Every finding on record at Chippewa Manor Nursing and Rehabilitation

Based on observation, interview and record review, the facility did not ensure that 3 of 4 residents (R) reviewed for pressure injuries (PI) (R48, R47, and R51) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R48 and R47 are being cited at (actual harm/isolated). R51 is being cited at (potential for minimal harm/isolated).R48 and R47 were at risk for PI development. The facility failed to provide adequate interventions to prevent PI development, and did not complete comprehensive weekly assessment with staging of the PI. The facility did not complete weekly comprehensive skin assessments, obtain physician orders for wound treatments, and implement interventions to promote skin integrity and healing for R51. This is evidenced by Facility's policy titled Skin Integrity Policy dated 09/04/15 documented in part, Pressure Ulcer prevention recommendations include a comprehensive assessment of the skin, etiology, nutrition and risk assessment.Skin integrity assessments are done upon admission by a nurse.Risk assessment is completed to identify susceptible patients to target appropriated interventions to prevent pressure ulcers.Appropriate interventions are placed based on the above and include but are not limited to repositioning schedules, support surfaces such as pressure relief or reducing mattresses and chair cushions, heel floating, nutritional supplements/vitamins RD [Registered Dietician] recommendation. Treatment will be determined by accurate diagnosis and classification of pressure ulcers. Changes in treatment is based upon wound healing with MD notification of nonhealing or worsening pressure ulcers. Indicators of healing include weekly wound measurement with wound assessment documentation. Example 1 R48 was admitted to the facility on [DATE]. R48's diagnoses include encounter for palliative care hospice on 02/17/26, Alzheimer's disease, chronic diastolic congestive heart failure, and legal blindness. R48's admission Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of severely impaired cognition. R48 had altered level of consciousness. R48 is dependent on staff for all activities of daily living (ADL). R48 is at risk for PI and has no PI. On 02/17/26, the facility completed a Braden assessment with a score of 9, meaning at very high risk to develop PI. On 03/11/26 another Braden assessment was completed with a score of 9. Care plan: Problem: Resident is at risk for pressure ulcers R/T [related to] limited mobility, terminal diagnosis on hospice. Category - Start Date 02/17/2026 Last Reviewed/Revised 02/17/2026. Approach: Heel protectors or float heels at all times, air mattress Start Date 03/03/2026. Certified Nursing Assistant (CNA) care plan documented start date of 03/03/26 Heel protectors or float heels at all times, air mattress. R48's progress notes read in part,03/01/2026 at 2:20 PM, Skin Note Comments: red area noted to lower spine, measures approx [approximately] 8.8 cm long by 1.6 cm wide, blanchable. Applied 4x4 foam with border for protection. Repositioning resident as frequently as resident will allow, enrolled in Hospice 03/02/2026 at 1:07 PM, (Name) hospice RN, (Name), here for routine visit. Aware of reddened area to spine. Reports DTI (Deep tissue injury) to right heel that is open to air. Float heels. Foam border dressing and air mattress ordered. Note, facility did not comprehensively assess, and document the DTI to the right heel. 03/2/26 at 12:22 PM, documented right heel pressure ulcer measuring 4 cm x 3 cm. Physician orders documented 03/02/26 Float heels with pillows or heel protectors at all times Twice A Day 06:00 - 18:00, 18:00 - 06:00. 03/02/26 Change foam border to pink area on spine, Once A Day on Mon, 06:00 - 18:00. 03/09/2026 at 10:48 AM, Skin Note Skin and Ulcer/Injury Treatments: Wound care Comments: Dressing changed to spine, two pink areas noted, proximal measures 4.5cm by 3cm with superficial open area to center. Distal area measures 2cm by 1cm, skin intact. Pink areas are blanchable, areas cleansed and patted dry and foam with border applied for protection. Note, the facility did not comprehensively assess and stage the superficial open area/PI to the spine. No weekly PI assessment was completed for the right heel. 03/16/2026 at 3:23 PM, Skin Note Skin and Ulcer/Injury Treatments: Wound care, Turning/repositioning program, Pressure-reducing device for bedComments: changed mid-spine dressing, approximated 1.7cm by 1.5 cm, with a small dark scabbed area, surrounded by flaking red skin, cleansed with normal saline, dried with gauze, and applied foam border. Note, the facility did not comprehensively assess and stage the PI to the spine. No weekly PI assessment was completed for the right heel. On 03/24/2026 at 6:21 AM, Surveyor observed R48 in bed. Surveyor interviewed Certified Nursing Assistant (CNA) H asking how often does R48 get repositioned and if there are any open areas on R48's skin. CNA H stated R48 gets repositioned about every 2 hours. R48 does not have any open areas on R48's skin. On 03/24/2026 at 9:56 AM, Surveyor interviewed Hospice Registered Nurse (RN) I about R48 having any open areas. RN I stated R48 has a DTI to the right heel and skin is intact. Facility staff are to float heels and reposition R48. RN I removed R48's sock to observe the right heel. Surveyor noted R48 had a large circler black eschar area. RN I rolled R48 to observe the spine area. Surveyor noted R48's lower spine area was red and blanchable and above the blanchable area R48's skin was red and appeared to have an area that was open, dry and was not blanchable. Hospice RN I stated she does measurements weekly of the area and the facility gets the notes. Surveyor asked Hospice RN I if the PIs were avoidable or unavoidable. Hospice RN I stated the PIs were avoidable. When the PIs were noted an air mattress was ordered and to float R48's heels. On 03/24/26 at 10:17 AM, Surveyor interviewed Assistant Director of Nursing (ADON) E about facility policy and procedure regarding comprehensive weekly assessments including measuring and documenting R48's PIs. ADON E stated she does not have weekly assessment measurements of the heel. The Hospice RN would take over documenting the PIs. Typically, they don't have hospice assessing and would put in orders to document the PIs 3 times a week. This was not done. On 03/24/26 at 10:17 AM, Surveyor reviewed with Director of Nursing (DON) B regarding R48's PIs. DON B stated the facility did not complete weekly comprehensive PI assessments and staging. Interventions of pressure relief were not in place to prevent development of PIs when R48 was assessed on admission to be a very high risk of developing PI. The interventions of floating heels and an air mattress were not added until after the PIs developed. Example 2 R47 was admitted to the facility on [DATE]. R47's diagnoses include encounter for palliative care hospice (03/07/26), secondary malignant neoplasm of bone and lung, tumor lysis syndrome, depression, and chronic kidney disease stage 3a. An admission MDS dated [DATE] documented a BIMS score of 15/15, meaning R47 is cognitively intact. R47 requires moderate staff assistance to complete Activities of Daily Living (ADLs). R4 has one unstageable PI present on admission. A Braden assessment was completed on 02/25/26 and documented a score of 17, meaning at mild risk for development of a PI. On 02/25/26, an admission observation report documented R47 having no pressure injuries. Only having a scab on a toe. Physician orders documented on 02/27/26 Float heels with pillow or apply heel protectors at all times when restingTwice A Day 06:00 - 18:00, 18:00 - 06:00 03/20/26 L(left) plantar posterior heel. Cleanse with wound cleanser, pat dry with gauze. Apply puracol collagen 2x2 with bordered foam. Change weekly and PRN [as needed]. Hospice wound RN to assess and change weekly. Facility staff to change PRNOnce A Day on Fri 06:00 - 18:00 02/27/26 Heels sores - cleansed and apply bordered foam - measure and document on areas Once A Day on Mon, Wed, Fri 06:00 - 18:00 03/20/26 R (right) Heel sores - cleansed and apply bordered foam - measure and document on areas Once A Day on Mon, Wed, Fri 06:00 - 18:00. Care plan: Problem: Impaired skin integrity r/t [related to] unstageable pressure ulcer to left heel. Chemotherapy, end stage cancer. Category -Start Date 02/25/2026Last Reviewed/Revised 03/03/2026 13:00Approach: Air mattress to bed, heel protectors or float heels with pillows at all times except for transfers Start Date 03/02/2026 Progress notes: 02/25/2026 at 11:03 PM, Resident has a pink, blanchable area to her lower back bone and her sacral area, no open areas noted. Lotion was applied, per resident request. No reports of pain or discomfort.A wound management detail report created 03/03/26 by ADON E states an unstageable pressure ulcer was observed on 02/25/26 to the left heel measuring 1.2 cm x 1.2 cm with 100 % slough. Progress note dated 02/27/26 documented, .Left heel wound measures approximately 1.5 cm x 1.25 cm x 0.2 cm with black escar(sic) at lower edge border of wound. Peri wound is pink and no drainage noted. Right heel has an approximately 0.5 cm circumference black escar(sic) wound with no drainage. Note there are now two PIs, and the facility did not stage the PIs. 03/02/26 Left heel noted to have open area measuring 1.8 cm by 2.2 cm, yellow wound bed, pink surrounding skin that blanches, no s/sx [signs or symptoms] of infection noted. Pink area to right heel measuring 1 cm by 1.2 cm, blanches. Of note there is no comprehensive assessment for R47's right heel the week of 3/3/26. 03/03/26 Left heel 1.2 by 1.2 open area, with a dark/scabbed center. Moderate drainage noted on old dressing, miniscule amount of slough at wound bed. 03/09/26 Right heel red, blanchable, no open areas. Left heel open area measuring 1.3 cm by 2.3 cm, wound bed tan/yellowish slough, scant tan drainage. 03/10/26 Left heel wound bed noted to be beefy red, measures approx. 2.5 cm wide by 1.4 cm long.Changed dressing to right heel, no redness noted, heel feels slightly boggy to the touch. 03/13/26 Left heel has 2.2 x 1.6 with slough at wound bed, right heel has two small scabs about 1cm diameter. 03/16/26 Left heel minimal yellow drainage noted area is approximately 2.3cm by 1.3 cm .right heel has two almost pinpoint scabs measuring 0.2 cm diameter for both. Dark scabbed center. 03/20/26 Right heel pink but blanchable, left heel superficial open area measuring 0.7cm by 1.7 cm with beefy red wound bed . 03/23/26 Left heel superficial open area measuring 0.9 cm by 1.9 cm with pink wound bed. On 03/24/26 at 12:27 PM, Surveyor interviewed ADON E and DON B about when R47's PI to the left heel developed. ADON E stated the area was there on admission. Surveyor reviewed the wound management detail report with the created date of 03/03/26 stating it developed on 02/25/26. Surveyor asked if ADON E did the assessment on 02/25/26. ADON E stated she did not see the wound on admission. DON B stated DON B observed the wound. Surveyor asked if DON B took measurements and documented the assessment. DON B stated no. Surveyor reviewed R47's admission observation report with ADON E and DON B of the admission observation report documenting no PIs and the progress note documenting no PIs to the left heel. Interventions to float heels were not added to the care plan until 03/02/26. The progress notes assessments did not stage the PIs. Example 3 R51 was admitted to the facility on [DATE] with diagnoses including dementia, dependence on renal dialysis, heart failure, and obesity. R51 scored 11/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R51's Minimum Data Set (MDS) assessment, completed on 01/09/26, noted R51 was at risk of pressure ulcers and R51 had no pressure, arterial, or venous skin ulcers. R51's care plan included: Start Date 03/10/26, last reviewed/revised 03/10/26: Resident's skin will remain intact.Approach: Report any signs of skin breakdown (sore, tender, red, or broken areas).Approach: Use moisture barrier product to perineal area.Approach: Provide incontinence care after each incontinent episode. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin; avoid friction to skin.Approach: Use absorbent, skin-friendly pads/briefs to maintain personal hygiene and dignity.Approach: Float heels when indicatedApproach: Keep bony prominences from direct contact with one another with (pillows, foam wedges, etc).Approach: Reduce friction injuries by using lubricants, protective films, protective dressings, and/or protective padding.Approach: Avoid shearing resident's skin during positioning, transferring, and turning.Approach: Conduct a systematic skin inspection (weekly, daily, etc). Pay particular attention to the bony prominences.Approach: Keep linens clean, dry, and wrinkle free.Approach: Keep clean and dry as possible. Minimize skin exposure to moisture.Approach: Use lifting device(e.g., trapeze, lift sheet, etc.) to move resident in bed. R51's current physician orders did not include any skin treatments. Previous physician orders included, 11/25/25-01/01/26, Measure and document right buttock wound, cleanse with normal saline, dry with gauze, and apply foam dressing. Note, Surveyor was unable to find any other skin treatment orders in R51's record. A nutritional assessment completed on 03/19/26, noted R51 had no open skin areas. R51 has no orders for supplements for wound healing. Surveyor was unable to find weekly comprehensive skin assessments in R51's record. R51's progress notes included: -12/06/25, Skin Note: Skin temperature location: Warm, Skin and Ulcer/Injury Treatments: Wound careComments: Dressing noted to be soiled to left buttock, dressing removed, skin cleansed and patted dry, superficial open area noted measuring 0.4cm in diameter, no s/s of infection noted, new foam with border applied. Skin and Ulcer/Injury Treatments: Wound careComments: Dressing changed to right buttock, area cleansed and patted dry, two open areas noted, proximal measuring 1cm by 0.5cm, distal measuring 1cm by 0.4cm, scattered scabbed areas noted near open areas, new foam dressing applied. -12/09/25, open area right buttock is 0.5cm x 0.5cm. Area cleansed and patted dry. Foam dressing applied. Res. has excoriated area left buttock and is 2cm x 1cm. Area cleansed and patted dry. Foam border dressing applied. Posterior scrotum is sl. excoriated. Area cleansed and patted dry. Zinc applied. -12/23/25, open area right inner buttock is 0.3cm x 0.3cm and dry. Cleansed and patted dry. New foam border dressing applied. -12/24/25, Skin Notes: Shower given by staff, small open area noted to right buttock, measures approx 0.4 cm wide by 0.2 cm long, applied new 3x3 foam with border -12/25/25, Healing right inner buttock cleft dressing change. measures 1.2 cm x .75 cm with clear boarder. No sign of infection noted. Cleansed and dressed with 3x3 foam dressing. Resident had no complaint of pain or discomfort. Encourage positioning on side in bed. Resident prefers sleeping in recliner. Educated on benefit of sleeping in bed. -01/14/26, Dressing changed to left buttock. Noted to have a 0.75cm circular open area to left buttock. Scant amount of bloody drainage noted. Area cleansed and dried and new foam boarder applied. -01/21/26, Foam border dressing applied after shower to Resident's buttocks - three areas: a) left buttock, approximately 0.5 cm x 0. 75 cm x 0.1 cm; b) left upper posterior thigh, approximately 0.3 cm wide x 1. 5 cm long x 0.1 cm deep; c) right buttock approximately 0.3 cm x 0.3 cm x 0.1 cm. Scrotum area appeared greatly improved compared to writer's last observation. Mild redness noted, offloading practiced when able, Nystatin applied to areas where moisture prone fungal skin infection is present: groin. Improving with therapy. -01/27/26, Res. has a 2.5cm x 1.5cm superficial open area left buttock. Area cleansed with NS and patted dry. 3x3 foam border dressing applied. Res. has a 1cm x .1cm open area right buttock. Area cleansed with NS and patted dry. 3x3 foam border dressing applied. Res. has a reddened area left upper inner thigh, not open. Area cleansed with NA and patted dry. Zinc applied. -01/28/26, Skin and Ulcer/Injury Treatments: Wound careComments: right buttock 2.6 x 0.5, superficial with sanguineous drainage, flaking skin surrounding open area. Cleansed, dried, and applied foam border.left buttock open area is 1.2 by 1.0, superficial with sanguineous drainage, flaking skin surrounding open area. Cleansed, dried, and applied foam border. -02/01/26, Skin Notes: Changed dressing to left inner buttock, area measures approx 2.0cm wide by 2.0 cm long, superficial open area, cleaned with saline, applied new 4x4 foam with border. -02/15/26, Skin Notes: Open area noted to left buttock, measures approx 2.7 cm wide and 1.4 cm long, wound bed is white in color, small amount of active bleeding noted, cleaned with saline, applied new 4x4 foam with border. -03/04/26, Writer called to resident's room to place dressings on open areas to buttocks. Right buttock has superficial open area 1.5cm x 1.5cm. Cleansed, dried and foam border applied. Left buttock has 4cm x 4cm round open area noted with granular tissue in the center, margins are clean. Area cleansed and dried and foam border applied. Will have wound RN assess as well. On 03/04/26, R51 was hospitalized for urosepsis; he was re-admitted to the facility on [DATE]. R51's re-admission skin assessment on 03/10/26, noted 2 cm x 2 cm on left back of thigh, 1.5 cm x 2 on right back of thigh appears to be shearing from lift sheet. Surveyor was unable to locate any skin assessments or progress notes related to R51's skin after 03/10/26. On 03/24/26 at 11:00 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C confirmed R51 had an open area on his buttocks, but was unable to report left or right side. On 03/24/26 at 11:34 AM, Surveyor observed R51's buttock with CNA C and Registered Nurse (RN) G. Surveyor observed RN G remove a foam border dressing from R51's left inner buttock. Surveyor observed R51 had an open area to left inner buttock. R51's right buttock noted no open area, and skin was discolored, and presented dark purple in color. Surveyor asked RN G if R51's wound was a pressure ulcer. RN G stated R51, sits a lot. Surveyor asked RN G if the dressing removed from R51's left buttock was initialed or dated. RN G stated it was not. Surveyor asked if R51 had an order for treatment to his left buttock and RN G was not sure. RN G stated she was not sure who placed the dressing on R51. On 03/24/26 at 12:28 PM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) E, DON B and ADON E stated R51's wounds heal and reoccur. ADON E reported R51 should have a roho cushion and this is in R51's care plan. Surveyor reviewed R51's care plan with DON B and ADON E and confirmed a roho cushion is not on the care plan. Surveyor asked DON B and ADON E about other skin interventions and asked if R51's interventions were individualized. DON B and ADON E did not provide a statement. Surveyor asked DON B and ADON E if R51 had previous skin treatments ordered and noted R51 did not have current orders, and Surveyor was only able to find a single order from 11/2025-01/2026. DON B and ADON E were not sure why R51's order would have ended on 01/01/26. DON B and ADON E reported R51's provider should be aware of R51's wounds. Surveyor asked for documentation to support R51's provider was updated on R51's skin condition. The facility did not provide supporting evidence of this. Surveyor asked DON B and ADON E if the facility's Registered Dietician (RD) was aware of R51's wounds. ADON E stated the RD has access to the facility notes and would be able to see if R51 had wounds or skin concerns. ADON E stated if RD saw documentation of a wound she definitely would have ordered a supplement. Surveyor asked DON B and ADON E if there were weekly comprehensive skin assessments for R51. DON B and ADON E indicated R51's skin assessments were in the progress notes. Surveyor noted these assessments were not completed weekly and were not comprehensive. Surveyor noted some dates included both right and left side and other dates included only one side, and documentation did not confirm if and when wound healed or re-opened. DON B and ADON E did not provide a statement. Surveyor requested documentation to support R51's provider was updated, treatment orders, revised skin interventions, and weekly comprehensive skin assessments. DON B and ADON E provided no further information.

Based on interview and record review, the facility did not ensure that a resident who requires dialysis receives such service, consistent with professional standards of practice for 1 of 1 residents (R51) reviewed for dialysis.The facility failed to provide ongoing assessment of R51's condition and monitoring for complications before and after dialysis treatments.On 03/23/26 at 3:30 PM, Director of Nursing (DON) B reported the facility did not have a policy. On 03/24/26, DON B provided Surveyor with a policy titled Hemodialysis Policy and Procedure. DON B stated the policy was created on 03/24/26. The policy read in part, The facility will ensure that each resident receives care and services consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; ongoing assessment and oversight of the resident before, and after dialysis treatments, monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices; ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. R51 was admitted to the facility on [DATE] with diagnoses including dementia and end stage renal disease with dependence on dialysis. R51's Minimum Data Set (MDS) assessment completed on 12/29/25 confirmed R51 scored 11/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. R51's care plan included: -I have end-stage renal disease and depend on dialysis to remove extra fluid and waste from my body. My nutrition and fluid intake must be carefully managed to help me stay healthy between treatments. Start Date, 03/10/2026. Last Reviewed/Revised, 03/10/2026. -Interventions: I need my nurses to monitor my weight before and after dialysis and as ordered. Check for swelling, shortness of breath, or other signs of fluid overload. Monitor my labs (especially potassium, phosphorus, and albumin) and report changes to my doctor and dietitian. Remind me about my fluid limits if I am drinking too much between treatments. Give my medications and phosphate binders as prescribed. I need my aides to record how much I eat and drink, as directed. Report if I am refusing meals or seem more tired than usual after dialysis. Help me with meal setup and offer fluids within my limits. Watch for and report swelling, confusion, or decreased appetite. I need dietary staff to provide me with a renal diet that is lower in sodium, potassium, and phosphorus, as ordered. Offer high-protein foods to help me maintain my albumin and strength. Prepare foods I like within my diet restrictions to encourage eating. Monitor my intake and weight for any significant changes.Start Date, 03/10/2026. R51's orders included: -03/10/26, DIALYSIS, Mon-Wed-Fri - check in 2:15pm - Dialysis at 2:30pm. Patients Express Van taking at 1:45pm. Will return around 6:30-6:45pm. Kitchen aware to send out supper tray at that time.-03/10/26, Check and document bruit and thrill (left forearm fistula). -03/10/26, Give resident his supper when returning from dialysis-is in family room fridge. -03/10/26, Monitor vitals three times per week M-W-F post dialysis. On 03/23/26, Surveyor reviewed R51's record and noted vital signs, temperature, respirations, and blood pressure pre and post dialysis since 03/10/26. Surveyor reviewed weights and noted weekly weights with no pre and post dialysis weights. Surveyor was unable to locate communication with dialysis center. On 03/23/26 at approximately 2:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA reported the nurses are responsible for checking resident vital signs. CNA C was aware R51 was on a fluid restriction. CNA C stated R51 takes a packet with him to dialysis. CNA C did not know what information the packet contained. On 03/23/26 at 3:00 PM, Surveyor interviewed Registered Nurse (RN) D. RN D confirmed nurses take resident vital signs. RN D reported RNs assess R51's vital signs and bruit post dialysis and R51 has an order for a weekly weight. Surveyor asked RN D where R51's documentation of communication with facility and the dialysis center would be located, and RN D did not know where this would be. Surveyor asked RN D what type of dialysis R51 received, and RN D stated, Regular dialysis, not peritoneal. Surveyor asked RN D what assessments would be completed for a resident receiving dialysis, RN D stated, We check his vital signs and bruit after dialysis. On 03/23/26 at 3:03 PM, Surveyor interviewed DON B. DON B stated R51 switched dialysis providers, A while ago, more than six months. DON B reported she does not have documented communication with new dialysis center, related to R51's dialysis treatments. DON B reported nurses take R51's vital signs and monitor bruit post dialysis. DON B stated she thinks R51 has order for weights three times weekly. DON B stated she would confirm R51's orders and update Surveyor. On 03/24/26 at 7:30 AM, DON B reported she spoke with dialysis center, and the facility will begin a communication form. DON B stated she is unsure how this was missed.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was transmitted within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) for one of five residents (R7) reviewed for MDS.R7 expired in the facility on [DATE] with hospice services. R7's Minimum Data Set (MDS) assessment for a death in the facility was not submitted to the CMS System. On [DATE], Surveyor requested the facility's policy related to MDS assessments; the facility did not provide Surveyor with this policy. Per CMS requirements, within 14 days after a facility completes a resident's assessment, the facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including a resident's death. On [DATE] at 8:34 AM, Surveyor interviewed Registered Nurse (RN) F. RN F also acts as the MDS coordinator. RN F stated she completed R7's MDS, but Director of Nursing (DON) B and Assistant Director of Nursing (ADON) E are responsible for transmitting the assessment. RN F stated the MDS death assessment completed on [DATE], was not submitted. On [DATE] at 9:19 AM, Surveyor interviewed DON B and ADON E. DON B and ADON E stated the process is for MDS coordinator to hit complete button when finished with the MDS assessment, and then it is sent to NHA, DON, and/or ADON to complete and transmit. DON B reported only three staff have access to transmit MDS assessments, and that is NHA, DON, and ADON. DON B stated since MDS coordinator did not hit complete, NHA A, DON B, and ADON E were not aware R7's MDS needed to be transmitted.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This affected 5 out of 5 residents (R). (R29, R10, R24, R37, and R7) Laundry aide (LA) D did not sanitize hands in between delivering clean linens to R29, R10, R24, R37, and R7. Findings include: The facility policy, titled Laundry and Bedding, Soiled, revised September 2022, states: .Transport: #6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness . On 01/27/25 at 10:17 AM, Surveyor observed LA D carry residents' clothes up the stairs to the 1st floor to clean linen cart. Surveyor observed clean linen cart to be uncovered and exposed to potential debris and dust. LA D took R29's clothes and entered R29's room. LA D opened closet door and cabinet drawers, touching surfaces with bare hands, and placed R29's clothes in dresser. LA D exited R29's room and continued to push the uncovered clean linen cart down hallway without sanitizing hands. LA D took R10's clothes and entered R10's room. LA D opened dresser drawers, touching surfaces with bare hands, and placed R10's clothes in dresser. LA D exited R10's room and continued to push uncovered clean linen cart down hallway without sanitizing hands. LA D took R24's clothes and entered R24's room. LA D opened closet door, touching surfaces with bare hands, and placed R24's clothes in closet. LA D exited R24's room and continued to push uncovered clean linen cart down hallway without sanitizing hands. LA D took R37's clothes and entered R37's room. R37 is on Enhanced Barrier Precautions (EBP). LA D opened R37's closet door and cabinet drawers, touching surfaces with bare hands, and placed R37's clothes in dresser and closet. LA D exited R37's room with used clothes hangers, placed used clothes hangers in the clean linen cart with clean linens. LA D continued to push uncovered clean linen cart down hallway without sanitizing hands. LA D then took R7's clothes and entered R7's room. LA D opened cabinet drawers, touching surfaces with bare hands, and placed R7's clothes in dresser. LA D exited R7's room without sanitizing hands and continued down hallway with uncovered clean linen cart. On 01/28/25 at 10:27 AM, Surveyor interviewed LA D and asked what LA D's process is for covering clean linen cart. LA D stated, Oh yea you guys told us this last year that cart should be covered, I forgot. LA D indicated that clean linen cart should be covered. Surveyor asked LA D what LA D's process is for sanitizing hands between resident rooms when taking clean linens in, especially R37's EBP room. LA D indicated that hands should be sanitized in between rooms when touching closet doors and dressers. On 01/28/25 at 11:30 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectations for hand hygiene and clean cart covered when delivering clean linens. DON B indicated that DON B's expectation is that clean cart is always covered when delivering clean linens to prevent contamination of clean linens. DON B expects that all staff sanitize hands in and out of all resident rooms regardless of cares or delivery of clean linens.

Based on observation, record review and interview, the facility did not ensure all drugs and biologicals were securely stored for 2 of 2 residents (R) (R2 and R246) and did not ensure controlled drugs were stored in separately locked, permanently affixed compartments. Findings include: On 01/27/25, Surveyor reviewed Medication Storage Review sheets completed by monthly audits from the contracted pharmacy for 08/24-11/24. -On 09/30/24, Medication storage sheet stated in part: Recommendation Lorazepam concentrate should be double-locked. -On 10/26/24, Medication storage sheet stated in part: Recommendation Lorazepam concentrate should be double-locked. -On 11/23/24, Medication storage sheet stated in part: Recommendation Lorazepam concentrate should be double-locked. On 01/27/25 at 10:26 AM, Surveyor toured medication storage room with Assistant Director of Nursing (ADON) C. Surveyor observed two Lorazepam 2mg/ml bottles opened, one labeled R2 opened 12/16/24, and second bottle labeled R246 opened 01/01/25 in refrigerator in medication storage room. Surveyor observed that Lorazepam was not double locked in refrigerator. On 01/27/25 at 10:28 AM, Surveyor interviewed ADON C and asked about the two Lorazepam 2mg/ml bottles opened and if they are supposed to be stored in refrigerator unlocked. ADON C indicated that R2 has been discharged for a while and that the Lorazepam bottle should be discarded. ADON C indicated that ADON C would complete the destruction now. On 01/28/25 at 8:52 AM, Surveyor interviewed Director of Nursing (DON) B and asked if Lorazepam is supposed to be stored freely in the refrigerator in medication storage room. DON B indicated that all controlled medications are to be double locked, and the facility has now fixed the issue from yesterday 01/27/25. Surveyor indicated to DON B that Surveyor reviewed the pharmacy medication storage recommendations given to facility monthly after monthly audits are complete and pharmacy recommended that Lorazepam concentrate should be double-locked. Surveyor asked DON B who oversees auditing the monthly pharmacy recommendations and implementing the recommendations. DON B indicated that DON B oversees the monthly audits and DON B will be monitoring the monthly recommendations better.

Based on interview and record review, the facility did not ensure the resident's representative was provided notice of the resident's bed hold upon transfer for 1 of 1 resident (R) investigated. (R10) Findings include: R10 was admitted to the facility on [DATE] and diagnoses included metabolic encephalopathy, end stage renal disease, and dependence on renal dialysis. On 01/28/25, record review indicated R10 had a hospitalization on [DATE] for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. R10's records indicated R10 was dialyzed and improved. R10 returned to facility on 11/30/24. Hospital discharge notes from 11/29/24 indicated in part, R10 was admitted for urgent dialysis needs. On 01/29/25 at 8:45 AM, Surveyor requested documentation of any notification of the facility's bed hold provided to R10's representative upon R10's hospitalization . Surveyor was provided a copy of the Client Handbook, which is given to residents upon admission with information pertaining to the facility's bed hold policy. Surveyor informed DON B, facilities must provide written information about bed hold policies to all residents and/or residents' representatives prior to and upon transfer, regardless of their payment source and requested documentation the representative was provided this upon R10's transfer to the hospital on 11/29/24. No documentation notifying R10's representative of the bed hold policy upon R10's transfer or within 24 hours of the transfer, was received from the facility.

Based on interview and record review, the facility did not ensure the resident's representative or Ombudsman was notified in writing, in a language and manner they understand, of the resident transfer for 1 of 1 resident (R) investigated. (R10) Findings include: R10 was admitted to the facility on [DATE] and diagnoses included metabolic encephalopathy, end stage renal disease, and dependence on renal dialysis. On 01/28/25, record review indicated R10 had a hospitalization on [DATE] for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. R10's records indicated R10 was dialyzed and improved. R10 returned to facility on 11/30/24. Hospital discharge notes from 11/29/24 indicated in part, R10 was admitted for urgent dialysis needs. On 01/28/25, Surveyor requested R10's written notice of transfer from the facility on 11/29/24, from Director of Nursing (DON) B. No notice of transfer was received. On 01/29/25 at approximately 8:30 AM, Surveyor interviewed DON B, who reported the facility did not send written notice of the transfer to the representative or a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman because written transfer notice was not completed.

Based on interview and record review, the facility failed to assess resident (R) 28 using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 12 residents reviewed. The facility did not complete a quarterly Minimum Data Set (MDS) assessment for R28 with a frequency of not less than three months. Findings include: The facility policy, entitled Nursing Department Policy and Procedures, dated 10/01/23, states: The ARD [Assessment Reference Date] of the OBRA [Omnibus Budget Reconciliation Act] Quarterly assessments must be within 92 days of the ARD of any previous OBRA assessment. The assessment must be completed by ARD + 14 calendar days. On 11/07/23, record review of R28's past MDS assessments, it was revealed that the most recent MDS assessment was completed on 05/17/23. There was a gap of 174 days without an MDS assessment completion. On 11/07/23 at 11:57 AM, Surveyor interviewed Registered Nurse (RN) C, the facility's MDS coordinator, and the Assistant Director of Nursing. Surveyor asked RN C about the missing MDS assessment for R28. RN C stated it must have been missed. RN C's paper chart did say they had completed it on 08/08/23, but RN C further inspected the document and computer files and did not find a completed MDS assessment. RN C said they crossed it off, and it must not have gotten done, and they plan to do it immediately. On 11/07/23 at 3:22 PM, Surveyor interviewed Director of Nursing (DON) B regarding expectations around MDS completion and submission. DON B said they are starting the MDS assessment for R28 immediately. DON B would expect MDS assessments to be done quarterly and within the time frame they have set; this was just missed.

Based on observations and interview, the facility did not ensure the posted nurse staffing information was posted at the beginning of each shift. This has the potential to affect all 35 residents in the building. The facility's Nursing Staff sheet postings were not posted daily. Evidenced by: Division of Quality Assurance (DQA) memo 12-020 titled Clarification Concerning Posting Requirements for Nurse Staffing documents: Required Staffing Information .Nursing homes must post information about the number of staff directly responsible for resident care on each shift. This information must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift . The information that is posted must include the following . 1. Facility name. 2. The current date. 3. The total number of staff directly responsible for resident care per shift for each of the following categories: licensed (RN's (Registered Nurse), LPNs (Licensed Practical Nurse)), and unlicensed (CNAs (Certified Nursing Assistant)). (For example, 1 RN, 2 LPNs, and 4.5 CNAs.) The number of RN's must be separate from the number of LPNs. 4. The actual hours worked per shift for each of the following categories: licensed (RN's, LPNs), and unlicensed (CNAs). 5. Resident census. Timing: Information is to be posted daily and must be present at the start of each shift. Nursing homes can choose to post staffing information for the entire day or for the current shift. Nursing homes are required to update the posted staffing if any changes arise, for example, if a nursing assistant calls in sick or goes home sick and is not replaced. On 11/06/23 at 12:57 PM, Surveyor was not able to locate the daily nursing staff posting. On 11/07/23 at 7:01 AM, Surveyor could not locate the nursing staff posting. Surveyor asked staff sitting behind the desk if they had something that told them how many nurses and CNAs were working each day. Staff pointed to a binder on the counter behind the desk and indicated it was kept in there. On 11/08/23 at 9:53 AM, Surveyor interviewed Director of Nursing (DON) B and asked if they post the daily staff posting. DON B indicated that it is usually hung up by the nurse's station. Surveyor asked DON B to show Surveyor where it was at since it was not visibly posted the last 3 days. DON B walked around the nurse's station and noticed it was not there. DON B pointed to the wall at the front counter of the nurse's station where it is usually posted and noted it was not there. Surveyor asked who was responsible for posting the nursing staff sheet. DON B indicated the receptionist usually did but was off Monday and just returned Tuesday. Surveyor asked who was responsible to post it when the receptionist was gone. DON B indicated that I guess we need a backup.

Based on interview and record review, the facility failed to ensure that written bed hold notice required for facility-initiated transfers was given to the residents or resident representatives for two (R16 and R31) of two residents reviewed for hospitalization in the sample of 14. The facility failed to have a system in place to ensure that residents or resident representatives were given written bed hold notices upon transfers. This had the potential to affect all 35 residents that reside in the facility. The facility did not notify the residents' representatives in writing of the bed hold policy at the time of transfer or within 24 hours of transfer to the hospital for Resident (R)31 and R16. This is evidenced by: Example 1 Review of R16's medical record revealed R16 was transferred to the hospital on 03/17/23, 04/12/23, and 07/02/23. Surveyor reviewed the medical record for 03/17/23, 04/12/23, and 07/02/23 which did not reveal any written notice of bed hold policy was issued to the resident or resident's representative. 47807 Example 2 Record review of R31's past hospitalization s showed that on 08/12/23, R31 was transferred to the hospital for an extended stay. On 11/08/23 at 12:58 PM, Surveyor interviewed Social Worker (SW) D regarding bed holds for residents sent to the hospital. When the Surveyor asked to see copies of the bed hold for R31, SW D showed an email chain documenting that the family of R31 was contacted about the decision to hold R31's bed. The surveyor then asked if SW D presented written documentation of the transfer to the hospital to the family, to which SW D said no. SW D explained they usually don't have time to get a signed written notice to families or residents as they are transferred to the hospital, especially during an emergency, so they call the family and explain the bed hold and then document that they made the call. Record review of the email documenting the call made to R31's family about the bed hold and the family declined holding R31's bed. No other written bed hold documentation for R31 was given to Surveyor. On 11/08/23 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the bed hold policy. NHA A said that when someone goes out, they immediately call the family member to get information on the bed hold and explain the procedure. Surveyor then asked if they expected to get a bed hold in written form to the families with information regarding the bed hold. NHA A said they don't usually do this due to not always having time to get the forms to the family members.

Based on interview and record review, the facility failed to ensure that written notification required for facility-initiated transfers was given to the residents or resident representatives for two (R31 and R16) of two residents reviewed for hospitalization in the sample of 14. The facility failed to have a system in place to ensure that residents or resident representatives were given written notices upon transfers. This had the potential to affect all 35 residents that reside in the facility. The facility did not notify the resident's representatives in writing of a transfer to the hospital for Resident (R)31 and R16. Findings Include: Example 1 Record review of R31's past hospitalization s showed that on 08/12/23, R31 was transferred to the hospital for an extended stay. On 11/08/23 at 12:58 PM, Surveyor interviewed Social Worker (SW) D regarding if written notification for facility-initiated transfers for residents sent to the hospital was given to the resident and resident representative. SW D stated no. SW D explained they usually don't have time to get a signed written notice to families or residents as they are transferred to the hospital, especially during an emergency, so they call the family and explain the reason for transfer and then document that they made the call. On 11/08/23 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the transfer policy. NHA A said that when someone goes out, they immediately call the family member to inform them of the transfer. Surveyor then asked if they expected to get a notification of transfer form in writing to the families with information regarding the transfer. NHA A stated they don't usually due to not always having time to get the forms to the family members. 43352 Example 2 Review of R16's medical record revealed R16 was transferred to the hospital on 03/17/23, 04/12/23 and 07/02/23. Surveyor reviewed the medical record for 03/17/23, 04/12/23 and 07/02/23 which did not reveal written notifications for facility-initiated transfers of R16 being sent to the hospital were given to the resident and resident representative.

Based on interview and record review, the facility failed to have a system in place to verify code status desires of Resident (R) and ensure Resident wishes were accurately identified in the medical record for a Resident wishing to receive emergency care for 1 of 13 sampled Residents, R36. R36's CPR consent form, dated and signed by her on [DATE], indicates R36 as a full code. The information in the consent form was not transcribed into the medical record. When R36 was found pulseless and nonbreathing, staff did not have accurate information to know to begin CPR. Facility failure to follow the wishes identified in the consent form and begin cardiopulmonary resuscitation created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on [DATE] at 3:13 PM. The immediate jeopardy was removed on [DATE]. This is evidenced by: On [DATE] at 12:10 PM, Surveyor reviewed R36's closed clinical record. R36 was admitted to the facility on [DATE] for short term rehabilitation after hospitalization for urinary tract infection (UTI), pneumonia, [CONDITION(S)] (low potassium), and weakness. R36's goal was to return to the Assisted Living Facility where she resided prior to hospitalization . R36's Minimum Data Set (MDS) with Assessment Review Date (ARD) of [DATE] shows that R36's Brief Interview for Mental Status was not completed; however, R36's cognitive status on admission is documented as alert and oriented. R36 has a Power of Attorney for Health Care document, but this has not been activated. R36 was her own responsible party and decision maker. Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CPR consent form dated and signed [DATE] by R36 and Social Worker (SW) states that her desire is to have CPR. This CPR consent form was subsequently signed by R36's PCP on [DATE]. Face sheet in R36's clinical record dated [DATE] states, Advanced Directives: Full Code. No progress note or care plan was found that indicates R36's preference for code status. Progress notes stated, in part: [DATE] at 6:57 AM, Found at 6:25 with no pulse or respirations. [DATE] at 6:59 AM, new orders received and noted, [DATE] orders received to release body to funeral home. Coroner notified and is coming to review chart. Funeral home will be contacted afterwards. Daughter [name] to inform her that her mother has passed. Family will not be come into the facility. [DATE] at 10:55 AM, Coroner here at facility, ok to release body to funeral home. [DATE] at 10:56 AM, Time of death: 7:25, body released to funeral home. On [DATE] at 12:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN). LPN stated that residents who have a code status of CPR are given a green bracelet and that is what they look for in the event of an emergency. LPN states that there is a list of residents who want CPR posted at the nurses' station and a copy of this list is placed in a binder inside the medication cart for nursing staff to reference. On [DATE] at 1:00 PM, Surveyor reviewed CPR list for Residents admitted to the facility in [DATE]. R36's code status is listed as DNR with a documented date and time of [DATE] at 3:01 PM, meaning R36 would not have been issued a green bracelet identifying her as a full code. On [DATE] at 3:00 PM, Surveyor interviewed PCP. PCP stated that the CPR consent signed and dated by her on [DATE] would have superseded any order signed by her on [DATE] due to the possibility of resident changing her mind. R36, noted by the facility as alert and oriented and own decision maker, signed the CPR consent form on [DATE] indicating her wish for CPR during the admission process with SW. The facility did not have a process in place to ensure R36's code status was accurately reflected in the records nor did the facility include R36 on the full code list and provide R36 with a green bracelet. Facility failure to provide CPR and to contact emergency personnel - which were the resident's desires - created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] by implementing the following: All Resident records were reviewed for code status discrepancies. Code status will be reviewed prior to resident admission. Code status will be verified with all residents or their responsible party and documented upon admission by a licensed professional. Any discrepancies from previous Code Status documents or admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility verified code status will be entered into the medical record upon admission. All code status orders will be reviewed by two licensed professionals to ensure accuracy. All code status orders will be audited weekly by the Director of Nursing or her designee to ensure no discrepancies exist.

Based on observation, record review, and interview, the facility did not ensure that their infection control program included hygienic cares according to current standards of practice. This occurred for 2 of 3 resident (R) care observations, R8 and R30. The facility did not provide pericares in an hygienic manner for R8. The facility did not provide pericares in an hygienic manner for R30. The facility policy does not include handwashing after moving from a contaminated area to a clean area. This is evidenced by: The policy entitled Perineal Care Checklist, undated, states .wash buttocks and anal area, always cleaning from front to back. Rinse and dry. Remove incontinence pads and place in waste receptacle. Clean and return equipment to proper place. Remove gloves and wash hands. 1. R8 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R8's Minimum data Set (MDS) assessment, dated 05/20/21, indicated that R8 was frequently incontinent, and required 2 person assistance with toileting and 1 person assist with hygiene cares. R8's care plan, dated 06/09/21, with a target date of three months, states Potential for Urinary tract infection (UTI), related to incontinence. Interventions include: Maximize fluid intake. Assess for symptoms. Instruct in preventative measures (fluids, hygiene) .encourage fluids assist with hygiene, report changes. On 07/14/21, at 07:37 a.m., Surveyor observed Certified Nursing Assistants (CNAs) H and CNA I assist R8 with perineal cares. CNA H and CNA I were in the room when Surveyor entered. CNA H and CNA I washed their hands and donned gloves. Next, CNA H placed a basin with water, soap, washcloths and towels on a barrier covered bedside table. CNA H offered R8 a urinal. After providing resident privacy, and giving the resident time, R8 did not urinate, although R8's brief was urine soaked. Next, CNA H obtained peri wipes from a container. After obtaining the peri wipes, CNA H cleansed R8's penis cleaning from the meatus outward. Using a clean wipe in each area, CNA H cleansed R8's groin area. CNA H and CNA I assisted R8 to roll onto his right side. After rolling onto his right side, CNA H obtained a peri wipe and cleansed stool from R8's rectum. Then, using a clean wipe obtained from the container and before washing hands or performing hand hygiene, CNA H cleansed R8's outer buttock area. Barrier cream was applied by the nurse to each buttock, which showed moisture related [CONDITION(S)]. CNA H obtained a clean brief from the bedside stand and CNA H and CNA I assisted R8 to apply the brief. Next, CNA H and CNA I removed gloves and performed hand hygiene before changing R8's draw sheet and bottom sheet. CNA I gathered soiled items in plastic bags, while CNA H adjusted R8's sheets. CNA H and CNA I performed hand hygiene before leaving the room. 2. R30's MDS, dated [DATE], showed R30 is always incontinent of urine. R30 is frequently incontinent of stool. R30 requires extensive assistance with Activities of Daily Living (ADLs.) R30 requires 2 person assistance with toileting. R30's care plan, dated 06/18/21, with a target date of three months, states Impaired skin integrity related to .urinary incontinence/ fecal incontinence .Interventions include: Inspect skin daily .keep skin clean and dry use incontinent products when indicated . On 07/15/21, at 08:33 a.m., Surveyor observed CNA H and CNA I provide hygiene cares for R30. CNA H and CNA I entered the room and performed hand hygiene. After performing hand hygiene and donning gloves, CNA H obtained a basin filled with water. CNA H washed R30's face and, after removing R30's gown, CNA H cleansed R30's upper torso. After drying R30's upper torso, CNA H applied lotion to R30's torso and legs. Next, CNA I applied deodorant under each arm. Next, CNA H assisted the resident with dressing the upper torso with a shirt. CNA H removed a urine soaked brief. Then without removing gloves or performing hand hygiene, CNA H obtained peri wipes and using a front to back motion, cleansed R30 perineal area, beginning with the meatal area. Next, CNA H and CNA I assisted R30 onto right side. CNA H cleansed R30's buttock area, beginning with the surrounding area, progressing to the anus. Then without changing gloves or performing hand hygiene, CNA H dried the area. CNA H and CNA I next applied a clean brief and adjusted R30's clothes and sheets. CNA H applied A and D ointment to buttock area. CNA H placed items into a bedside table, while CNA I obtained and placed a heated blanket on R30. CNA H and CNA I removed gloves and performed hand hygiene after all cares were completed. On 07/15/21, at 09:10 a.m., Surveyor interviewed CNA H and CNA I. Surveyor asked when hand hygiene should be performed. CNA H replied that hand hygiene should be performed when hands are visibly soiled. Surveyor asked if hand hygiene should be performed when moving from a clean area to a contaminated area. Both CNA H and CNA I responded yes. CNA H responded that this was not done for R30 or R8. On 07/15/21, at 01:10 p.m., Surveyor interviewed DON B. DON B told Surveyor that hand washing should occur during perineal cares when moving from a clean to contaminated area.

Based on interview and record review, the facility did not ensure that 2 of 5 residents (Resident (R) 8 and 17) reviewed who use [MEDICAL CONDITION] drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. R8 and R17 receive [MEDICAL CONDITION] medications and did not have an attempted Gradual Dose Reduction (GDR). The facility did not have documentation of a facility team review of behaviors and non-pharmacological intervention to identify indications for use of the medications. The physician did not document a rationale if the medications would be clinically contraindicated for a GDR to be completed. This is evidenced by: Review of R8's medical record documented date of admission of 07/31/18 and with diagnoses, in part: adult failure to thrive and [MEDICAL CONDITION]. Review of physician orders [REDACTED].>07/31/18 [MEDICATION NAME] HCL (anti-depressant) 10 mg daily 0800 For: Anxiety 07/16/19 [MEDICATION NAME] (anti-anxiety) 0.5 mg by mouth twice per day 0800 1800 anxiety. Review of the Minimum Data Set ((MDS) dated [DATE] a quarterly assessment documented a PHQ - 9 score of 1. A score of 0-4 indicates having none to minimal depression severity. The MDS dated [DATE] a quarterly assessment documented a PHQ - 9 score of 0 and the same on the 11/03/18 MDS assessment. Review of MD's note, dated 12/31/18, read in part: I would agree with the medication recommendations, daughter is very hesitant to change anything without discussing with (Dr. Name) first. She plans to. if she is ok with it would switch from [MEDICATION NAME] to [MEDICATION NAME] 10 mg daily R8 did complain of depression symptoms. No further follow-up was documented. 06/12/19 DPOA-HC is agreeable to dose reduction of [MEDICATION NAME] but wants what pharmacist recommended of 0.5 mg po QHS and 1 mg in AM questioned if ok and if so will need new script. The [MEDICATION NAME] GDR was not addressed prior or after [MEDICATION NAME] dose was changed. 06/11/19 physician progress notes [REDACTED]. She is up for a trial of dose reduction on either of these medications. I am most concerned regarding the [MEDICATION NAME] which certainly can cause increased depression, worsened dementia symptoms and produce fatigue symptoms which R8 is also complaining of today Review of nurse's notes, document in part: 10/04/18 self transferring, not using call light, resident found up unassisted multiple times during shift, first looking for the bathroom and then trying to call daughter. resident redirected, reoriented reeducated to use call light and wait for assistance. 06/13/19 restlessness, propels self down the hallways and says will someone help me when asked what could we help her with she wants to go to her place (room) we then bring her there and she will return to hallway and says help me help me, this continues til she has been put to bed, we have redirected her, did 1 on 1 with her, give her M&Ms, put her music on take her to day room etc. 07/20/19 res. has been somewhat anxious today. Wheeling self in halls and going into other res. rooms. Asking for Help at times and saying I don't know where to go. 22:14 Restless and anxious after supper propelling self up and down hallway, asking staff, visitors and residents for help, When asked what she needs she wants to go to her room but when there she comes back out and starts again, needing 1:1 continuously. 07/21/19 21:55 pleasant does get restless after supper and needs constant redirection and 1:1, asking staff and visitors for help and wanting to go to room which we do and then she comes out and all is repeated. 07/23/19 Pleasant but still get anxious about going to room and calling out help, redirected and 1:1 given Review of medical record identified no documented review or summary of behaviors or non-pharmacological interventions. 07/24/19 09:15 AM Interview with DON indicated staff talk with the MD about the behaviors and wanted to talk with the daughter who is the POA and is reluctant to try any med changes. DON indicated staff chart by exception. Reviewed with DON the charting of behaviors and mood could also be R8 requesting needs to be met. Reviewed with DON no follow-up if the POA would be in agreement with GDR and no documentation of education was provided to the family. DON indicated there is no summary of behaviors were completed and what non-pharmacological interventions were tried to indicate justification for continued use of the [MEDICAL CONDITION] medication. DON indicated a review with staff on a quarterly basis with the MDS of the medications. Reviewed with DON the MD did not provide a rationale why a dose reduction was clinically contraindicated. DON indicated the MD did a dose reduction of the [MEDICATION NAME] and did not want to do a reduction at the same time for the [MEDICATION NAME]. Reviewed with DON R8 did not have two GDR attempts of the medication in the first year or rationale given to be clinically contraindicated. DON expressed understanding. Resident #17 Review of R17's medical record identified [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].>04/20/18 [MEDICATION NAME] HCL 5 mg by mouth 6 x wk. Monday Tuesday Wednesday Thursday Friday Saturday 0800 For: depression Review of behavior monitoring identified no documentation of depressive symptoms/behaviors from 01/11/17 - present. Review of the Minimum Data Set ((MDS) dated [DATE] an annual assessment documented a PHQ - 9 score of 1. A score of 0-4 indicates having none to minimal depression severity. The MDS dated [DATE] a quarterly assessment with the PHQ - 9 score = 3 and also assessment dated [DATE]. 07/24/19 9:15 AM, Interview with DON indicated daughter is very reluctant to change medications. Reviewed with DON there is no summary of behaviors were completed and what non-pharmacological interventions were tried to indicate justification for continued use of the [MEDICAL CONDITION] medication. Reviewed with DON of no documentation of education was provided to the family. Reviewed with DON the MD did not provide a rationale why a dose reduction was clinically contraindicated. DON expressed understanding.

Based on medical record review and interview, the facility did not ensure a comprehensive, individualized care plan was developed for 1 of 12 sampled residents whose care plans were reviewed (R23). R23 has a [DIAGNOSES REDACTED]. No care plan has been developed to promote sleep. This is evidenced by: On 08/08/18 at 2:50 p.m., Surveyor reviewed R23's medical record. On 09/06/16, the physician ordered [MEDICATION NAME] 3 milligrams (mgs) by mouth daily for [MEDICAL CONDITION]. Surveyor reviewed the interdisciplinary care plan and found no care plan developed for [MEDICAL CONDITION]. On 08/08/18 at 4 p.m., Surveyor reviewed R23's interdisciplinary care plan with the Director of Nursing (DON) and found no care plan for [MEDICAL CONDITION]. Surveyor requested a care plan for sleep from the DON. The DON stated she would look for it. On 08/09/18 at 8:50 a.m., Surveyor asked the DON if she found more information. The DON stated she did not have a care plan for sleep for R23.

Based on observation, interview and record review, the facility did not review and revise the comprehensive care plans for two of twelve residents (Resident (R) 29 and 23) whose care plans were reviewed. 1. R29's care plan was not updated with the use of a one-half tray table, which is located on the resident's wheelchair. 2. R23's care plan was not updated with the use of a foley catheter drainage bag. This is evidenced by: 1. On 08/07/18, Surveyor reviewed R29's medical record. The resident's Brief Interview for Mental Status (BIMS) score, dated 06/21/18, was a 03 out of 15 possible points. According to the BIMS assessment, a score of 03 indicates the resident has severely impaired cognitive function. On 08/07/18 at 8:47 a.m., Surveyor observed R29 sitting in a wheelchair, in a hallway. A one-half tray table was attached to the right side of the resident's wheelchair. At 11:41 a.m., R29 was observed eating the noon meal in a dining room. At this time, the resident was sitting at a dining room table, seated in a wheelchair. The resident was resting her right arm on the one-half tray table which was attached to the right side of the resident's wheelchair. On 08/08/18 at 6:48 a.m., R29 was sitting in a wheelchair, in a hallway. The resident was resting her right arm on the one-half tray table which was attached to the right side of the resident's wheelchair. Surveyor reviewed the resident's Certified Nursing Assistant (CNA) and comprehensive care plans. Neither care plan identifies the resident uses a tray table on the wheelchair. On 08/08/18 at 4:30 p.m., Surveyor informed the Director of Nursing (DON) R29's one-half tray table is not identified on the resident's care plan. The DON confirmed the resident's tray table is not identified on R29's care plan. On 08/09/18, Surveyor received and reviewed R29's assessment for the resident's use of the wheelchair tray table. The assessment, dated 08/08/18, states the following, in part, .SUPPORTIVE DEVICE: half tray table. BENEFITS/PURPOSE: resident's choice, enable better sitting, balance and positioning, and res (resident) likes to write as used to be teacher. PLAN: device appropriate Res demonstrated ability to pick up tray table and move to down position. On 08/09/18 at 7:07 a.m., Surveyor interviewed Registered Nurse (RN) B. RN B stated R29 has had the one-half tray table for approximately one year. At 9:05 a.m., Surveyor interviewed the DON. The DON reviewed R29's comprehensive care plan, and stated the one-half tray table is not identified on the resident's care plan. 2. On 08/08/18 at 2:30 p.m., Surveyor reviewed R23's medical record. R23 has a foley catheter with a [DIAGNOSES REDACTED]. Surveyor reviewed R23's interdisciplinary care plan which stated, Catheter care per policy-Leg bag on when up. Drainage bag on when in bed. On 08/07/18 at 12:10 p.m., Surveyor observed R23 in the dining room seated at the dinner table eating. R23 had a foley catheter with a drainage bag on. On 08/08/18 at 12:30 p.m., Surveyor observed R23 seated in a wheelchair in the dining room with a drainage bag connected to a foley catheter. On 08/09/18 at 8:10 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) A. Surveyor asked CNA A what kind of bag do staff apply to the resident's foley catheter. CNA A stated staff put a drainage bag on the resident when he is up. Surveyor asked CNA A if they put a leg bag on the resident when he is up out of bed. CNA stated no, they put the drainage bag on and put a cover over it. On 08/09/18 at 8:50 a.m., Surveyor interviewed the Director of Nursing (DON). Surveyor reviewed the interdisciplinary care plan with the DON. Surveyor informed the DON of the observations of a leg bag not used on two days of survey. Surveyor questioned the DON as to what kind of bag are the staff to place. The DON stated staff are to use the drainage bag and not the leg bag. Surveyor asked if the care plan should be updated. The DON stated yes the care plan needs to be updated.

Based on observation, interview, medical record and policy review, the facility did not ensure 1 of 3 residents reviewed for pressure injuries (R1) received the necessary treatment and services to promote healing and prevent new ulcers from developing. R1 was admitted to the facility on [DATE] with skin breakdown and multiple risk factors putting him at high risk for developing pressure injuries. His heels were intact upon admission. The facility did not prevent R1 from developing a pressure injury on his right heel, which was discovered on 07/29/17. This is evidenced by: R1's medical record states that he was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. He was admitted to the facility with skin breakdown on his coccyx (tailbone) and had multiple skin erosions on his scrotum. R1 experienced a fall prior to hospitalization and was admitted with a bruised right hip. Section M0150 of R1's Minimum Data Set (MDS) states R1 is at risk for the development of pressure injuries, and M1040D states R1 had open [MEDICAL CONDITION], and had no pressure ulcers. R1's heels were described on 07/19/17 as, No skin problems or [MEDICAL CONDITION] skin intact - no pressure area. On 07/24/17, a nurse's note states R1 now had a moderate amount of non[MEDICAL CONDITION] to his bilateral lower extremities. Subsequent notes are made stating whether R1 had [MEDICAL CONDITION], ranging from none to a trace of [MEDICAL CONDITION]. On 07/29/17, Registered Nurse (RN) G charted the outer aspect of R1's right heel had a Fluid filled intact blister with dark area but unable to measure dark area due to fluid and the surrounding tissue was reddened, blanchable states tender to touch at times around blister and measured 2.5 by 2 cm. The interventions for this pressure injury were documented as foam dressing, reposition/turning program, pressure reduction device to bed/chair, podus boots, or float heels. There is no indication R1 was provided with boots before the pressure injury was discovered. A nurse's note on 07/29/17 at 4:18 p.m. states, Dressing in place to right heel, heel protector in place at all times except with ambulation. On 07/30/17, RN H, who is the facility's Wound Care Certified nurse, described the area as unstageable - suspected deep tissue injury in evolution .Fluid filled blister with deep purple center .float heels, and or podus boots .C/o (complains of) tenderness only with touch . The facility's policy entitled Skin Integrity Policy dated 09/04/15 states, The goal of skin integrity policy is to minimize the potential for skin breakdown and prevent the development of pressure ulcers. The NPUAP (National pressure ulcer advisory panel) are the clinical practice guidelines used for pressures ulcer prevention and treatment as well as the CMS RAI (Centers for Medicare and Medicaid Resident Assessment Instrument) manual. This policy states skin is assessed daily by the CNAs providing care, and also a weekly head to toe thereafter with a visual inspection of all skin surfaces done by the CNA. Any breaks in the integrity of the skin or other skin concerns are assessed by the wing nurse and interventions implemented. This policy also lists Heel floating as one of the appropriate interventions. R1's Certified Nursing Assistant (CNA) care plan, under the section of SKIN CARE currently states, Report changes to nurse; Heel protectors on both heels when in bed, to right heel at all times, except therapy or transfers, no shoe right foot. If he refuses heel protectors in bed float heels on pillow. Reposition every 1 hour, pressure reduction mattress. ROHO cushion to chair. There is no documentation in R1's chart that R1 has refused to wear the heel protectors. On 07/31/17 at 8:40 a.m., Surveyor observed R1 in his bed with the head of the bed rolled up. Surveyor noticed R1 had green boots in a chair across his room, and asked R1 if his heels hurt, and R1 pointed to his right foot and said, That one does. R1's heels were pressing directly on the mattress. On 07/31/17 at 11:25 a.m., Surveyor asked the Director of Nursing (DON) for any information showing that the pressure injury on R1's heel was unavoidable. The facility did not provide such information. On 07/31/17 at 11:45 a.m., Surveyor observed R1 in his room, seated in his wheelchair, with his feet dressed in gripper socks, and there were no boots on his feet which were resting directly on the metal foot pedals of his wheelchair. R1 was being assisted and observed by Speech Therapist (ST) I. On 07/31/17 at 1:15 p.m., Surveyor observed R1 in his room in his wheelchair, and he was wearing the green boots. CNA A and RN B assisted R1 to the bathroom. They removed his boots for the transfer, and replaced them on his feet after the transfer. R1 did not resist when the boots were put back on his feet. On 08/01/17 at 6:14 a.m., Surveyor observed R1 in his bed. The green boots were not on his feet. There was a flat pillow at the foot of his bed, his feet were dressed in gripper socks, and his heels were pressing directly onto the flat pillow, and not suspended. Surveyor observed CNA A provide personal cares for R1 in his bed. The Surveyor asked CNA A if she knew why R1 was not wearing his green boots, and CNA A stated, I don't. CNA C entered the room at 6:18 a.m. to assist with cares. When cares were completed, the CNAs did not place the boots on R1's feet. The flat pillow was placed under R1's calves, and CNA A stated, It's ok to use a pillow if he doesn't wear the boots. The Surveyor pointed out that R1's heels were still pressing directly onto the bed, and the heels were not suspended on the flat pillow. The CNAs did not put the boots on R1's feet, nor did they go get another pillow to suspend R1's heels. On 08/01/17 at 6:45 a.m., Surveyor observed RN B provide wound care. R1 was not wearing his boots. RN B asked CNA A to boost R1 up in bed so he could eat his breakfast in bed. The head of the bed was raised to an upright position. Surveyor asked RN B if she was done with R1's cares, and RN B stated, Yes. Surveyor asked RN B if R1's heel is currently suspended, and RN B pulled back the covers and stated, There's a pillow. RN B then exposed R1's feet, and Surveyor noted R1's heels were directly pressing on the bed, and the pillow was flat. RN B moved the pillow down closer to R1's feet, but the heel was still on the bed, and RN B verified this. CNA A then stated, The boots are in the closet and took them out and put them on R1's feet. R1 did not resist when the boots were put on his feet. On 08/01/17 at 2:15 p.m., Surveyor observed R1 having his legs exercised by therapy staff in his bed. The green boots were on his feet. There was no documentation provided that R1's heels were closely monitored/inspected during cares prior to the discovery of R1's deep tissue injury. Surveyor interviewed CNA E, after the above observation. CNA E stated she was assigned to R1's hall during the previous week, and R1 usually wore gripper socks, and that we're supposed to take them off and examine them (R1's feet), and report to the nurse if we see something. CNA E stated she did not look at his (R1's heels) at all last week when she cared for him. On 08/02/17 at 6:20 a.m., Surveyor observed R1 in his bed. He was lying on his back. The green boots were on his feet; however, they were loose and twisted, and his left foot was resting directly on the top of his right foot. At 7:35 a.m., Surveyor observed R1 in his bed, and the boots were off his feet at the bottom of the bed, and his right heel was pressing directly on the bed. There was no pillow under his calves. The head of his bed was rolled up in anticipation of his receiving his breakfast tray. Surveyor asked LPN D if there was a reason why R1 was not wearing his boots. LPN D stated, Oh, he probably kicked them off; I'll put them back on. R1 did not resist when LPN D put the boots on his feet. On 08/02/17 at 8:43 a.m., Surveyor observed RN G perform wound care for R1. RN G wrote the following description of R1's pressure injury. Has partial thickness loss of skin layers that presents itself as an abrasion or blister (pressure stage 2) Bottom outer aspect of right heel .WOUND TISSUE: Deep beefy red granulation to wound bed with 0.5 cm by 0.3 cm dark discolored area to center . INTERVENTIONS: Podus boots. The measurement for the wound was 2.5 by 2.8 cm. In an interview with the DON by Surveyor on 08/02/17 which began at 9:00 a.m., the DON stated she expects the facility staff to float the heels of all residents. Surveyor asked if the facility could provide an investigation into the cause of the pressure injury on R1's heel, including interviewing staff to discover who had last looked at R1's heel. No investigation was provided. The DON agreed she would expect that an investigation would have begun when the pressure injury was discovered. She also agreed a flat pillow does not provide enough lift to suspend heels, and there should be monitoring to ensure that interventions, such as boots, are being implemented.

Based on interview and record review, the facility did not ensure each resident's drug regimen is free from unnecessary drugs. This occurred for one of three residents (Residents (R) 9) who were reviewed for unnecessary medications. R9 was given antibiotics four separate times in four months for urinary tract infections prior to the urine culture results. The culture results are used to determine what antibiotics would be susceptible to the bacterial infections and be appropriate to administer. This is evidenced by: According to the Centers for Disease Control (CDC) campaign, and the American Medical Directors Association (AMDA), Long term care facilities should have clear policies and procedures to ensure patients are not started on antibiotics without a credible clinical picture. Facilities should establish minimum criteria for initiating antibiotics, using the McGeer, Loeb, or modified Loeb criteria as a starting point (AMDA Common Infections in the LTC Setting, 2011). On 08/01/17 at 2:00 p.m., Surveyor reviewed R9's medical record and identified [DIAGNOSES REDACTED]. R9's is dependent on staff for transfers, personal hygiene and toileting assistance. Surveyor reviewed R9's nurses' notes, from 03/01/17 to 08/01/17. The notes state the following, in part: -03/01/17: The resident was appropriately treated with an antibiotic for a urinary tract infection [MEDICAL CONDITION], for five days, after the urinanalysis culture and sensitivity results returned from a lab. -03/17/17: .nurse practitioner .examined resident .new orders received .for UA (Urine Analysis) with C (Culture) and S (Sensitivity) . -03/19/17: .res. (resident) denies any UTI sx (symptoms) . -03/20/17 at 8:24 a.m.: .Fax sent to (name of primary physician) regarding UA results, UC (Urine Culture) pending, afebrile (no fever present), asymptomatic (no symptoms of a UTI present), UA/UC ordered by palliative care for c/o (complaints of) burning (with urination) .new orders received .[MEDICATION NAME] (an antibiotic medication) 500mg (milligrams) .TID (three times a day) x7 days for UTI, await sensitivity (results) . -11:19 a.m.: Fax sent to (name of a physician) regarding UC results, previously MD (Doctor of Medicine) ordered [MEDICATION NAME] .questioned if MD wants this changed . -4:14 p.m.: Fax returned with notation to continue with [MEDICATION NAME] . The culture and sensitivity reports are conducted in order to determine if the bacteria present in a resident's urine will be susceptible to different types of antibiotic medications. R9 was administered an antibiotic medication for a UTI, prior to the results of the urine culture and sensitivity report, and without any documented rationale for the antibiotic's use prior to the UC. R9's nurses' notes continue to state, in part: -04/18/17: Fax sent to (name of primary physician) that (resident) continues with loose stools despite increasing [MEDICATION NAME] (sic) .Notation that attempting to get multistick (urine test strip or dipstick) d/t (due to) c/o burning with urination, if positive questioned if MD wants a UA/UC sent (to lab) .Fax returned (from physician) .may obtain UA/UC if multistick is (positive) . It is noted, a resident with loose stools may be more susceptible for having UTIs, as fecal matter may become present in the urethra. -04/19/17: Fax sent to (primary physician) regarding UA results, notation UC pending . -04/20/17: Consulted with (primary physician) over the phone regarding current UTI and treatments. Fax returned with orders for [MEDICATION NAME] (an antibiotic medication) 500mg (every eight hours) x 10 days . -04/24/17: SENDING FAX TO: (primary physician) with UC results .FAX RETURNED: From (a physician) to take antibiotics as prescribed (for UTI) . R9 was administered an antibiotic medication for a UTI, prior to the results of the urine culture and sensitivity report, and without any documented rationale for the antibiotic's use prior to the UC. R9's nurses' notes continue to state, in part: -06/16/17: .nurse practitioner .saw resident in facility .RESULT: new orders received and noted .UA/UC for burning with urination . -06/17/17 at 10:58 a.m.: Call received from .NP (Nurse Practitioner) .stated she reviewed UA results on patient and reviewed last few UA/UC results .and she requests to hold off on treating until UC is back. She will call back when UC is finished with treatment orders. -1:24 p.m.: Call received from .NP regarding UC preliminary is growing bacteria she would like to treat her with previous treatment of [REDACTED].[MEDICATION NAME] 500mg .(every eight hours) x 10 days for UTI . -1:30 p.m.: URINARY FINDINGS: no problems noted denies any: frequency, urgency, burning, -06/18/17: Call received from .NP .reviewed UC results new orders received and noted .to D/C (Discontinue) [MEDICATION NAME] and start on Bactrim (an antibiotic medication) .BID (twice a day) x 5 days . Surveyor reviewed R9's Medication Administration Record [REDACTED]. R9 was administered an antibiotic medication for a UTI, prior to the results of the urine culture and sensitivity report. R9's nurses' notes continue to state, in part: -07/03/17: The resident was appropriately treated with an antibiotic for a UTI, for seven days, after the urinanalysis culture and sensitivity results returned from a lab. -07/20/17: Fax sent to (primary physician) regarding resident has been very weepy and anxiou(s), c/o tenderness to peri area when she voids again, multistick checked and very positive .questioned if ok for UA/UC .new orders received .UA/UC . -07/23/17: The resident's UA needed to be repeated. -07/24/17: Fax sent to (physician) regarding UA results, UC pending .new orders received .[MEDICATION NAME](an antibiotic medication) 500mg .BID x 7 days-resident is allergic to this medication .so MD was called and a message left to clarify orders. Order not implemented as of tonight . -07/25/17 at 9:28 a.m.: Spoke with (name of primary physician's) nurse reviewed UA results with UC pending, allergy [MEDICATION NAME] was ordered yesterday .Stated she would consult with (physician) . -9:32 a.m.: New orders received .D/[MEDICATION NAME] start Bactrim single strength BID x 5 days (for UTI) . -1:47 p.m.: Fax sent to (physician) .with UC results-has been started on Bactrim . -3:33 p.m.: Fax returned from (physician) with notation 'Looks like it (bacteria) is susceptible to Bactrim so may continue this' R9 was administered an antibiotic medication for a UTI, prior to the results of the urine culture and sensitivity report, and without any documented rationale for the antibiotic's use prior to the UC. On 08/01/17 at 7:05 a.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated nursing staff try to educate the doctors on the facility's policy when ordering antibiotics for UTIs, but the nurses may not have necessarily documented this education. The DON indicated the facility follows the McGeer standard of practice criteria when testing and treating a resident for a UTI. On 08/02/17 at 2:18 p.m., Surveyor interviewed the DON. The DON indicated the facility's protocol is to not start a resident on an antibiotic medication before the culture and sensitivity results for a UA returns.

Based on record review and interview, the facility did not complete a comprehensive pain assessment, and use a standardized pain assessment scale, for a resident with cognitive deficits. This occurred for one of four residents (Resident #2), who are cognitively impaired, who were reviewed for pain. Resident #2 has cognitive impairments and is not able to consistently use a numerical pain rating scale. No other pain rating scales were used to rate Resident #2's pain. The facility did not complete a comprehensive pain assessment. This is evidenced by: On 08/31/16, Surveyor received and reviewed a facility policy entitled, PAIN MANAGEMENT POLICY AND PROCEDURE. The policy, last revised 10/30/14, states the following, in part: .Our goals are: Identify and manage pain, Meet the client's comfort level goals . Process .Clients will also be assessed as appropriate at each MDS (Minimum Data Set) and condition change .Pain is the fifth vital sign .The client's perception of pain or self-report of pain will be the standard for determining their individual pain level. For the alert and oriented client, a scale of 0-10 will be used. For the cognitively impaired client or the client who is unable or unwilling to use the 0-10 scale, nonverbal symptoms of pain will be assessed and evaluated within the context of the client's clinical condition .The RN (Registered Nurse) competing the comprehensive assessment will identify client-centered goals, develop or review the plan of care and implement approaches. On 08/30/16 at 10:03 a.m., Surveyor reviewed Resident #2's medical record. Resident #2 has [DIAGNOSES REDACTED]. As of 08/30/16, Resident #2 was receiving the following medications for pain management: -Tylenol Extra Strength 1,000 milligrams (mg) at 8:00 a.m. and 4:00 p.m.; and every six hours as needed (PRN) -[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5 mg-325 mg, every four hours as needed for moderate to moderately severe pain Resident #2 receives [MEDICATION NAME] (an antianxiety medication) 0.25 mg, every six hours as needed for anxiety. Resident #2's most recent Brief Interview for Mental Status (BIMS) score, dated 08/04/16, was a 07 out of a possible 15 points, indicating severe cognitive impairment. Surveyor reviewed Resident #2's nurses' notes, from 02/01/16 to 09/01/16. The nurses' notes state the following, in part: -02/08/16: .Resident verbalizes pain, Acute Pain Level= 5/10, Pain is continuous . -04/21/16: Progress Notes .At 8:30am res. (resident) noted to be very anxious. C/o (Complaints of) right leg aching and was saying 'I've never had this before. What's wrong with me?' then saying 'Help me Jesus'. Distressed look on face. Shakey (sic). Given sched. (scheduled) Tylenol and prn [MEDICATION NAME] . -04/30/16: Resident #2 fell , hitting the head and sustaining a small, left pelvic fracture. -05/01/16: .General Pain Comments= Given for 'a little' pain in right upper leg. Res. unable to rate or describe the pain. The nurses' notes do not identify the medication given to Resident #2 for pain management. -05/02/16: A physician ordered [MEDICATION NAME] (used to treat pain) 50 mg, every six hours as needed. -05/03/16: .[MEDICATION NAME] .given for pain. PAIN LEVEL BEFORE MED (Medication): not applicable. FACIAL EXPRESSION: facial grimacing (2) (two times). BODY LANGUAGE: rigid; fists clenched; knees pulled up; pulling or pushing away; striking out (2) . -05/05/16, 5:50 a.m.: .[MEDICATION NAME] .given for pain. PAIN LEVEL BEFORE MED: not applicable. LOCATION: Left pelvic area. FACIAL EXPRESSION: facial grimacing (2). BODY LANGUAGE: rigid; fists clenched; knees pulled up; pulling or pushing away; striking out (2). CONSOLABILITY: unable to console, distract, or reassure (2) . -1:28 p.m.: .[MEDICATION NAME] .given for pain .PAIN LEVEL BEFORE MED: not applicable Res. unable to rate .left pelvic area . -05/19/16, 7:56 p.m.: .[MEDICATION NAME]-[MEDICATION NAME] .for c/o throbbing pain in right hip radiating all the way to the right foot .PAIN LEVEL BEFORE MED: 10/10 . -8:16 p.m.: .[MEDICATION NAME] .given for anxiety related to pain, PRN pain meds given and resident continued to calling out and yelling . -05/20/16: .[MEDICATION NAME]-[MEDICATION NAME] .given for pain. PAIN LEVEL BEFORE MED: not applicable, Res. unable to rate . -05/21/16: .[MEDICATION NAME]-[MEDICATION NAME] .given for pain Not able to give a number but resident has facial grimacing and it (sic) yelling out in discomfort . -05/23/16: anxiety calling out 'please and help' Staff assisted her to bedside commode and back into bed and she rang to get back up stating 'I just don't know what I want. This leg hurts me so' Given PRN [MEDICATION NAME] and [MEDICATION NAME] . -05/29/16, 9:53 a.m.: .[MEDICATION NAME]-[MEDICATION NAME] .given for pain. PAIN LEVEL BEFORE MED: not applicable, res. unable to rate . -10:19 p.m.: .[MEDICATION NAME] .given for pain/discomfort. PAIN LEVEL BEFORE MED: not applicable, Calling out, 'Please help me, my back hurts so terrible.' . -10:21 p.m.: .[MEDICATION NAME] .given for restlessness, calling out . -05/30/16: .Aplrazolam .given for anxiety repeated calling out and yelling for help. Given under direction of RN .CURRENT PAIN LEVEL: unable to answer pain level when questioned, c/o pain to right hip . -06/01/16: .[MEDICATION NAME] .given for pain/discomfort .PAIN LEVEL BEFORE MED: 9/10 . -07/20/16: .[MEDICATION NAME] .given for pain/discomfort .CURRENT PAIN LEVEL: unable to answer when questioned, c/o pain all over . -08/28/16: .[MEDICATION NAME]-[MEDICATION NAME] .given for questionable pain . -08/30/16, 6:00 p.m. .[MEDICATION NAME]-[MEDICATION NAME] .given for questionable pain, resident restless and anxious . -6:42 p.m.: (Resident #2's name) is alert and able to state that she has pain but d/t (due to) her dementia her ability to describe or rate pain or express the need/type of [MEDICATION NAME] is impaired, when she is asked regarding pain she does deny having pain . -08/31/16: [MEDICATION NAME]-[MEDICATION NAME] .given for suspected pain and discomfort . Resident #2 is not able to consistently rate her pain on a numerical scale, and the facility is not administering consistent medications to treat the pain. There is no documentation in the medical record of a standardized self-pain assessment scale for a cognitively impaired resident, used to assess Resident #2's level of pain. On 08/31/16, Surveyor received and reviewed Resident #2's most recent pain assessments. The pain assessments state the following, in part: -07/30/16: CURRENT PAIN LEVEL: 00/10 no pain. BEEN ON A SCHEDULED PAIN REGIMEN? Yes. RECEIVED PRN PAIN medications: [REDACTED]? no .RESPONSE TO medications: [REDACTED]. RESPONSE TO TREATMENT: treatment effective . -08/27/16: CURRENT PAIN LEVEL: 00/10. BEEN ON A SCHEDULED PAIN REGIMEN? Yes. RECEIVED PRN PAIN medications: [REDACTED]? yes . The facility does not thoroughly assess Resident #2's pain including location, root cause, duration, intensity of pain, precipitating factors, non-pharmacological interventions for pain management, or the effectiveness of interventions. On 08/31/16, the facility informed Surveyor the Wong-Baker FACES Pain Rating Scale is used on those residents who are cognitively impaired. According to the Wong-Baker scale, the resident must be able to understand the instructions and select a face on the scale, which corresponds to the level of pain the resident is currently experiencing. There is no documentation in Resident #2's medical record the facility has used the Wong-Baker FACES Pain Rating Scale, or other scale for the cognitively impaired. According to the Resident Assessment Instrument (RAI) Manual, Pain Assessment Interview (Page J-6), it states, in part, .Resident self-report is the most reliable means for assessing pain. Pain assessment provides a basis for evaluation, treatment need and response to treatment .Pain assessment prompts discussion about factor that aggravate and alleviate pain .Consistent use of a standardized pain intensity scale improves the validity and reliability of pain assessment. Using the same scale in different settings may improve continuity of care. Pain intensity scales allow providers to evaluate whether pain is responding to pain medication regimen(s) and/or non-pharmacological intervention(s) . The RAI manual provides instruction on how the facility should complete the MDS, which the facility identified in their pain management policy. On 09/01/16 at 9:01 a.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated the nurses try to use the 0-10 numerical pain scale for Resident #2 when the resident is able. When Resident #2 is not able to use the number scale, the nurses should be using the Wong-Baker scale, or assessing Resident #2's non-verbal signs and symptoms of pain.

Based on observation and interview, the facility did not provide pharmaceutical services, including procedures which assure accurate acquiring, receiving and dispensing of all drugs and biologicals, in of 1 of 3 nebulizer treatment observations. Resident #7 was left alone while a duo-neb updraft was running for approximately one hour, and was not cognitively able to self-administer medication. This is evidenced by: Resident #7 has a brief interview for mental status score of 4, on the most recent Minimum Data Set (MDS) with Assessment Reference Date of 06/23/16. This means Resident #7 has severe cognitive impairment. The physician orders [REDACTED].>Duo-Neb solution, 3 ml (milliliter) inhalation twice per day . On 08/31/16 at 8:58 a.m., Surveyor observed Resident #7 with a nebulizer mask on and the machine running as Resident #7 sat in her chair. Registered Nurse (RN) A was down the hall by the medication cart. RN A went to enter Resident #6's room to pass medications. Surveyor continued to observe the updraft running. Next, RN A went into another resident room to pass medications. At 9:20 a.m., the mask was still on Resident #7; there was no medication dispensing at this time. At 9:35 a.m., a Certified Nursing Assistant walked by Resident #7's room and went to RN A and told the nurse the treatment was done. At 9:41 a.m., RN A went into Resident #7's room and removed the mask. Resident #7 had indentations from the mask on both sides of her face, from her ears to her mouth. Surveyor asked RN A how long the updraft had been running. RN A replied, Longer than it should have. Surveyor asked if Resident #7 had been assessed to self-administer her medication. RN A said she would check on that. At 9:53 a.m., RN A told Surveyor that Resident #7 did not have a self-administer assessment or order, and to the best of her recall, she started the nebulizer treatment at 8:30 - 8:40 a.m RN A acknowledged she should not have left Resident #7 after the duo-neb treatment had started.

Based on record review, observation and staff interviews, the facility did not provide adequate supervision and assistance devices to prevent accidents for 3 (Residents #14, #6 and #1) of 14 sampled residents assessed to be at risk of falls. The facility's approach to resident safety did not include a systematic approach to evaluate and analyze hazards and risks, and the monitoring for effectiveness and modification of implemented interventions when necessary for three residents who experienced an accident/fall. 1. Resident #14 had falls on 07/09/13, 07/27/13, 07/29/13, 8/14/13, 08/16/13, 09/06/13, 10/14/13, and 10/22/13. On 07/27/13, Resident #14 sustained a laceration on the back of her head that required transport to the emergency room and nine staples to close the wound. The facility did not place new interventions or supervision to prevent further falls and injury. The facility did not investigate and identify the root cause of each fall. 2. Resident #6 had a history of [REDACTED].#6 fell , and again on 07/02/13 at 5:45 a.m. Later in the day of 07/02/13, Resident #6 was diagnosed with [REDACTED]. Resident #6 continued to have numerous falls where the facility did not promptly implement interventions after each fall to prevent further falls or thoroughly investigate the falls. 3. Resident #1 had four falls between 09/16/13 and 11/11/13 and a history of other falls. The facility did not implement additional interventions or increased supervision after each fall to prevent further falls. They did not fully investigate and document the circumstances of each fall. This is evidenced by: On 11/13/13, Surveyor requested a copy of the facility fall policy and procedure. On 11/14/13 at 7:55 a.m., the Nursing Home Administrator (NHA) provided Surveyor with an undated document titled: "Fall Management Program" which read in part as follows: "This is an interdisciplinary approach designed to assist the facility in providing individualized, person-centered care for improving fall care processes and outcomes through education and quality improvement. Chippewa Manor Nursing Home (CMNR) utilizes American Medical Director Association (AMDA) Falls and Fall Risk Clinical Practice Guidelines. Our efforts will focus on minimizing fall risks and the risk of fall related injuries while maximizing individual dignity, freedom and quality of life. Fall Risk Assessment All residents will be assessed upon admission, quarterly and as needed for their risk of falls using the Briggs Fall risk assessment tool. Interventions will discussed with residents and family member and implemented as deemed necessary. All residents who experience falls will be assessed and a Post Fall Investigation and Intervention plan will be documented. Casual or contributing factors will be identified and Interventions and care plan approaches implemented based on that assessment. " 1. On 11/13/13, Surveyor reviewed Resident #14's medical record and noted Resident #14 had eight falls between 07/09/13 and 10/22/13. Resident's Brief Interview for Mental Status (BIMS) scores on most recent Minimum Data Set (MDS) indicated moderate memory impairment (scores included 10 out of 15 on 7/8/13, 7 out of 15 on 7/22 and 7/29). On 11/13/13, Surveyor was provided the following copies of documentation of incidents and noted the following entries which read in part as follows: 07/05/13 at 9:09 p.m. "Res (resident) took off sweater she was wearing which had TABS unit attached to it and walked self to the bathroom without assistance. Res did not have call light on. Res was reminded to use call light and to wait for assistance." 07/09/13 at 9:57 a.m. "INCIDENT TYPE: Found down (unwitnessed) Laceration approximately 2 cm (centimeters) wide and 0.1 cm long. Does not appear suspicious d/t (due to): Resident was found down, when questioning resident stated (I had to go to the bathroom.) I reminded resident to use her call light and ring for assistance. Resident has taken TABS monitor off herself in the past. This writer was with this resident last, TABS monitor was hooked to the shoulder of the residents pajamas. When found, resident's TABS were hanging off the monitor box, by the, magnet. Resident could not recall what she hit her head on or that she even hit her head." "Date of Incident: 07/09/13 Time of Incident: 9:40 a.m. Size/Location: center of forehead approx 2-3 cm wide by 0.1 cm long. Found down from where: wheelchair Where did incident occur: room(wheelchair was parked with brakes on, in from of bed side stand directly across the room from bathroom door). Resident found sitting on the floor, legs stretched out in from of resident approx (approximately) 2-3 feet from bathroom door. Mental state: CNA's (Certified Nursing Assistants) alerted this writer that resident was not (herself). This writer entered the room and assessed resident, and had findings of confusion, slight difficulty to arouse, and weakness upon standing. Resident suspected of removing her TABS alarm (as she has done this in the past) and was self transferring to the bathroom. Call light was not on. First Aid: Immediately applied, area cleansed left open to air. Known Cause: Removed own TABS. Personal Alarm Sounded: No. Actions: Resident toileted, and frequent reminders to use call light, TABS monitor reapplied. Teaching done: Instructed on use of call light, waiting for assistance." The facility reapplied the tabs alarm even though they were aware the resident removes it. No new interventions were implemented despite the fact that the resident's BIMS score is a 10 out of 15 (moderate impairment) and reminders to use call light have been ineffective in the past. "07/27/13 at 11:27 a.m. Incident type: Found down (unwitnessed). Date of Incident: 07/27/13. Time of incident: 11:00 a.m. Found down from where: bedroom doorway into the hall. Where did incident occur: doorway into the hall. Activity at time: Ambulating in room. Injury: 3 inch laceration noted in the back of her head. Moderate amount of bleeding. Pressure dressing applied immediately. Bleeding ceased. Pressure dressing applied. Reasonable Cause: Lost balance, res noted to have her tabs monitor laying underneath her and was alarming. 5 minutes prior to her fall she was noted to be sitting quietly in recliner eating ice cream. Personal alarm sounded; yes. Personal alarm re-applied: Yes. Actions: No obstructive walkway lighting is adequate No trip hazards Keep within line of sight. Teaching done: Use of call light Mental state: Normal for resident confused, impulsive." No new interventions were implemented despite the fact that the resident's BIMS score is now a 7 out of 15 (moderate impairment) and reminders to use call light have been ineffective in the past. "07/27/13 at 11:37 a.m. Spoke with Medical Doctor (MD) on call to question need for sutures. Ok to send to SHH (Sacred Heart Hospital) ER (emergency room )." "07/29/13 at 7:08 a.m. F/U (Follow Up) Incident: Fall Injury: laceration (9 staples to the back of the head)" "07/29/13 at 1:47 p.m. Incident Type: Found down (unwitnessed) Date of incident: 07/29/13 Time of Incident: 1:15 p.m. Found down from where: Recliner Where did incident occur: room-found on knees at foot of recliner and had arms resting on arm chair next to recliner. Mental state: Normal for resident Activity at time: Ambulating to/from bathroom without assistance Injury: No apparent injury. Personal alarm sound: Yes Personal alarm re-applied: Yes. Actions: Resident's daughter was questioning if resident would benefit from a walker (therapy made aware). Teaching done: Instructed on using call light and waiting for assistance from staff." "07/29/13 at 8:41 p.m. F/U Incident: Resident was found down on 07/27/13 at 11 am and 07/29/12 at 1:15 p.m. Resident did sustain injury from fall on 07/27/13 - Laceration to back of head needing staples. RC: Cognition - Confusion.dementia, Gait d/t Parkinson. Continence currently being treated for [REDACTED]. Resident also likes to keep busy and feel like she is doing something productive. Big bright sign that says, (Ring for help) was applied to her bedside table, and closet door in hopes to remind her to ring for help. Resident has also been provided with activities to her busy/productive. ie folding laundry and sorting cards." The son stated that the resident was very regimented in her schedule, and the last three falls have occurred going to the bathroom, yet no toileting plan was added. "08/14/13 at 1:44 p.m. Incident Type: Resident found sitting on foot rest of recliner (recliner tipped up, with back of recliner off the floor). No injury noted. Date of incident: 08/14/13. Time of incident: 1:30 p.m. Found down from: Recliner Where did incident occur: room. Mental state: Normal for resident unable to recall why she is trying to get up. Resident toileted 10 minutes prior to being found. Activity at time: Attempting to get out of recliner, resident unable to state why she was getting up. Known Cause: attempting to get up without staff assist. Actions: Brought resident up to nurses station to be monitored. Teaching Done: Instructed on Use of call light waiting for assistance." "08/14/13 at 9:31 p.m. F/U Incident: Resident was found sitting on foot rest of recliner with the foot rest on the floor and the back part of the recliner tipped up. No injury, tabs alarm sounded. INTERVENTIONS/RECOMMENDATIONS: RC: Intrinsic-Poor balance, up without assistance and impulsive, resident often forgets to use call light. Extrinsic: her recliner not appropriate for her will replace recliner." "8/16/13 at 2:09 p.m. Incident type: Found down (unwitnessed) sitting on recliner footrest as recliner was tipped forward. Does not appear suspicious d/t: Behavior normal for resident, Resident has history of self transferring. Date of Incident: 08/16/13 Time of Incident: 1:20 p.m. Mental State: Normal for resident Alert orient to, person and place at times. Resident has history of confusion at times. Personal alarm sounded: Yes Personal alarm re-applied: Yes. Actions: Food/fluids offered, toileted resident. Teaching done: Instructed on use of call light waiting for assistance." "08/16/13 at 8:48 p.m. F/U Incident: INTERVENTIONS/RECOMMENDATIONS: RC: Intrinsic: Cognition resident is impulsive and does not ring/or wait for assistance. Appears resident attempted to self transfer out of recliner and was unable to get foot rests down to get to a standing position. Will no longer use foot rests while sitting in recliner." "08/30/13 at 11:00 p.m. MOOD: Res continues to attempt to self transfer and gets upset when TABS alarm is activated. Res also upset with staff when they respond to TABS alarm. Res stated that she (is not a baby) and (she is sick and tired of being told what to do.) Res insisted on walking to dining room without staff assist and without her walker. Staff followed res with her wheel chair." "09/06/13 at 9:02 p.m. Incident type: Found down (unwitnessed) Resident found sitting on floor between her stationary chair and the wall facing her closet. Date of incident: 09/06/13 Time of incident: 8:00 p.m. Found down from where: Stationary chair in room working her cross word puzzle. Activity at time: Getting up unassisted. Injury: Resident has a approx 2 cm in diameter red raised area to left forehead with 1 cm abraded area, residents right cheek bone and eye area noted to be pink and puffy. First Aid: Immediately applied, ice applied to areas on head. Personal alarm sounded: No staff interviewed and stated that it was in place when she was placed in chair, resident has been known to un-hook her tabs monitor. Personal alarm re-applied: yes. Actions: Pain assessed/meds given Resident denies pain after or prior to fall. Medications reviewed. Received all scheduled medications. Environment assessed: call light was within reach and personal items within reach. Will continue with low bed, toileting program, grippy socks and mobility monitor, will have staff only place tabs monitor to middle of back so she is unable to un-hook it independently. Teaching done: Use of call light and waiting for response." The tab alarm is continued even though the facility is aware she is upset by the alarm and she removes it. "09/09/13 at 8:22 p.m. F/U Incident: Interventions/Recommendations: Room was rearranged and trash can placed within reach when in stationary chair, will also encourage staff that if her mobility monitor goes off 3 times in 20 minute time frame to assist with a change in scenery. Tabs will be placed in center of mid back so resident is unable to hook independently so easily." "10/14/13 at 7:37 a.m. Incident type: Found down (unwitnessed) Other:(specify) Abrasion in back along spine 1.2 cm wide x 7 cm long Date of incident: 10/14/13 Time of Incident: 6:15 a.m. Activity at time: Getting out of bed Known cause: Failure to use call light, getting out of bed alone Personal alarm sounded: No-unhooked by resident, on bed. Personal alarm re-applied: Yes. Action: Personal alarm placed-continued; low bed continued; Nonslip footwear/grippy socks worn; Room is clutter free continued; Non obstructive walkway continued; Teaching done: reinforced to call, leave tabs unit alone, have assistance." "10/22/13 at 3:53 a.m. Incident type: Found down (unwitnessed) Date of incident: 10/22/13 Time of incident: 3:35 a.m. Found down from where: chair. Activity at time: Getting up from recliner/chair Resident states she did not know where she was going. She had her water mug in her hand. Injury: None. Personal alarm sounded: No Resident unhooked it. Personal alarm re-applied: Yes. Actions: Needed items placed closeby. Teaching done: Instructed on Use of call light." On 11/13/13 at 12:30 p.m., Surveyor interviewed the Director of Nursing (DON) regarding the above falls and process for follow up. The DON stated, "We have a fall team that meets monthly where we review all the falls for the month." Surveyor asked the DON who the members are." The DON replied, "Myself, the p.m. nursing supervisor, the restorative nurse/restorative CNA, a night shift CNA, social services, activity staff and a staff member from housekeeping." The DON went on to explain the process of the fall team during the monthly meeting which is: "We go over and review the falls for the month, we look at patterns and any trending, the time of day, time of shift, if a resident has multiple falls, and the root cause." Surveyor asked if the fall reports are reviewed daily by anyone? The DON replied, "When I am here I review them with the p.m. nursing supervisor at which time we look at the root cause and if the interventions are related to the root cause. Some of the interventions we utilize are: orthostatic blood pressures, refer to therapy, we look at where did they fall from." On 11/13/13, review of Resident #14's document titled "Care Plan" dated 06/29/13 with "PROBLEM identified as "Potential for injury Potential for Trauma-Falls" RELATED TO: Decline in functional status, unsteady gait which read in part: APPROACHES: Nurses --- Observe, record and report all unsafe conditions and situations. Monitor neuro status. PRN (as needed), Encourage to ask for assistance. Instruct resident in use of adaptive equipment, monitor closely. Instruct on safety. Assess change in level of consciousness, instruct on safety. Update MD PRN, Nurse Aide --- Encourage to ask for assistance, call light in reach, assist with ambulating, transferring toileting. Anticipate needs, Bed at appropriate height, Report unsafe behavior to the nurse, 07/29/13: Nurse Aid--- Offer activities i.e.: folding laundry and sorting cards. Big bright sign to bedside and closet door to remind to ring for help. 09/09/13 Nurse Aid--- if mobility monitor alarms 3 times in 20 minute time frame offer a change of scenery." No further information was provided. 2. Upon review of Resident #6's medical record beginning on 11/12/13: Resident #6 experienced a fall on 07/01/13 at 11:45 p.m. At this time the resident was independent in ambulation and was walking back from her bathroom. Resident #6 fell again at 5:45 a.m. while ambulating to and from the bathroom. Following this fall, the facility completed a multistick check to rule out a UTI (urinary track infection). The facility then considered the changes in medication (Gabapentin and Vicodin) as possible contributors of the falls. The resident was then sent to the ER for evaluation of change of condition. It was determined that weakness was likely related to hyponatremia. At this time the resident was also diagnosed with [REDACTED]." A mobility monitor was initiated on 07/05/13 and on 07/11/13 an intervention of placing bed in lower locked position was added. A 09/16/13 10:29 p.m. nurses' note identified Resident #6 fell on [DATE] at 8:50 p.m. from her wheelchair in her room. Resident #6 reported to staff she had bumped her head. This nurse's note read in part: "REASONABLE CAUSE: up without assistive device up without staff assist PERSONAL ALARM USED: Yes PERSONAL ALARM SOUND: No Resident removed it PERSONAL ALARM RE-APPLIED Yes ACTIONS: Assisted and placed in/on Bed bedside mats applied TEACHING DONE: Instructed on waiting for assistance" The facility staff did not implement additional interventions or increase supervision to prevent further falls. They re-applied the alarm, despite knowing Resident #6 was able to remove the alarm so it would not sound. Resident #6 had the [DIAGNOSES REDACTED]. Instructing Resident #6 on waiting for assistance was an inappropriate approach given her cognitive status. On 09/17/13, a nurse's note identified they would have Occupational Therapy (OT) evaluate resident for wheelchair positioning and fit and involve Physical Therapy for gait and balance. A nurse's note of 10/04/13 at 9:59 a.m. read in part: "INCIDENT TYPE: Found down (unwitnessed). ... reddened area on left forehead approximately 2 inches long by 1/2 wide. It has since disappeared and no swelling or bruising noted to that area. Loud bang noted from residents room and she was found sitting under her tray table in the middle of the room on her right side with puzzle pieces noted to be under the table that she was concerned about. TIME OF INCIDENT: 7:00 a.m. INJURY: No apparent injury FIRST AID: attempted to apply an ice pac to her forehead but she refused PERSONAL ALARM USED: No PERSONAL ALARM SOUNDED: No PERSONAL ALARM RE-APPLIED Yes" "ACTIONS: Medications reviewed Environment assessed: Room is clutter free Non obstructive walkway lighting is adequate Nonslip footwear/grippy socks CAM boot on Needed items placed closeby Remains on 1 hourly checks TEACHING DONE: waiting for assistance." This is the first mention of Resident #6 being on hourly checks. A nurse's note at 9:36 p.m. on 10/04/13 read: "F/U INCIDENT: Resident was found down at 7 a.m. this date found sitting under tray table in her room. It appears she was attempting to pick up a puzzle pice (sic) she was working on off the floor. RC (root cause): Sleep deprivation resident had not slept all night, cognition resident is confused and restless. Will continue with hourly rounding, low bed, roll bolster, tabs, non skid foot wear." The nurses' notes related to Resident #6's 7:00 a.m. fall on 10/04/13 did not include documentation as to why Resident #6's personal alarm was not in use and since it was not in use it would not sound. Surveyor requested the facility's investigation of this fall. Surveyor was provided with a hand written note from the DON on 11/14/13 that read "RCA (root cause analysis) of 10-4 fall was she leaned forward to pick up a puzzle off of the floor. Eval of current intervention found appropriate." The facility did not investigate to determine why the personal alarm was not in use. A nurses' note of 10/04/13 of 10:11 p.m. identified Resident #6 was found sitting on the bathroom floor at 7:00 p.m. Resident #6 had been in bed sleeping. The note identified her personal alarm was sounding. No apparent injury was noted. "ACTIONS: Continue with care plan that is in place." No additional interventions, root cause analysis or increased supervision were implemented after this fall. A nurses' note of 10/05/13 at 10:32 a.m., identified Resident #6 had a witnessed fall in her room at 10:15 a.m. "ACTIVITY AT TIME: had been in w/c wheeling self about. tabs alarm sounded and res. found by staff to be standing up from w/c next to bed. Lost balance and fell on to bed. ACTIONS: assisted by staff in bed. bedside mats applied." A nurse's note of 10/14/13 at 11:26 a.m. identified Resident #6 had a witnessed fall in the lobby at 11:05 a.m. "KNOWN CAUSE: Lost balance Slipped (specify) Possibly from CAM boot. Res had been sitting in w/c in lobby quietly looking out windows, suddenly stood up to likely self transfer, knees buckles and res went down slowly landing on her butt and back. Did not hit head. TABs alarm sounded but staff unable to reach in time to prevent fall. ACTIONS: Will check orthostatic B/Ps (blood pressures) and review current meds. Res has appt (appointment) with Ortho MD (orthopedic medical doctor) this week for possible removal of CAM boot. Will then be able to walk resident more to assist in strengthening in ambulation. OT for w/c positioning was recently done with no new recommendations." Resident #6 was wearing the CAM boot on her left lower extremity as a result of the distal fibula fracture diagnosed [DATE]. The note identified the CAM boot was possibly slippery. At 1:14 p.m. on 10/14/13, a nurse's note read: "res. con't (continued) to be restless. Wheeling self up and down halls. Found standing up next to bed with Tabs unit unhooked, had been in place." A 10/22/13 10:03 p.m. nurses' note identified Resident #6 had been in wheelchair in the hallway, went into her room and at 6:45 p.m. was "noted by CNA to be sitting on the mat next to the right side of her bed. Res had removed the TABS alarm from her clothing ..." "ACTIONS: Continue to follow current care plan." On 10/23/13 at 9:44 a.m., a follow up incident note read: "Resident was found down on 10/22/13 at 6:45pm with no injury. RC: Intrinsic: Self transfer attempt is impulsive d/t (due to) her progressing dementia, UTI (urinary tract infection) resident had a positive multistick and UC (urine culture) is pending some of her confusion/attempting to transfer could be from that as well. Will attempt to see if there is a pattern to her daily routine to intercept some of these transfer/toileting attempts." Nurses' notes identify that Resident #6 had exited from her low bed and was found on her floor mat on 10/25/13 at 9:15 p.m. and 11/10/13 at 1:45 a.m. The notes identify her personal alarm was sounding. They do not identify when Resident #6 had last been seen prior to being found on the floor mat or when she had last been toileted. Surveyor found two documents in Resident #6's medical record. One of these read: "1/2 Hourly Rounding" Resident #6's first name and last initial were on the sheet. A place to write "Week of:___________" was blank. It identified night shift for Friday the 4th and Saturday the 5th. There was no month or year on the sheet. There were initials for each half hour for the 4th. For the 5th, there were initials for hourly checks. The sheet that read "Hourly Rounding" for Resident #6 identified it was for the week of 09/29-10/05. No year was identified. This sheet was for the day and evening shift from 7:00 a.m. to 11:00 p.m. The spaces for the initials for hourly rounding on the 29th were all blank, for the 30th 11 spaces were blank, the 1st 14 spaces were blank, the 2nd 1 space was blank, the 3rd 6 spaces were blank, the 4th 13 spaces were blank and for the 5th 2 spaces were blank. Resident #6's care plan for falls identified the last interventions added were dated 09/26/13 and included roll bolster to right side of bed and wedge cushion to wheelchair with non-slip mats on top and bottom of cushion. 3. On 11/11/13 beginning at 11:20 a.m., Surveyor observed Certified Nursing Assistant (CNA) G and Licensed Practical Nurse (LPN) H provide personal cares for Resident #1. During this care observation, Surveyor noted Resident #1 had what looked to be bruises under both of her eyes and on her forehead, just above her eyebrows. At 11:44 a.m., Surveyor asked if those were bruises under her eyes and by her eyebrows. CNA G said "It's new, wasn't there on Friday." On 11/12/13, Surveyor began review of Resident #1's medical record and identified Resident #1 had the following four falls: A 09/16/13 6:11 a.m. nurse's note identified Resident #1 was found down (unwitnessed) at 5:55 a.m. Had been in her low bed. Resident stated she was getting out of bed, she wasn't going to go anywhere. No apparent injury, able to move all extremities, is able to bear weight. 10:49 a.m. Fax sent to (Resident #1's doctor) - List of MD (medical doctor) orders with notation regarding restless, ? R/T (related to) pain, POA HC (Power of Attorney for Health Care) requesting dose increase in analgesics, not concerned if causes sedation, "I want her comfortable." 5:42 p.m. Fax returned from (Resident #1's doctor) regarding update on pain and POA request, orders obtained to increase Fentanyl to 100 mcg (microgram)...." 8:19 p.m. Follow up of incident: Resident was found down on floor mat 09/16/13 at 5:55 pm (it was a.m.) from low bed, no injury. "INTERVENTIONS/RECOMMENDATIONS RC: Resident may have been woken up and attempted self toileting/transfer, staff has been asked to allow resident to sleep in until she awakens, Pain, resident was displaying more non verbal indicators of pain, MD was updated and Fentanyl patch was increased. Resident #1's Potential for Injury-Falls care plan nor Resident #1's CNA care plan include the approach to not wake her. Resident #1's Potential for Sleep pattern disturbance does include the approach under the date of 09/28/12 that read "Do not disturb when sleeping." No interventions other than increasing the Fentanyl were implemented after this fall. A nurse's note of 09/16/13 at 3:06 a.m. (This is the time the entry was made in the computer) read "noc (night) shift: Resting quietly." This note does not identify the actual time Resident #1 had last been checked on. The incident charting nor follow up charting of the fall do not identify when Resident #1 had last been checked on prior to being found on the floor at 5:55 a.m. or when she had last been toileted. The notes do not identify what she was wearing on her feet, if her call light was on, and/or if the call light had been in her reach. A 09/26/13 9:35 a.m. nurse's note identified Resident #1 was found sitting on mat at bed side with back up against bed. Bed in lowest position. Time of incident was 7:10 a.m. No apparent injury, able to move all extremities, denies pain. Slid from bed, had been incontinent of BM (bowel movement) and when asked if she had to go to the BR (bathroom) rs. (resident) said yes. There was no follow up of this fall charted. No new interventions were implemented. A nurse's note entered in the computer at 4:19 a.m. on 09/26/13 read "noc shift: Resting quietly in bed." The charting does not identify the time resident had last been checked on or toileted or what resident was wearing on her feet. A 10/24/13 7:44 a.m. nurse's note identified Resident #1 was noted to be awake at 7:20 a.m. Checked on resident again within a few minutes. Resident resting but awake. At 7:25 a.m. resident's personal alarm sounded. Responding to this right away, staff found resident sitting on floor by side of bed with back against the bed and arms resting on the mattress. Bed was in lowest position. Resident assisted back to bed. Resident would not answer staff when questioned what she needed, just kept trying to get out of bed. Was assisted to toilet and morning cares given. Surveyor noted there was no follow up charting to this fall. There were no new interventions or increased level of supervision identified. The notes do not identify if Resident #1 was on a mat on the floor, what she was wearing on her feet or when she had last been toileted. A 11/10/13 7:55 a.m. nurse's note read in part: "INCIDENT TYPE: Found down (unwitnessed) Large egg shaped hematoma on her forehead, hematoma also noted on her nose. Small skin tear from her glasses noted on her nose." Date and time of incident were identified as 11/10/13 on 7:10 a.m. "Location was the hallway outside of her room. She had been sitting in her w/c (wheelchair). She had just gotten dressed and up in w/c. Prior to getting up in w/c, she had been toileted ... REASONABLE CAUSE: Bent forward and fell straight out of her w/c onto her forehead, impulsive slid from chair." The note identified her personal alarm was sounding. On 11/12/13. Surveyor was provided with an additional nurse's note dated 11/10/13 with the time of 7:59 a.m. that contained additional information regarding Resident #1's 11/10/13 fall that was not included in the original nurses' notes provided to Surveyor . This note read in part: "TYPE OF INCIDENT: Found on floor (unwitnessed) LOCATION OF FALL: hallway No FOOTWEAR AT TIME OF INCIDENT: nonskid slippers LOCATION LAST SEEN: in her bedroom Last seen doing what: sitting in her w/c INTERVENTIONS/RECOMMENDATIONS: Non-skid pad. Wedge, etc Non-slip foot wear Lower bed to floor Mats at bedside Personal items close by Move closer to nurses station." Resident #1's care plan identified all of the above interventions had been previously put in place prior to this fall except for the wedge and move closer to nurses' station. Resident #1's care plan for Impaired Physical Mobility identified Place Items in Reach; this approach was dated 11/22/10. Resident #1's care plan Potential for Injury Trauma-Falls contained the approaches, dated 08/10/12, "Floor mat on floor beside bed when resident is in bed, ... bed in low position when in it." And "grippy socks if she is not wearing her shoes" dated 10/04/11. Resident #1's care plan Potential for Injury Trauma-Falls contained the approach dated 03/21/12 Nurses and Nurse Aides "Do not leave unattended in room when up in wheelchair." The above nurses' notes are unclear if Resident #1 had been in the hallway or in her room at the time of the fall. The 11/10/13 7:55 a.m. entry identified she was in the hall yet the 11/10/13 7:59 a.m. entry identified she had been last seen in her room and location of fall read "hallway No" On 11/12/13 at 3:45 p.m., Surveyor spoke with the Director of Nursing (DON) regarding Resident #1's fall on 11/10/13. Surveyor asked if they had more documentation regarding the fall. Surveyor pointed out the nurses' notes provided did not identify who heard the alarm and first responded and found Resident #1 on the floor. How was she gotten off the floor and by whom. Surveyor also asked if Resident #1 was restless/agitated prior to the fall as Resident #1's care plan "Potential for Injury Trauma-Falls" contained an intervention/approach dated 10/04/11 that read "Nurses, Nurse Aides--keep in line of sight when agitated." (Surveyor noted this was not included on Resident #1's CNA care plan). The DON said she would need to check and get back to Surveyor . No further information was provided. During the above interview, the DON was asked what new interventions were put in place after the 11/10/13 fall. The DON stated she is being checked for a urinary tract infection (UTI). Surveyor said the nurse's note listed a wedge as an intervention but Surveyor did not see one in use in Resident #1's wheelchair. The DON stated (RN E) thought it was a good idea, but it would make her too high up in the wheelchair so it didn't happen. On 11/14/13, the DON and NHA were m