoyer lift with Resident #1 to avoid future occurrences of Resident #1's wheelchair getting stuck again and to avoid Resident #1 getting hit in the face again with the Hoyer. On 5/25/16 at 8:45 a.m., Director of Nursing B informed Surveyor # that there had been a skills fair back in January 2016, which included the use of the Hoyer lift. Surveyor # noted that there was no follow up in regards to observing CNA DD and QQ as to how they were using the Hoyer lift on 5/15/16 and how to avoid future occurrences of Resident #1 getting hit with the Hoyer lift. On 5/25/16 at 3:15 p.m., Surveyor # asked Administrator A, Director of Nursing B and President TT, if there was any additional information regarding Resident #1 getting hit in the face with the Hoyer lift and if any follow up was done in regards to this incident. No further information was provided. 4.) Surveyor # reviewed Resident #16's medical record on 5/26 through 6/1/16. Resident #16's annual Minimum Data Set (MDS) with a reference date of 6/22/15 and a quarterly MDS indicates Resident #16 is cognitively intact, with no behavioral symptoms. Resident #16 transfers with extensive assistance with two staff. Resident #16's current Certified Nursing Assistant (CNA) care sheet, not dated, states, Hoyer Lift for transfers. According to an Incident Report dated 5/7/16, Resident #16 was being transferred from the commode to an electric recliner and controller was triggered during the transfer, pushing foot rest into resident's left leg, resulting in a hematoma. At the time of the incident, Resident was assessed, elevated leg, ice applied and prn analgesic was administered. The Incident Report indicated that the equipment was working fine and that the injury was a Hematoma left shin. Surveyor # asked Administrator A, Director of Nursing B and President TT, if there was any additional information regarding Resident #16's incident with the Hoyer lift as to whether there was any follow up with staff as to the circumstances surrounding this transfer, to avoid future potential occurrences. No further information was provided. 5.) Resident #2's medical record was reviewed by Surveyor # . Resident #2 was admitted to the facility on [DATE]. The most recent MDS (Minimum Data Set) assessment is a Significant Change in Status completed on 3/11/16. This assessment indicates that Resident #2 requires 2 staff for transfers. The CNA (Certified Nursing Assistant) plan of care dates 5/23/16 indicates Resident #2 needs 2 staff and a mechanical lift for transfers. Resident #2's Interdisciplinary Notes indicate that on 3/28/16 Resident #2 had a discoloration to their forehead from a Hoyer lift transfer. On 5/25/16 at 3:23 p.m. at the facility exit meeting Surveyor # requested additional information regarding Resident #2 being bumped in the head during a Hoyer lift transfer. On 5/26/16 at 7:39 a.m., Administrator-A provided Surveyor # with the facility investigation regarding Resident #2 on 3/28/16. The investigation description indicates the CNAs reported they bumped Resident #2's forehead on the mechanical lift during a transfer. The actions at the time include assessing Resident #2 and updating necessary parties. The follow-up summary, dated 4/4/16 indicates Resident #2 has some scratches now, however no ill effect from bumping his head. The investigation does not include any staff statements of exactly the cause of Resident #2 bumping his head on the lift. The investigation does not include any follow-up or interventions with staff, or the lift, on preventing this from occurring in the future. On 5/26/16 at 8:44 a.m., Surveyor # spoke with Administrator-A. Administrator-A indicated they had a all staff training in the beginning of the year. There was not staff training of lifts pertaining to this occurrence. There was not additional information documentation with this investigation. On 5/31/16 at 3:35 p.m. at the facility exit meeting Surveyor # shared Resident #2's investigation concerns. 6.) Resident #18's medical record was reviewed by Surveyor # . Resident #18 was readmitted to the facility on [DATE] and has a [DIAGNOSES REDACTED].#18's most recent MDS (Minimum Data Set) assessment is a Quarterly completed on 3/23/16. This assessment indicates Resident #18 has impaired cognition and requires staff assist for all activities of daily living. The Interdisciplinary Note dated 1/26/16 indicates another resident touched Resident #18's arm, Resident #18 then jerked their arm away, which resulted in 4 skin tears and an abrasion. The other resident was transported to the dining room and Resident #18 refused any first aid at that time. No other information as to why this occurred was documented in the medical record. On 5/31/16 at 11:30 a.m., Surveyor # requested the facility investigation for Resident #18 skin tears from Administrator-A. This was received and reviewed. The facility investigation indicates that Resident #18 was at the nurses station when another resident touched their arm. Resident #18 jerked their arm away, which resulted in 4 skin tears and an abrasion. The investigation does not identify the other resident, any information on why it occurred, any statements to gather more information and follow-up prevention. On 5/31/16 at 12:54 p.m., Surveyor # spoke with Administrator-A. Administrator-A did not have any additional documentation pertaining to the investigation. Administrator-A believes the other resident involved also had dementia. Administrator-A indicated that both residents have dementia and does not know any more details about the occurrence. On 5/31/16 at 1:16 p.m. Surveyor # spoke with LPN-E (Licensed Practical Nurse) who was the day shift nurse on 1/26/16. LPN-E indicated they saw the interaction out of the corner of their eye. The other resident had dementia and ambulated around the unit. LPN-E saw Resident #18 jerk their arm and nobody else was around. This occurred during shift change and the evening nurse followed-up on it. LPN-E did not actually see what led up to the interaction, nor any other involvement. On 5/31/16 at 2:34 p.m., Surveyor # spoke with LPN-D who worked the evening shift on 1/26/16. LPN-D indicated they saw the tail end of the interaction. LPN-D stated, they both had dementia and nobody else was around. LPN-D did not actually see what led up to the occurrence, nor ask any staff on the unit if they saw or heard anything. LPN-D indicated the other resident's nails were trimmed already. LPN-D indicated there was no other people around at the time of the occurrence and they did not obtain statements. LPN-D indicated they fill out the report and let the Nurse Manager know. LPN-D indicated there were no other occurrences the rest of the shift. The Nurse Manager from 1/26/16 no longer is at the facility. On 5/31/16 at 3:35 p.m. at the facility exit meeting Surveyor # shared concerns with the completed investigation from 1/26/16 regarding Resident #18's skin tears. 7.) Surveyor # reviewed Resident #13's medical record on 5/23/16 to 5/26/16. Resident #13's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an assessment reference date of 4/20/16 and signed as complete on 4/22/16 documents that Resident #13 has short & long term memory problems and is moderately impaired for cognitive skills for daily decision making. Resident #13 requires extensive with two plus person physical assist for bed mobility, toilet use, & transfers and does not ambulate. Resident #13 is coded as having two falls with no injury since prior assessment. The Resident Information Sheet dated 5/23/16 under the section additional information documents, HIGH FALL RISK--keep bed in low position, wheels locked. Non-skid footwear. BODY PILLOW to left side when in bed. Encourage to be in common area when up in wc (wheelchair). On 5/23/16 at 10:40 a.m. Surveyor # observed Resident #13 in bed on his back with the head of the bed up. Surveyor # observed there is a body pillow along the left side of Resident #13 and a mat on the floor on the left side. Surveyor # observed there is not a mat on the right side and the mat is folded next to the chair. On 5/23/16 at 11:35 a.m. Surveyor # observed Resident #13 continues to be in bed on back with the body pillow along the left side and the floor mat on the left side. Surveyor # observed there is not a mat on the right side and the mat continues to be folded up by the chair. On 5/24/16 at 4:06 a.m. Surveyor # observed Resident #13 awake in bed on his back. Surveyor # observed that today there is a mat on the floor on each side of Resident #13's bed and there is a body pillow along Resident #13's left side. On 5/24/16 at 6:10 a.m. Surveyor # asked CNA (Certified Nursing Assistant)-G if Resident #13 can turn himself in bed. CNA-G explained that she doesn't know Resident #13 very well but he's a fall risk so she thinks that Resident #13 can turn himself and that's why he has mats on the floor. On 5/26/16 at 7:35 a.m. Surveyor # observed Resident #13 asleep in bed on his back. Surveyor # observed there is a mat on the floor along the right side but the left side does not have a mat on the floor. Surveyor # did observe the body pillow along Resident #13's left side. On 5/26/16 at 8:16 a.m. Surveyor # observed Resident #13 continues to be in bed on his back. Surveyor # observed there is still not a mat on the floor on the left side and the body pillow is now on the floor. On 5/26/16 at 8:20 a.m. Surveyor # observed Resident #13 has his left leg over the edge of the bed and then moved his leg back. Surveyor # observed there is not a mat on the left side and the body pillow is on the floor. On 5/26/16 at 8:22 a.m. Surveyor # asked LPN (Licensed Practical Nurse)-E to accompany Surveyor # to Resident #13's room. Surveyor # explained to LPN-E that Resident #13 had been moving his leg over the edge of the bed, there hasn't been a mat on the left side this morning and the body pillow is on the floor. LPN-E thanked Surveyor # , placed the body pillow back on Resident #13's left side and placed the mat on the floor on the left side. On 5/26/16 at 3:20 p.m. during the daily exit conference Administrator-A, DON (Director of Nursing)-B, and President-TT were informed of the above.

Based on record review and interview, the facility did not ensure that 1 out of 4 residents (Resident #6) reviewed at risk for pressure ulcers received the necessary care and services to promote the healing of pressure ulcers that were present and prevent the development of additional pressure ulcers. * The facility failed to conduct Braden Risk assessments as identified on the plan of care and update the plan of care to reflect approaches to minimize risk factors; * On 12/16/15, the facility failed to recognize a deep tissue injury and other skin breakdown located on the coccyx/sacral area as pressure ulcers. Instead these areas were addressed as non-pressure and abraded areas in documentation and not initially followed by the Wound Certified Nurse or Wound team. * On 12/21/15 the Wound Certified Registered Nurse (WCC) examined the resident and did not address the skin breakdown areas to Resident's left heel side blister, buttocks or coccyx (tailbone) areas of skin alteration. The right heel blister is addressed as a non-pressure area. * On 12/23/15, this abraded area to the coccyx/sacrum was determined to have gotten bigger with changes to the wound bed and foul odor. No action was taken at this time by the physician, the wound nurse or the wound team. * On 12/27/15, the skin alteration to the buttocks and tailbone area continued to show signs of deterioration. There is no assessment of this by the physician, wound nurse or wound team and no treatment change is put in place to address the wound bed now having yellow slough. * On 12/30/15, the skin alteration to the buttocks and tailbone area continued to show signs of deterioration, now black in color and foul odor. The measurements of this area had gotten bigger in size. There is no evidence the wound nurse or physician evaluated the deterioration of this wound. * On 1/6/16, the wound deteriorated again, with a larger size, odor, color changes. No wound nurse or physician consultation occurred. * On 1/8/16, a different wound certified nurse, the Director of Nursing (DON), was summoned to evaluate the wound by a LPN (Licensed Practical Nurse). On 1/8/16, the wound was now properly categorized and assessed. The physician was also updated. On 1/11/16, new wound orders were put in place to clean the wound. On 1/20/16, Resident #6 was admitted to the hospital with [REDACTED]. The failure of the facility to take proper action in identifying a pressure ulcer vs. a non-pressure ulcer, and consult with the physician when a skin alteration became worse and properly document complete assessments led to a finding of immediate jeopardy, that began when the coccyx/sacral wound showed rapid deterioration on 12/23/15 and was not addressed until 1/8/16. The facility Administrator-A was notified of the immediate jeopardy at F314 on 2/25/16. The facility took corrective action on 1/27/16 when the issue became an allegation of neglect, evaluated the situation and identified internal needs for correction. A facility plan of action was put in place and the Immediate Jeopardy was removed and the deficiency corrected on 2/1/16. This is being cited as past noncompliance. Findings include: Resident #6 was originally admitted to the facility in 2013. A plan of care for resident #6, with a start date of 5/13/15, indicates that Resident is at risk for impaired skin integrity related to history of surgical incision. The goal is that resident's skin will remain intact and free from breakdown. The last Full Minimum Data Set (MDS) screen is dated 5/18/15. The MDS identifies resident as requiring extensive assistance with 2 people for bed mobility, toilet use and transfers. This MDS indicates resident to have no limitations in range of motion and uses a wheelchair, and is frequently incontinent of bladder and bowel. This MDS identifies resident as having no pain. This MDS identifies Resident #6 as being at risk for developing pressure ulcers. The 5/18/15 MDS identifies resident as not having any unhealed pressure ulcers stage 1 or higher. The 5/18/15 MDS indicates no venous and arterial ulcers. The MDS indicates resident having a pressure reducing device for chair and for bed. Section M1200 does not identify resident as having a turning/repositioning program or nutrition/hydration intervention to manage skin problems. Approaches on the plan of care listed with dates of 5/26/15 indicate: -Complete Braden Scale on Admission X 4 weeks, quarterly, annually, and with significant change of condition; -provide pressure relief devices to bed and w/c, air mattress in place for pressure relief, pressure relief cushion noted to w/c; -reposition every 2 hours and encourage resident to make changes in own body position as able; -provide toileting and/or incontinent cares; -administer medications/supplements as ordered; -monitor skin weekly on shower/bath day and report concerns to nurse; -request therapy screen with change in mobility. Resident #6 was readmitted to the facility from the hospital on [DATE] after a 4 day stay for an Acute Urinary Tract Infection and Generalized Weakness. Resident's chronic problems and [DIAGNOSES REDACTED]. On 6/11/15, resident hospital weight was 180 pounds. On 6/15/15, her hospital discharge weight was 175 pounds. On 6/15/15, her discharge skin assessment from the hospital indicated resident's skin to be warm and dry without rash. There is no mention of any skin breakdown. On 6/15/15, the nursing admission notes identify resident having an intact blister to the right heel. This admission note also identifies scarred area noted right upper buttock, but no measurement or other description. The admission nursing progress note also identifies resident have 2+ [MEDICAL CONDITION] to both lower extremities and resident continuing to wear [MEDICATION NAME] to bilateral lower extremities. On 6/15/15, there is documentation of physician notification of the heel blister. Physician orders [REDACTED]. * may follow wound care Policy/Protocol * document in AOD (Answers on Demand charting) skin assessment and measurements of non-pressure wounds every Wednesday * Blue Boots on when in bed for skin protection. On 6/15/15, (following hospitalization ) a new approach was added to this plan of care. Resident to utilize blue pressure reducing boots while in bed was added to the plan of care. On 6/25/15 the hardened blister to the right heel with skin prep applied per orders and heels off loaded are documented in the nursing notes. Resident had BRADEN SCALES FOR PREDICTING PRESSURE SORE RISK score of 18 on 6/25/15. A score of 12 or less is considered to be at risk for pressure ulcer development. The plan of care indicates Braden Risk assessments should be completed weekly X 4 following admission, quarterly, annually and with significant changes in condition. There is no evidence of Braden Risk Assessments were completed weekly four times following admission. The next Braden scales, completed 7/9/15 and 7/16/15 showed scores of 16 and 15 respectively. On 7/27/15, a podiatrist examined resident. The podiatrist addresses resident with pleasant disposition, alert and oriented to name, location and time. The resident presented with generalized lower extremity pain of unknown duration, radiating proximally with applied pressure and activity. The discomfort is alleviated by rest. The podiatrist addressed resident having significant evidence of peripheral arterial insufficiency which warrants further diagnostic evaluation. A Doppler lab was ordered on [DATE]. The podiatrist evaluation indicates the patient presenting with signs and symptoms of [MEDICAL CONDITION]/PAD. The podiatrist recommends weekly skin checks for tissue breakdown at shower time and keeping the feet covered or in socks. Physician order [REDACTED]. Nursing progress notes, MD notes and orders, and Nurse practitioner notes and orders from 10/30/15-1/20/16 indicate the following. On 10/30/15, the plan of care was updated regarding a scratch on the left buttock, cleanse with normal saline, pat dry, apply TAO (triple antibiotic ointment) and cover with Allevyn. Change daily X 14 days. This issue was documented as resolved on 1/11/16. On 11/21/15 at 1:57 PM, there is documentation that the MD was spoken to about an area to the right outer heel. The MD was in agreement with the wound team recommendations. On 11/21/15, a telephone order was obtained to apply skin prep twice daily to the outer callous of the right outer heel for protection. On 11/22/15 at 3:53 AM there is documentation that resident has no complaints of pain or discomfort related to the abrasions on the buttock area. On 11/22/15 at 10:13 PM there is documentation of an open area to the right buttock being monitored. Calazine cream was applied. No complaints of pain to the affected area. On 11/22/15, Resident was to be provided MED PASS supplement at med pass three times a day. On 11/23/15 at 6:57 AM there is documentation of no change in the abrasion, no complaints of pain or discomfort. On 11/23/15 at 10:22 PM, the MD was updated of the abraded area to the right buttock and ordered the area to be cleaned with NS (normal saline), apply TAO (triple antibiotic ointment), cover with Duoderm every 72 hours X 14 days or until healed. Skin tab was made at time of s/t (skin tear). Ordered and FAXED. No pain to area. Patient did not wish to have treatment done this evening as she stated she was too tired and wished to continue to sleep. On 11/24/15 a new treatment was added to the treatment record for Abraded area to right buttock, cleanse with NS, apply TAO and cover with Duoderm once every 3 days X 14 days. There is no Skin Assessment Form completed for this area, no measurements or other description of this abraded area. On 11/24/15, a new approach was added to the plan of care to apply skin prep twice daily for protection to the right heel and to apply Duoderm to the right and left buttock and change every 3 days. On 11/25/15 at 6:50 AM documentation that Duoderm intact to buttocks, no signs or symptoms of infection noted. The facility provided no evidence that Skin Assessment Forms were being completed for the month of November, 2015, with descriptions of these skin alterations that would include measurements of these alterations. The 6/15/15 physician orders [REDACTED]. There is no evidence of any measurements of any of these skin alterations in November. There is no nursing note documentation between 11/25/15 and 12/11/15. On 12/3/15, Nurse Practitioner-C documents a visit with resident .no concerns from patient or staff today. The extremities were addressed as no [MEDICAL CONDITION], pedal pulses present. On 12/8/15, Nurse Practitioner-C indicates resident having a low H & H (hemoglobin/hematocrit-a measure of blood cells that bring [MEDICATION NAME] blood to vital organs), feeling weak and tired. Plan is to start iron and get stool occult (a test to detect internal bleeding). General appearance is deconditioned and confused. Extremities described as no [MEDICAL CONDITION], pedal pulses present. There is no documentation of any other skin abnormalities. On 12/10/15, Nurse Practitioner - C sees the resident. There is no documentation that the resident's skin was assessed or addressed. 12/11/15 - 12/14/15 all documentation related to [MEDICATION NAME] and tolerance to medications. No documentation of skin alterations or anything skin or pain related during this time is recorded in nursing progress notes. On 12/14/15, the dietitian assessment indicated resident's decline noted in November with caretracker documentation showing meal intakes averaging 54 % and 17% meal refusals. Med Pass supplementation was added on 11/22/15 due to family requests. Resident weight had declined to 164 pounds. Resident was also receiving diuretics and had been found with elevated TSH levels that may be contributing to weight fluctuations. Resident was noted with a low [MEDICATION NAME] (2.6) and total protein (5.0) on lab draws of 12/8/16. On 12/16/15, Resident current treatment to coccyx was discontinued and a new treatment was started to the Coccyx to cleanse with normal saline, pat dry, apply unasep gel followed by Allevyn every other day. On 12/16/15: Nurse practitioner documentation. Abraded area to right buttock, cleanse with normal saline and cover with Duoderm once every 3 days. 12/21/15 - no complaints of pain from blister area, area intact at this time, heel boots in place. 12/21/15 - Registered Nurse, Wound Certified Nurse-H - writer in to assess left heel blister, site noted to be on resident's right heel in which we are following on non-pressure wound rounds. Treatment in place consisting of skin prep every shift. MD and family aware of site and are in agreement with current treatment. Will d/c (discontinue) from report. 12/21/15 - Nurse practitioner and son (name) updated about the left medial side heel blister. On 12/21/15, Nurse Practitioner-E [MEDICATION NAME] resident. This nurse practitioner documents resident seen resting in bed and states that she is doing okay. Resident reports she has a sore on her foot that is causing her discomfort. The patient is moaning. Per nursing, the blister is approximately 2 cm with no signs or symptoms of infection. The assessment and plan on this note identifies the left medial blister and to keep covered and monitor, float leg. 12/21/15 - Dietitian note .monthly weight loss of 164.4 pounds reflects significant weight losses at 1 month (-6.8%), 3 months (-10.9%) and 6 months (-11.6%). Weight losses due to decreased intakes, diuretics and possibly due to elevated TSH levels. [MEDICATION NAME] dose was changed and iron was ordered as resident has had [MEDICAL CONDITION]. New heel blister was noted by nursing. Will continue to monitor and follow up as needed. 12/22/15 - Resident had BRADEN SCALES FOR PREDICTING PRESSURE SORE RISK score of 15. A score of 12 or less is considered to be at risk for pressure ulcer development. 12/22/15 - Licensed Practical Nurse (LPN)-I documents resident slept well, no signs/symptoms of discomfort noted, blister to left heel remained intact, skin prep applied, blue boots in place. No signs/symptoms of infection to area of blister. 12/23/15 - sleeping quietly, no complaints of signs/symptoms of pain or discomfort noted. Cooperative with cares. Blue boots in place, blister filled with fluids to left heel remained intact, skin prep applied, no signs/symptoms of infection noted. 12/23/15 - Fluid intact blister remains to left inner heel. Denies pain/discomfort. No s/s (signs/symptoms) of infection. Blue boots present. Pleasant and cooperative. T 97.2. 12/23/15 - skin prep order to the left heel every shift obtained, treatment done. No complaints of pain. Orders also indicate to monitor for signs and symptoms of infection. 12/23/15 - A Skin Assessment form for a non-pressure skin alteration, completed by LPN-I, indicates the coccyx to have a white wound bed with slight pinkness, a strong foul odor and moderate clear drainage. The surrounding skin is described as macerated and the measurements of this area are 2.0cm X 2.0cm. There is no evidence this change in the wound status of having a white center and foul odor was reported to the physician or to the wound nurse for evaluation. There is no treatment change at this time. 12/24/15 - slept well, no signs/symptoms of pain or discomfort. Blister remained intact, skin prep applied, blue boots in place. 12/24/15 - treatment done as ordered to left heel. Blister remains intact with moderate of fluid. No signs/symptoms of infection. Pleasant and cooperative. Temp 97.0. 12/24/15 - 12/27/15. Documentation each day indicates the fluid filled blister remains intact to left inner heel. No complaints of pain or discomfort. 12/27/15 - Registered Nurse - J documents that a dressing to coccyx was missing this shift. CNA (nurse's aide) notified writer of this. Area to coccyx shows yellow slough wound bed, approximately 1.8 cm X 1.0 cm. Periwound is [DIAGNOSES REDACTED]tous, scant serous drainage. No odor noted. Area again cleansed with NS, [MEDICATION NAME] (antimicrobial wound gel) applied and covered with Allevyn. BLE (bilateral lower extremities) warm to touch, 2+ [MEDICAL CONDITION], left lower extremity more than right lower extremity. Blue boots on in bed. There is no evidence the change of this wound was reported to the physician or to the wound certified nurse or wound team for evaluation now that the wound bed has yellow slough. 12/28/15- blister to left heel remains, no pain, no bleeding, no signs/symptoms of infection. Will continue monitoring. 12/28/15 - blister remains to left heel. No drainage noted. No complaints of pain/discomfort. On 12/28/15, a new approach was added to this plan of care to apply skin prep to left heel every shift for protection of intact blister. 12/29/15- blister remains to left heel, no complaints of pain, no signs of infection/drainage noted. 12/29/15- resident alert denies any complaints of pain or discomfort at this time, resident has blister to left heel intact with no drainage noted will monitor. 12/30/15 - skin intact to left heel blister. No complaints of pain. No signs of infection noted. 12/30/15 - left heel blister deflated. Area hard to site. No signs/symptoms of infection. Peri wound wnl (within normal limits). Observed heels floating while in bed. Denies pain/discomfort. Pleasant and cooperative. 12/30/15 - blister to left heel remains, no pain, no bleeding, no signs/symptoms of infection, will continue monitoring. 12/30/15 - a Skin assessment form completed by LPN-I documents a description of the coccyx wound to now be larger in size of 2.5 cm X 4.0 cm. The wound is described now as having a white wound bed and black discoloration with foul odor. There is no evidence of physician consultation or an assessment by the wound certified nurse or the wound team. 1/6/16 - Care Plan conference meeting held. Resident's spouse and 2 sons were present at the care plan meeting held on today's date. There is no documentation that Resident's wound status was discussed at this care conference. 1/6/16 - Dietitian-G documents that monthly weight is pending, but last weight of 173.8 pounds reflected a 9 pound gain in 2 weeks which was desired and overall loss of 6.5 pounds in 6 months. On 1/6/16, LPN-I documents that the coccyx wound has increased in size to 3.5cm X 6.5cm, has odor, is dark tan in color covering 75% of the wound base. Outer area noted with pinkness surrounding the center. Area noted with macerations throughout site and foul odor is noted. There is no indication the physician was consulted for treatment change or there was additional assessment by a wound certified nurse or the wound team for treatment change. On 1/8/16 at 2:17 PM, the DON, who is wound certified, documented the condition of the wound. The wound is now being categorized as a pressure ulcer and partial-thickness wound. The DON indicates on the Skin Assessment Form that the pressure area 100% covered with soft grey/black necrotic tissue, even with skin surface, edges well defined, surrounding skin normal color. The wound measures 3.5cm X 6.5 cm with undermining wound edges, necrotic/eschar, purulent drainage, unstageable slough and or eschar. There is now documentation that the physician was notified on 1/8/16 at 1:00 PM. A narrative nursing note completed by the DON indicates resident with medical [DIAGNOSES REDACTED]. Resident (name) is incontinent of bowel and bladder and wears incontinent brief. Resident (name) is dependent on staff for ADL's (activities of daily living) and positioning. She likes to stay up during the day in her w/c (wheelchair) and does not like to lay on her side in bed. She has a w/c cushion in place as well as an air relief pressure mattress. Wound assessed by writer and new order recommended to help debride necrotic tissue. Will continue with current interventions and re-eval area on a weekly basis. On 1/8/16, Physician-D examined resident and describes resident seen in bed sleeping, responds to touch on shoulder and awakes. Patient states that she is doing okay. The physician documents resident having a left medial blister with plan to keep covered and monitor, float leg and addresses resident's [MEDICAL CONDITION]. There is no documentation or mention of any other skin problems. The coccyx and sacral skin breakdown did not get documented as addressed by the physician. On 1/8/16, Resident's current treatment to the coccyx site was changed to Cleanse with normal saline, pat dry, followed by Dakin's solution 1/8 strength three times a day followed by a dry dressing, secure with tape. There is evidence that a new treatment order is now in place on 1/8/16 to apply Dakin's solution, 1/8 strength and cover with ABD (abdominal) pad dressing every day. On 1/11/16, a new approach was added to the plan of care to cleanse the coccyx wound with normal saline, pat dry, cleanse with Dakin's 1/8 str solution and cover with dry dressing three times a day. This is 3 days after the wound was assessed as a pressure ulcer by a Wound certified nurse. On 1/12/16, the Nurse Practitioner-C examined the resident .The husband verbalized concern with resident's increased pain, especially during turning and repositioning. The plan was to start resident on a [MEDICATION NAME]. The only mention of any alteration in skin by this nurse practitioner was resident's extremities having no [MEDICAL CONDITION], pedal pulses present, open sore on left medial heel with bandage c/d/i and Hose on Bilateral lower extremities. There is no mention of resident's ulcer on the coccyx/sacrum by this nurse practitioner. 1/13/16 - Treatment completed to coccyx. Wound bed yellow slough, small amount of sanguineous drainage; wound edges are irregular and surrounding skin [DIAGNOSES REDACTED]tous. Cleansed and debridement solution applied. On 1/14/16, the January treatment record lists a nursing approach to validate air mattress is plugged in every shift. There is no other documentation to indicate why this approach was needed. There is no known incident of problems with the air mattress and there is no nursing documentation in the nurses' notes of problems with the air mattress. The facility investigation into the wound care concerns did not address this problem. On 1/15/16 at 10:43 AM, a Skin Assessment Form is documented by Registered Nurse, Wound Certified Nurse-H, for Partial thickness Wound with treatment of [REDACTED]. Description of the coccyx wound is coccyx wound remains 100% covered with soft grey/black necrotic tissue. Wound base is even with edges surrounding skin normal color. The measurements of this wound are documented as 3.5 CM X 3.5 CM with no depth documented. The wound edge is irregular in shape with undermining. Necrotic and Eschar, purulent drainage that is light. The stage is unstageable slough and eschar. Additional nurse's notes indicate writer in to assess resident for weekly pressure rounds. Resident is alert and oriented times 1-2. Able to make needs known to staff. Resident is incontinent of bowel and bladder and utilizes attends. Resident requires assist of one for all cares with two with the Hoyer for transfers. Resident has recently had a weight loss and receives a supplement. Resident eats meals in the Elizabeth room and requires re-direction at times. Resident has [DIAGNOSES REDACTED]. Resident is up daily in w/c (wheelchair). Pressure relieving cushion is in w/c. Resident is offered to lay down after meals however refuses at times. Air mattress in place to bed for pressure relief. Resident is turned and repositioned with the assist of pillows by staff. Wound is irregular in shape, site measures in it's entirety 7.5 X 5.0, center of the wound measures 3.5 X 3.5 and consists of thick firmly adhered grey/black eschar surrounding tissue presents as pink granulation tissue. No foul odor noted at this time. Small amount of drainage noted to previous dressing. Scant amount of bleeding noted during dressing change. No c/o pain noted at this time, will monitor. On 1/18/16 a new order was received by the Nurse Practitioner-C to discontinue current treatment to buttocks and start after normal saline wash, pat dry. Apply Santyl ointment to necrotic tissue, cover with Allevyn, change daily and prn if soiled. On 1/18/16 a new order was received for resident to be up for meals only. 1/19/16 - Nurse Practitioner- C saw resident. Resident's extremities were described as no [MEDICAL CONDITION], pedal pulses present. Open sore to left medical heel with bandage that is c/d/i (clean, dry, intact). Hose on BLE (bilateral lower extremities). Pain is 0. The Nurse Practitioner assessment does not speak to any decubitus ulcers or other alterations in the skin condition, but does address resident's [MEDICAL CONDITION], pain problem with use of a [MEDICATION NAME], but not addressing what pain is from, and the resident's current problem with a high sodium level and current IV therapy and monitoring of resident's sodium. On 1/19/16, IV orders for elevated sodium level was ordered. 1/19/16 - IV line ordered, attempts performed and failed due to collapsed and fragile veins. Ambulance is called, pharmacy is called and order faxed. 1/20/16 - Skin conditions noted to right inner heel round deflated blister noted. Area soft and intact. (see skin tab), right heel, dark red noted to site. Area C/D/I (clean/dry/intact) (see skin tab) and left ankle bone (see skin tab). Redness noted to site. Area C/D/I Unit manager aware of findings. Nurse Practitioner-C updated on above findings. New orders received. On 1/20/16, treatment change to right inner heel, right heel and left ankle bone to apply skin prep daily for protection. 1/20/16 - Dressing changed to buttock as ordered due to soiling. Reposition side to side to off load pressure. Cooperative with cares. No distress noted. 1/20/16 - Dietitian - G documented .4 oz Med Pass supplement TID remains in place via med pass to help meet nutritional needs especially for wound healing of coccyx wound. Per Nursing, wound has been getting worse over the past week. Monthly weight of 166.7 pounds (1/12/16) reflected significant weight loss at 3 months (-9.6%) with loss at 6 months (-8.5%) and small gain in the past month (=1.4%). Will have nursing obtain weekly weight to determine if there is further weight loss. Social Services to set up family meeting to clarify goals for care and if TF (tube feeding) may be desired. Will continue to monitor and follow up PRN (as needed). On 1/20/16, physician orders [REDACTED]. On 1/20/16 resident was sent to hospital for [MEDICAL CONDITION], dehydrations, increase in skin breakdown and ulcerations to periphery and coccyx. On 1/21/16, one day after resident was transferred to the hospital, the treatment record indicated resident was to have skin prep applied to the left ankle bone. Surveyor reviewed hospital documentation for the hospital admission on 1/20/16. The hospital documentation indicates the following: 1/20/16 7:20 PM - chief complaint given at 7:24 PM was increase in lethargy, [MEDICAL CONDITION], and skin breakdown to coccyx. Resident has [MEDICATION NAME] on. Vital signs 97.8 - 92 - 18 BP 125/59. 5 ' 4 172 pounds, pulse ox 97%. Pain occasional moan, tense, distressed, fidgety. No signs of abuse or neglect documented. Straight cathed cloudy urine. WBC 7.9 WNL, Na 154 (high)and K 3.5. Serum [MEDICATION NAME] low at 1.7. emergency room MD documentation .deep sacral decubitus ulcer with possible bone exposure, pressure ulcers to the bilateral heels, she is in padded boots. 1/20/16 9:35 PM - Wound care to be consulted for coccyx and bilateral heels. History and Physical: 1/21/16 11:43 AM - pat (patient) has bad decub wound in the back. 1/21/16 3:25 PM Hospital photos taken of wounds. 1/22/16 Wound assessment by (Nurse Practitioner name) .unstageable sacral pressure ulceration with left periwound deep tissue injury and open blisters. Center of wound with soft yellow necrotic tissue, no palpable bone, undermining, or tunneling, no odor, [DIAGNOSES REDACTED], ischemia. Right heel with intact blister. Clear fluid filled. Left lateral ankle pea sized intact deep tissue injury. Left heel intact. Sacrum 8.2 X 9.6 cm Right heel 0.6 X 3.1 cm Left heel 2.0 cm Labs on 1/24/16 show elevated WBC to 11.1 1/26/16 Nurse Practitioner wound nurse note unstageable pressure ulcer of lower extremity, unstageable right heel, currently intact pressure, pressure other site, stage unstageable and deep tissue injury sacrum. Protein malnutrition in hospital records. 1/26/16 MD (name), infectious disease, the sacral area reveals unstageable coccyx ulcer with boggy base odor with mild [DIAGNOSES REDACTED] and excoriation and no direct bone probe was seen. Left heel with dry eschar. Right heel with dry blister .unstageable sacral pressure ulcer with necrosis, mild odor, possible deep involvement/osteo[DIAGNOSES REDACTED], bilateral heel ulcer. 1/26/16 Surgical consult pt (patient) would benefit from debridement, however, this is not urgent. I believe the risks of surgical debridement outweighs any possible benefit at this time. I don't believe there is active infection under the sacral ulcer - she is malnourished. 1/27/16 Infectious Disease MD indicates infected sacral decub ulcer .[MEDICATION NAME] (name of antibiotic). 1/29/16 SW (Social Worker) spoke with son/POA (Power of Attorney) who reports family has met with surgeon and elected not to proceed with surgery. SW requested a family meeting and patient to be referred to Palliative (end of life) Care and have family to discuss goals of care. 2/1/16 Palliative Care consult for context of dementia and failure to thrive. 2/2/16 Discharge summary, admitted for altered mental status, dehydration and UYI (urinary tract infection) and sacral wound. Wound care and surgery was consulted for Stage 4 sacral wound. She was started on atb (antibiotic) per Inf Dis (infectious disease) for UTI and sacral wound. Due to poor [MEDICATION NAME] feeding nutrition was consulted, G tube (gastrostomy tube) considered by not felt to be prudent to be done now. Surveyor interviewed LPN-I on 2/17/16 at 10:36 AM. LPN-I described his experience doing wound care in the facility for [AGE] years. LPN-I indicated he was responsible to do weekly wound rounds on the non-pressure wounds, and the RN in charge, who was Wound Certified, would evaluate the pressure ulcers weekly. LPN-I told surveyor that he was the regular nurse on the day shift and knew the resident and her husband well. LPN-I described the resident as having advanced dementia, slowly declining, and able to feed herself when she first arrived on the long term care unit, but became more dependent on staff. She could assist to turn herself, but needed to be assisted. LPN-I told surveyor that there were times when resident would scream out, some days she was really good, and some days she was guarded, afraid of falling and she would be scared. Her roommate was her hu

Based on record review and staff interviews, the facility did not always ensure that they provided the necessary care and services to attain or maintain the highest practicable physical well- being of 2 out of 2 residents ( #11 and #21) who experienced a decline in bowel continence. The facility did not comprehensively assess and develop a plan of care based on the results of a comprehensive assessment for Resident #11 and Resident #21 when they were made aware they had a decline in bowel incontinence. * From 5/14/13 through 10/29/13, Resident #11 went from "no bowel incontinence/continent," to "always incontinent" of bowel to "frequently incontinent" of bowel with no evidence of an assessment to determine the cause of Resident's decline in bowel continence status, and did not develop a bowel incontinence care plan in order to provide services to restore or increase Resident #11's bowel continence. * The 12/31/12 and 7/1/13 MDS' indicated Resident #21 was "continent" of bowel. A 7/3/13 Bowel and Bladder tool indicates Resident #21 as "frequently incontinent" of bowel. The 9/30/13 quarterly MDS indicates Resident #21 is "occasionally incontinent" of bowel. The facility did not comprehensively assess Resident #21's bowel decline to determine the cause for Resident #21's decline in bowel continence, and did not develop a bowel incontinence care plan in order to provide services to restore or increase Resident #21's bowel continence. (Cross Reference F272 and F279) This is evidenced by: 1. Resident #11 identified to be alert with cognitive deficits was assessed per the initial MDS (Minimum Data Set) 05/14/13 to have no bowel incontinent issues as evident of a "0" scoring. The first quarterly MDS of 07/31/13 identified that Resident #11 is "always incontinent" of bowel. The second quarterly MDS review of 10/29/13 now identifies that Resident #11 is "frequently incontinent." A review of the clinical record noted no evidence that the resident's bowel incontinence was assessed that included the reason for the decline and if the decline was avoidable or unavoidable. A review of the "Resident Bowel and Bladder by Shift Chart" noted and confirmed that the resident had experienced incontinent bowel movements. From 07/31/13 through 10/29/13, the resident experienced 61 incontinent bowel movements over a varied of three shifts. From 10/31/13-12/04/13, the resident experienced 21 incontinent bowel movements over varied of three shifts. In addition, the facility did not have evidence that the declines that occurred between the initial and first quarterly assessment were addressed and that the necessary care and services were provided to maintain Resident #11 with the highest practicable well-being. On 12/05/13 at 11:40 a.m., Surveyor requested of the Director of Nursing (DON) information regarding the resident's bowel decline from admission to the quarterly and what services or care was provided as the result of the decline and slight improvement after the last quarterly. The DON indicated that there was no other information then what was provided. 2. On 12/4/13, Surveyor # initiated a medical record review on Resident #21. Resident # 21 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), dated [DATE], Resident #21 needs extensive assistance/ 1 person physical assistance to use the toilet. The MDS also states that Resident # 21 is "occasionally" incontinent of bowel. Surveyor # conducted a review of the previous quarterly MDS, dated [DATE] which stated that Resident #21 is "always continent" of bowel. The most recent full/annual MDS, dated [DATE] states that Resident #21 is "always continent" of bowel. A review the Care Area Assessment (CAA) for urinary incontinence and indwelling catheter, dated 1/9/13, states the reasons for a plan of care to be developed is to refer to indicators for information, continue to careplan to provide for staff assistance with toileting per plan, rehab referral for changes in mobility, as needed bladder scan for changes in patterning, as well as manage risk factors with overall goal of decreased incidence of incontinence of bowel and bladder. Surveyor # conducted a review of Resident #21's most current individual plan of care, (date unknown) which stated that Resident #21 had urinary incontinence, but does not address that Resident #21 has had a decline in bowel incontinence and is now occasionally incontinent of bowel. On 12/5/13 at 10:15 a.m., Surveyor # interviewed Director of Nursing (DON ) - B in regards to Resident #21's change in bowel continence. DON- B stated that she believes that Resident #21 has been frequently incontinent of bowel for a long period of time and would check previous bowel and bladder assessments. Surveyor # was provided with the most current "Quarterly Bowel and Bladder Review" dated 10/2/13. This review stated that that the bowel and bladder tool was reviewed and that there was no changes, continue with current plan. The review provided no additional information related to bowel incontinence. (Surveyor # noted that the MDS dated [DATE] stated Resident #21 is now occasionally incontinent of bowel). The "Bowel and Bladder Tool", dated 7/3/13 states that Resident #21 is forgetful, and uncooperative with toileting and perineal cares, evidenced by resident refusal. The level of bowel incontinence is noted to be frequently incontinent ( 2 or more times in 7 days), there was no indicators checked for bowel elimination patterning, or did the tool indicate when the bowel incontinence started. DON- B also provided Surveyor # with a copy of the caretracker " Bowel and Bladder by Shift" charting from 1/1/13 to 12/6/13. The charting indicated that over this period of time, Resident #21 has had 213 instances of bowel continence and 30 instances of bowel incontinence. DON- B was not able to provide any information as to why Resident #21 did not have a plan of care addressing Resident #21's bowel incontinence, causes for the incontinence or goals to maintain as much bowel function as possible. Surveyor # interviewed RN- MDS Coordinator- I on 12/5/13 at 10:25 a.m.. RN-I stated that she has conducted Resident #21's last MDS's and that she looks at charting, caretracker information and talks with staff and through personal experiences with the residents conducts her assessments. RN- I believes that the MDS's are accurate and that if there is a decline noted on the MDS, she would alert the nursing team and they would conduct a comprehensive assessment. RN- I stated that if she looks at the 7 day reference period on the caretracker and if a resident has 1 loose stool, that would trigger the resident to be 'occasionally incontinent.' RN- I stated that she will look at the bowel and bladder tools, but nursing does not always have these assessments done in a timely manner for her to review. Surveyor # again interviewed RN- I on 12/5/13 at 11:30 a.m. RN- I stated that she was not able to find a current 3 day bowel and bladder patterning for Resident #21 and that she needs to meet the MDS completion deadline and will sometimes have to complete the assessment without the nursing assessments to review. RN- I verified that the last 3 day patterning was completed on 1/1/12 and that she was unaware that a plan of care had not been developed and was not sure if Resident #21 was really experiencing bowel incontinence. RN- I stated that when she completed the previous MDS's that she looked at the required timeframe of 7 days, and resident #21 did not have bowel incontinence during that timeframe. RN- I stated that after reviewing the annual MDS, dated [DATE], she realized she did not complete the Care Area Assessment correctly and did not complete the summary. As of the time of exit on 12/5/13, no additional information had been provided as to why Resident #21 did not have a comprehensive assessment of her bowel functioning, an updated patterning and why the facility did not complete an individual plan of care based on the comprehensive assessment addressing Resident #21's bowel incontinence.

Based on staff interview and record review, the Facility did not ensure that each Resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #3) of 3 Residents reviewed. The Facility did not consistently identify root causes for unwanted self-transfers, did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. Resident #3 had thirteen unwitnessed falls prior to 7/7/13. Resident #3 had another unwitnessed fall on 7/7/13 and sustained a laceration above his right eye. Resident #3 was transferred to the hospital and returned with 10 sutures above his right eye. Resident #3 had two more unwitnessed falls on 7/8/13 & 8/1/13. The Facility did not consistently identify root causes, did not follow care plan approaches and did not implement new interventions to prevent further falls. Findings include: Surveyor # reviewed Resident #3's medical record on 8/21/13 & 8/22/13. Resident #3 has [DIAGNOSES REDACTED]. The falls plan of care dated 8/1/12 documents that "Resident #3 is at risk for falls related to poor understanding on limitations - increased restlessness with UTI (urinary tract infection)/when needing to have a BM (bowel movement) - history of repeated falls/impulsiveness/Parkinson's disease/Dementia." Approaches include "gripper socks -NOC (night) and body pillows in bed" dated 8/1/12, "Keep in supervised area when up in w/c (wheelchair)" dated 2/18/13, "Give PRN (as needed) Bisacodyl suppository during awake hours, do not give at HS (hour sleep)" dated 2/23/13, "wheelchair cushion wrapped in dicem (green turf) to help with resident scooting forward" dated 3/28/13 and "1:1 started 7/8/13 on PM's" dated 7/8/13. The CNA (Certified Nursing Assistant) assignment sheet provided to Surveyor # on 8/21/13 documents for Resident #3 "1:1" 7/8/13 until discontinued", "Check for BM (bowel movement) needs every 2", "low bed/body pillows, grip socks/shoes @ (at) all x's (times) Turf to w/c (wheelchair) floor mats up 0600/h.s. (hour sleep) 8 p.m. Soft touch call light to L (left) bedside TOILET BEFORE BED FOR BM. Close door when not in room, encourage to stay in public area. FALLS ALERT GET RES. (RESIDENT) UP IN W/C DURING NOC (NIGHT) IF AWAKE OR RESTLESS. KEEP IN SUPERVISED AREA WHEN UP IN W/C TURF WRAPPED AROUND THE W/C CUSHION." On 8/21/13 at 2:30 p.m. Surveyor # asked the Director of Nursing to provide Surveyor # with all fall investigations or other documents that would not be in the computer regarding Resident #3's falls as Resident #3 had 13 falls prior to falling on 7/7/13 when he received a laceration above his right eye requiring 10 sutures. The Director of Nursing provided Resident #3's fall information to Surveyor # on 8/21/13 at 3:15 p.m. 1. Unwitnessed Fall 2/22/13 The nurses note dated 2/23/13 documents "Late entry 2325 (11:25 p.m.) 2/22. Called to residents room by CNA. Resident observed kneeling on carpet mat on floor next to bed. Knees reddened and abrasion noted to right knee. Resident stated he was trying to get to the bathroom. Call light on when CNA entered room. Resident barefoot." The incident report dated 2/22/13 for 23:25 (11:25 p.m.) documents under describe incident "Resident observed kneeling on carpet mat next to bed. Call light on. States he needed to go to bathroom. No gripper socks on, barefeet." "Unwitnessed" is checked. Under injury documents "Abrasion to right knee." The CNA Fall Report dated 2/22/13 for the question last time resident toileted documents "PM's (evening)" and for the question last time safety checks completed documents "PM's." The nurses note dated 2/23/13 documents "Afebrile, has no memory of fall, able to move all extremities." Resident #3 was not wearing gripper socks according to his 8/1/12 plan of care. 2. Unwitnessed Fall 3/10/13 The nurses note dated 3/11/13 at 59:56 (12:56 a.m.) documents, "Resident slid out of wheelchair onto the floor in the main hallway at 1800 (6:00 p.m.). The Fall was unwitnessed. Resident denied any and all pain. RN (Registered Nurse) assessed resident and cleared his transfer back into his wheelchair. Vital signs where obtained and recorded electronically and put on the neuro check sheet that was initiated since the fall was not witnessed. Resident has a small red bump on the top of his head. His last set of vital signs revealed a slightly elevated temperature of 100.6 and the resident has a persistent wet cough that is thus far non-productive. Does not appear to be in any respiratory distress." The incident repot dated 3/10/13 for 18:00 (6:00 p.m.) documents under describe incident "Res. (Resident) on floor in heritage central hallway. Unable to describe what he is trying to do." "Unwitnessed" is checked. Under injury documents "Bump to top of head noted." The falls committee weekly review dated 3/6 - 3/13 for Resident #3's fall on 3/10/13 documents for the question "Is there evidence that measures were taken beforehand to prevent the fall?" "turf to w/c (wheelchair)." For the question "Is there evidence that a plan was implemented to prevent further occurrences documents "medical f/u (follow up) pneu (pneumonia) wedge cushion." The Facility did not identify the root cause for the fall, did not address if the green turf was on the wheelchair cushion and did not follow the approach of keep in supervised area when up in wheelchair. 3. Unwitnessed fall 3/22/13 The nurses notes dated 3/22/13 document, "Resident observed sitting on floor in hallway near w/c. Resident had been up in w/c self mobilizing in hallway. Denied need for toileting. Suprapubic catheter intact, draining clear yellow urine. Attempting to get self up, "just get me up". Denies pain. No apparent injury noted. ROM WNL. Neuro check WNL. No c/o (complaints) or s/s (signs/symptoms) of pain noted. Assisted off of floor and to bed. T (temperature) 97.9 P (pulse) 72 R (respirations) 20 BP (blood pressure) 138/67. Anti-slip turf applied to top of w/c cushion." The incident report dated 3/22/13 for 01:10 (1:10 a.m.) documents under describe incident "Resident observed sitting on floor near w/c." "Unwitnessed" is checked and was an injury involved documents "no." Interventions to prevent further falls were PT/OT (physical therapy/occupational therapy), Broda trial and green turf. Surveyor # noted the green turn was already an approach as indicated in the falls committee weekly review dated 3/6 - 3/13. The Facility did not identify the root cause for the fall, did not follow the approaches of keep in supervised area when up in wheelchair and green turf in wheelchair . 4. Unwitnessed fall 3/27/13 The nurses note dated 3/27/13 at 06:46 (6:46 a.m.) documents, "Resident observed sitting on carpet mat next to bed. Incontinent of stool. No apparent injury. ROM (range of motion) WNL (within normal limits) Hand grasps bilaterally firm. Slippers on." The incident report dated 3/27/13 for 06:30 (6:30 a.m.) documents under describe incident "Resident observed sitting on carpet at next to bed. Incontinent of stool. Slippers on. Call light not on." "Unwitnessed" is checked. Was an injury involved documents "no." The CNA Fall report dated 3/27/13 for the question ask resident what they were trying to do documents "Go to bathroom." For last time resident toileted documents, "Suprapubic denied need for BM." The Facility did not address if the body pillow (per 8/1/12 care plan intervention) was on Resident #3's bed and did not implement interventions to help prevent further falls. The significant change MDS (minimum data set) with an assessment reference date of 4/8/13 documents that Resident #3 has a BIMS (brief interview for mental status) summary score of "3" which indicates severe impairment. Resident #3 has a Suprapubic catheter, is always incontinent of bowel, and requires extensive assistance with two plus persons physical assist for transfer and dressing. Resident #3 has fallen since prior assessment with 2 falls with no injury and 2 falls with injury. 5. Unwitnessed fall 4/26/13 The nurses note dated 4/27/13 documents, "Late entry for 4/26/13 at 2137 (9:37 p.m.) I was called to the resident room by CNA because resident was on fall mat next to his bed. Per CNA resident was observed kneeling next to his bed, when I entered the room he was sitting on his bottom with his legs extended and crossed at the ankles and his hands were folded in his lap." "Body pillows were in place and the call light was not pressed but was clipped within reach to his bed sheets. Resident did have bare feet and was wearing his gown." The incident report dated 4/26/13 at 21:37 (9:37 p.m.) documents under describe incident "Resident was sitting beside bed with legs extended and crossed and hands folded in lap. resident alert and calmly talking. Resident was barefoot and in his gown. Body pillows in place." "Unwitnessed" is checked and "no" is answered for was an injury involved. The CNA Fall report dated 4/26/13 indicates that Resident #3 was last toileted at 8:15 p.m. and the last time safety checks completed is "blank." The Facility did not identify the root cause for the fall, Resident #3 was not wearing gripper socks according to his 8/1/12 plan of care, and did not implement interventions to prevent further falls. 6. Unwitnessed fall 5/9/13 The nurses note dated 5/9/13 documents, "Observed sitting on floor in hallway @ (at) 2045 (8:45 p.m.). Resident incontinent of stool. Assessed and assisted to w/c. Zero injuries noted. Neuro checks WNL (within normal limits)." The incident report dated 5/9/13 at 20:45 (8:45 p.m.) documents under describe incident, "Noted sitting on buttocks in hallway. Incontinent of stool." "Unwitnessed" is checked and "no" is answered for was an injury involved. The CNA fall report dated 5/9/13 documents for the question last time resident toileted "2:30 p.m." According to CNA assignment sheet Resident #3 is to be checked for BM every two hours. Under describe positioning/safety devices this section is blank. For the question what was resident doing when last observed before the fall documents "wheeling down the hall" and last time safety checks completed "20:15" (8:15 p.m.) According to RN (Registered Nurse)-C safety checks are when they visually see a Resident. The Facility did not identify the root cause for the fall, did not address if the green turf was on the wheelchair cushion, did not follow the approach of keep in supervised area when up in wheelchair, and did not implement interventions to prevent further falls. 7. Unwitnessed fall 5/12/13 The nurses note dated 5/12/13 documents, "At 0220 (2:20 a.m.) resident was on his back on the floor mat next to bed. Awake, alert, and talking. Vital signs taken and were stable. Resident unable to explain exactly what happened. No injuries present. Resident assisted back to bed. Neuro check within normal limits for resident. ROM (range of motion) within normal limits for resident. Will continue to monitor for safety." The incident report dated 5/12/13 at 02:20 (2:20 a.m.) documents under describe incident "Resident was on the floor mat next to bed. Awake, alert, talking. No new injuries noted." "Unwitnessed" is checked and "no" is answered for was an injury involved. The CNA fall report dated 5/12/13 documents under describe positioning/safety devices "bed in lowest position/mats/call lights/pillows." The last time safety checks completed is "0215 (2:15 a.m.) and the last time resident toileted is "blank." The Facility did not identify the root cause for the fall, did not address if Resident #3 was wearing gripper socks according to his plan of care, and did not implement interventions to prevent further falls. 8. Unwitnessed fall 5/12/13 The nurses note dated 5/12/13 at 0745 (7:45 a.m.) documents, Resident was found on the floor next to bed on floor mat. No injuries present. Vital signs stable. Alert, awake and talkative. Denies any pain. Neuro check remains normal for resident. ROM within normal for resident. Will continue to monitor." The nurses note dated 5/14/13 documents, "Resident alert, self propelled in w/c. aggression noted at times with ADL's (activities of daily living). No apparent injury noted from falls. ROM WNL for resident." There is no other information regarding this fall other than the nurses notes. 9. Unwitnessed fall 5/17/13 The nurses note dated 5/17/13 documents, "0330 (3:30 a.m.) called to residents room by CNA, resident observed laying on back on floor in room. Incontinent of BM. No apparent injury noted. ROM WNL. Neuro check WNL. No c/o or s/s pain noted. Suprapubic catheter intact draining yellow urine. Assisted off of floor and into bed. Incontinent cares provided. Up in w/c and out to TV lounge and eating a snack. Resident states he had to prepare his speech for Governor." The incident report dated 5/17/13 at 03:30 (3:30 a.m.) documents under describe incident, "Called to resident room by CNA, resident observed laying on back on floor in room. Incontinent of BM, received a Bisacodyl suppository at HS (hour sleep). Resident barefoot, no gripper socks in place." "Unwitnessed" is checked and "no" is answered for was an injury involved. The CNA fall report dated 5/17/13 documents for last time resident toileted documents "Suprapubic cath (catheter)." The intervention to prevent further falls was to give PRN Bisacodyl suppository during awake hours and not HS. Surveyor # noted this intervention was already implemented on 2/23/13. Resident #3 was not wearing gripper socks according to his plan of care, and the Facility did not implement interventions to prevent further falls. The Morse Fall scale assessment dated [DATE] has a total score of 55 which is high risk. 10. Unwitnessed fall 6/2/13 The nurses note dated 6/2/13 documents, "0350 (3:50 a.m.) called to resident's room by CNA. Resident observed sitting on floor in room, incontinent of stool. Resident barefoot at time of fall. Soft touch call light on. Dark purple bruise noted to right wrist area. ROM WNL. Neuro check WNL. Denies pain. Assisted off of floor, incontinent cares provided and out to TV lounge for observation." The incident report dated 6/2/13 at 03:50 documents under describe incident, "Resident observed sitting on floor in room, incontinent of stool." "Unwitnessed" is checked and for was an injury involved "yes" is documented and under please describe documents "Dark purple bruise noted to right wrist area." Resident #3 was not wearing gripper socks according to his plan of care, the Facility did not address if the body pillows were in place, when Resident #3 was last toileted, did not identify the root cause for the fall, and did not implement interventions to prevent further falls. 11. Unwitnessed fall 6/14/13 The nurses note dated 6/14/13 documents, "0520 (5:20 a.m.) Called to TV lounge as resident laying on floor on back between w/c and stationary chair with cushion from stationary chair on floor. Denies pain. No apparent injury noted. Neuro check WNL. Hand grasps bilaterally firm. Denied need for toileting. Suprapubic catheter patent draining yellow urine." The incident report dated 6/14/13 at 05:20 documents under describe incident, "Resident laying on floor on back in TV lounge in between w/c and stationary chair. Cushion from stationary chair on floor. Resident attempted to transfer self in chair. Resident was up in w/c as was attempting to get out of bed earlier in shift. Stating had "rounds" to do. Denied need for toileting." "Unwitnessed" is checked and "no" is answered for was an injury involved. The Facility implemented an intervention of a 3 days sleep study but the Facility did not identify the root cause for the fall, did not address if the green turf was on the wheelchair cushion, and did not follow the 2/18/13 care plan approach to keep in supervised area when up in wheelchair. 12. Unwitnessed fall 6/27/13 The nurses note dated 6/27/13 documents, "0200 (2:00 a.m.) Called to resident room by CNA, resident sitting on floor in room. CNA state as she was walking past room, resident was calling out "hey, hey, hey" and observed sitting on floor. Incontinent of stool." The incident detail dated 6/27/13 for time of event 0200 documents for event description "Resident observed sitting on floor in room. Incontinent of bowel. No apparent injury." The CNA fall report dated 6/27/13 documents for last time resident toileted "PM's." According to CNA assignment sheet Resident #3 is to be checked for BM every two hours. The Facility did not identify the root cause for the fall, did not address if Resident #3 was wearing gripper socks according to his plan of care, and did not implement interventions to prevent further falls. 13. Unwitnessed fall 6/28/13 The nurses note dated 6/28/13 documents, "Called to activity lounge with resident lying on right side next to chair with w/c at head. Denies any pain. No moaning, wincing and denies pain upon active ROM to extremities. No external/internal rotation or lengthening/shortening of LE's (lower extremities) noted. Denies hitting head. Oriented to self. Suprapubic catheter leaked with pant wet on buttocks and side. Resident unable to state how fell ." The incident detail dated 6/28/13 for time of event 1645 (4:45 p.m.) documents for event description, "Resident found lying on right side on floor with w/c by resident head and next to chair." The Facility implemented an intervention to toilet Resident #3 first on PM rounds before supper but did not identify the root cause for the fall, did not address if the green turf was on the wheelchair cushion, and did not follow the approach of keep in supervised area when up in wheelchair. The Morse Fall scale assessment dated [DATE] has a total score of 55 which is high risk. 14. Unwitnessed fall 7/7/13 The nurses note dated 7/7/13 documents, "Resident observed on floor in hallway on near Rm (room) 127 @ (at) 1930 (7:30 p.m.). Resident was propelling self in w/c. CMA (Certified Medication Aide) alerted staff of resident's fall. Observed face down on floor. Laceration and bleeding noted above Rt (right) eye. Pressure and ice applied and resident turned onto backside for further evaluation. ROM WNL to all extremities. Pupils small but reactive" "Left the facility @ 2010 (8:10 p.m.). resident wearing shoes at the time of fall. Toilet before supper per plan of care. Resident did not have bowel movement at that time. Supra pubic patent and in place. Clear yellow urine noted. Some restlessness noted early in shift. Scheduled Ativan provided at that time with improvement noted." The nurses note dated 7/8/13 documents, "Resident returned from hospital at approximately 0045 (12:45 a.m.). Has 9 or 10 sutures above right eye." The incident detail dated 7/7/13 for time of event 1930 (7:30 p.m.) documents for event description, "Resident observed on floor in hallway on near Rm 127 @ 1930. Resident was propelling self in w/c. CMA alert staff of resident's fall. Observed face down on floor. Laceration and bleeding noted above Rt. eye. Pressure and Ice applied and returned o" (Surveyor noted nothing else was written after the letter 'o' and the sentence was left uncompleted.) The CNA fall report dated 7/7/13 documents for question what was resident doing when last observed before the fall "moving around facility in chair." Last time toileted documents "before dinner" and last time safety checks completed is blank. "Wheelchair, shoes" is documented for describe positioning/safety devices. "N/A" (non applicable) is documented for describe fall interventions in place. The Facility did not identify the root cause for the fall, did not address if the green turf was on the wheelchair cushion, did not follow the approach of keep in supervised area when up in wheelchair, and did not implement interventions to prevent further falls. The Morse Fall scale assessment dated [DATE] has a total score of 90 which is high risk. 15. Unwitnessed fall 7/8/13 The nurses note dated 7/8/13 documents, "@ (at) 1830 (6:30 p.m.) writer was informed by staff RN (Registered Nurse) that resident fell . Observed resident off wheelchair. He was on floor on Heritage South hall He was lying on his right side of body, leaning on heat register on wall. Resident verbally denied pain. Upon RN assessment, resident was hoyered lifted with full body sling off of floor and into his wheelchair. Neuro checks wnl. Hand grasps good and firm. Speech clear. Pupils round, reactive to light. Found small laceration to RUE (right upper extremity) with scant amount of blood." The incident detail dated 7/9/13 (fall was 7/8/13) for time of event 1830 (6:30 p.m.) documents for event description "Resident found on floor on Heritage South hall. He was found laying on his right side." The CNA fall report dated 7/8/13 documents for describe positioning/safety devices "Turf no longer wrapped around w/c cushion replaced after fall. Non skid shoes." The Facility implemented an intervention of 15 minute checks which was then changed to one on one. The Facility did not identify the root cause for the fall, did not follow the approaches of keep in supervised area when up in wheelchair and green turf on his wheelchair cushion according to his plan of care. 16. Unwitnessed fall 8/1/13 The nurses note dated 8/1/13 document, "At 0200 (2:00 a.m.) resident was on the blue mat sitting on his bottom. Assessed for pain, resident denies pain or discomfort. ROM WNL. Neuro check WNL. Vital signs stable." The incident detail dated 8/1/13 for time of event 0200 (2:00 a.m.) documents for event description, "Call light was on for resident's room. CNA (Certified Nursing Assistant) ___ (left blank) went to answer, and Resident #3 was" (Surveyor noted nothing else was written after the word 'was' and the sentence was left uncompleted.) The Facility did not identify the root cause for the fall, did not address if Resident #3 was wearing gripper socks or had the body pillow in bed according to his plan of care, and did not implement interventions to prevent further falls. On 8/22/13 at 9:50 a.m., Surveyor # informed OT (Occupational Therapist) Rehab Director-D that an intervention for Resident #3's fall on 3/10/13 was to provide him with a wedge cushion. Surveyor # inquired if Resident #3 received the wedge cushion. OT Rehab Director-D informed Surveyor # that he would look into this and get back to Surveyor # . On 8/22/13 at 10:19 a.m., Surveyor # informed RN (Registered Nurse)-C that the Director of Nursing recommended Surveyor # speak with her regarding Resident #3's falls. RN-C informed Surveyor# that she is the Lead MDS coordinator for the Facility but she was involved with the falls. Surveyor # informed RN-C if she isn't the right staff member for Surveyor # to speak with could she direct Surveyor # to whom she should speak with. RN-C informed Surveyor # that staff that might have information no longer work at the Facility as they left during prior Administration. Surveyor # asked RN-C if she could explain what would occur when a Resident falls. RN-C explained that staff would assess the Resident and up until the end of June the incident report would be in the health record. After this time they switched to IRIS. In the middle of July they did a Q.A. (quality assurance) and realized that IRIS was not meeting their needs and put the incident report back into place. RN-C stated that they continued documenting in IRIS but also completed the incident report as they did prior. RN-C informed Surveyor # in addition to the incident report there is a packet which includes a fall follow up that the supervisor or team leader with the supervisor will fill out, the CNA fall sheet is completed and a post fall huddle when the staff on the unit gets together to talk about the Resident's fall. Surveyor # asked if there is an intervention for a Resident to be kept in a supervised area at all times what does that mean. RN-C informed Surveyor # that the person should be supervised so that staff can see that person at all times. On 8/22/13 at from 10:29 a.m. to 11:30 a.m. Surveyor # reviewed Resident #3's falls with RN-C. For the 2/22/13 fall, Surveyor # informed RN-C that Resident #3 did not have his gripper socks on according to the plan of care, toileting just states PM's and didn't address whether the body pillow was in place. RN-C reviewed the fall information provided to Surveyor # , looked in the computer and informed Surveyor # that there isn't any notation about the body pillow. For the fall on 3/10/13, Surveyor # informed RN-C that they did not address if the green turf was on the wheelchair cushion and did not follow the approach of keep in supervised area when up in wheelchair. RN-C informed Surveyor # that she doesn't see anything documented. For the fall on 3/22/13, Surveyor # informed RN-C that the Facility did not identify the root cause for the fall, did not follow the approaches of keep in supervised area when up in wheelchair and green turf in wheelchair . For the fall on 3/27/13, Surveyor # informed RN-C that the Facility did not address if the body pillow was on Resident #3's bed and did not implement interventions to help prevent further falls as the green turf was already an approach. For the fall on 4/26/13, Surveyor # informed RN-C that Resident #3 did not have gripper socks on according to his plan of care and asked what intervention the Facility implemented to prevent further falls. RN-C informed Surveyor # that the intervention that is documented was to reinforce to use the call light. Surveyor # asked if that was realistic for Resident #3. RN-C shook her head no. For the fall on 5/9/13 Surveyor # informed RN-C that according to the CNA fall report the last time Resident #3 was toileted was at 2:30 p.m. and he fell at 8:45 p.m. According to the care plan he is to be checked every two hours. Surveyor # also informed RN-C that they didn't address if the green turf was on the wheelchair and what interventions did the Facility implement to prevent further falls. RN-C informed Surveyor # that they did a medical work up with chest x-ray and labs as Resident #3 had agitation and increased confusion at that time. For the fall on 5/12/13, Surveyor # informed RN-C that the Facility did not identify the root cause for the fall, did not address if Resident #3 was wearing gripper socks according to his plan of care, and what interventions were implemented to prevent further falls. RN-C informed Surveyor # that they determined that Resident #3 had a UTI (urinary tract infection) and that the prior Director of Nursing reviewed this fall but RN-C didn't see any conclusion. For the fall on 5/17/13, Surveyor # informed RN-C that Resident #3 was not wearing gripper socks according to his plan of care, and asked what interventions were put into place to prevent further falls. RN-C informed Surveyor # that they changed the prn suppository to during the day. Surveyor # informed RN-C that intervention was already put into place on 2/23/13. RN-C informed Surveyor # that maybe they recognized this wasn't being done and put the intervention back. For the fall on 6/2/13, Surveyor # informed RN-C that Resident #3 was not wearing gripper socks and asked what interventions were implemented to prevent further falls. RN-C informed Surveyor # that they educated staff. For the fall on 6/14/13, Surveyor # informed RN-C that they did not identify the root cause for the fall, did not address if the green turf was on the wheelchair cushion, and did not follow the approach of keep in supervised area when up in wheelchair. For the fall on 6/27/13, Surveyor # informed RN-C that they did not address if Resident #3 was wearing gripper socks according to his plan of care, and inquired what interventions were implemented to prevent further falls. RN-C informed Surveyor # that they re-educated the Resident on the need to call for assist for transfers and toileting. For the fall on 6/28/13, Surveyor # informed RN-C they did not address if the green turf was on the wheelchair cushion, and did not follow the approach of keep in supervised area when up in wheelchair. RN-C informed Surveyor # that she doesn't see any documentation that the green turf was on the wheelchair. For the fall on 7/7/13, Surveyor # informed RN-C did not identify the root cause for the fall, did not address if the green turf was on the wheelchair cushion, did not follow the approach of keep in supervised area when up in wheelchair, and inquired what interventions were implement interventions to prevent further falls. RN-C informed Surveyor # that she doesn't see anything documented. For the fall on 7/8/13, Surveyor # informed RN-C that the green turf was not on Resident #3's wheelchair cushion according to his plan of care. For the fall on 8/1/13, Surveyor# informed RN-C that they did not identify the root cause for the fall, did not address if Resident #3 was wearing gripper socks or had the body pillow in bed according to his plan of care, and inquired what interventions were implemented to prevent further falls. RN-C informed Surveyor # that she didn't see anything in place. On 8/22/13 at 12:03 p.m., Surveyor# met with the Administrator and Director of Nursing. Surveyor # informed the Administrator and Director of Nursing of the concerns regarding Resident #3's falls. The Director of Nursing informed Surveyor # that they did identify there is an issue with falls and are putting a system into place. The Administrator informed Surveyor # that they brought this issue to Q.A. and that she instituted a tool in June and more systems were put into place when Director of Nursing-B came to the Facility. The Administrator informed Surveyor # that they educated staff and the new system was put in on August 1st. Surveyor # informed the Administrator and Director of Nursing that Resident #3 fell on [DATE] and the Facility did not identify the root cause for the fall, did not address if Resident #3 was wearing gripper socks or had the body pillow in bed according to his plan of care, and did not implement interventions to prevent further falls. On 8/22/13 at 12:22 p.m., OT Rehab Director-D informed Surveyor # that therapy wasn't involved with Resident #3 on 3/10/13 and wasn't sure if he received the wedge cushion as there isn't any documentation. OT Rehab Director-D indicated that there are cushions in the storage area in therapy and that often nursing staff will just come down and get a cushion. On 8/22/13 at 1:37 p.m., Surveyor # asked the Director of Nursing what does one on one mean for a Resident. The Director of Nursing informed Surveyor # that a staff member would be with the Resident at all times. Surveyor # asked even at night? The Director of Nursing replied "yes." Surveyor # asked the Director of Nursing where the one to one person was when Resident #3 fell on [DATE]. The Director of Nursing informed Surveyor # that she thought the one to one was only for a short period of time and was discontinued. Surveyor # informed the Director of Nursing that the one to one is still on Resident #3's care plan and CNA assignment sheet. On 8/22/13 at 1:48 p.m., the Administrator informed Surveyor # that she instituted the one to one after Resident #3 fell on [DATE] and that it was changed to only the night shift on 7/25/13. The Administrator informed Surveyor # that Resident #3 was moved to the lead unit, the Facility's dementia unit, on 7/27/13 and then the one one one was discontinued. Surveyor # informed the Administrator that it is still a current approach on Resident #3's fall care plan and the CNA assignment sheet. On 8/22/13 at 1:08 p.m., Surveyor # spoke with RN Supervisor-E on the telephone regarding Resident #3's fall that occurred on 7/7/13. RN Supervisor-E was the Supervisor for the Facility that evening. RN Supervisor